23D-023 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
„ . 1 Congress Street, Suite 100
.'= Boston, MA 02114 -2017
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibiv
Name ( Business /Organization/Individual): , ( VAR 11 C e SE) 1 ' ,..1.. k
Address: n ► CMf
City /State/Zip S kft .tom e i- (Y o ►o 7 Phone #: 4 i b a a 9 -1 t 3 Co
Are you an employer? Check the appropriate box: Type of project (required):
1. [E]'I am a employer with 3 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. [demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.: 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub- contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,� rCILn l tv ,S - ry b
Policy # or Self -ins. Lic. #: C— 0 04 -( 14- 3 a R Expiration Date: Id , 5' a-- O 1 (9-
Job Site Address: ,. City /State /Zip: NO r'- /1QP-ipita It/a tria 0106o
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereb certify der the pains and penalties of perjury that the information provided above is true and correct.
•
1 a ur �� / Date
Phone #: )4 1 - 5- 1c )- /3(o
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/ Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SeCe T .. IOt4 $ • G(7NSTROCTION SERVICES 1
8.1 Licensed Construction Supervisor: Not Applicable ❑
Nam, of License Holder : I (F & rd (t ) ) OS z y c. /o 9
License Number
C95 , �cofl�cxwt N o i / ' 6 • . hy
Address Expiration Date
43 �'r3� l(007
Sign elephone
° iltesilafar' s tsiri`etni`rovement-Contractor, :,
Not Applicable ❑
Awl Sgi6v/ /4"7 7
ComoanvName Registration Number
9- v
6 lr ci) 6/, (0, ,'VFl dioa/ T y• aoi3
Address Expiration Date
Telephone 1 / -3
SECTION 10- 'WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes D' No ❑
ome:O Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official. that he/she shall be
responsible for all such work performed under the buildine permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature /V /1i
6/25/12 1 (2560x3258)
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aoolicabie)
New House ❑ Addition ID Replacement Windows Alteration(s) n Roofing n
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D Decks [0 Siding ID) Other psi
Brief Description of Proposed .
Work: t I M )„.....e..._
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes
No
Attached Narrative Renovating unfinished basement Yes '✓ No
Plans Attached Roll - Sheet
6a. if New house and or addition to existing housing. complete the following:,
a Use of building One Family Two Family Other
b Number of rooms in each family unit. Number of Bathrooms
c Is there a garage attached?
d Proposed Square footage of new construction. Dimensions
e. Number of stones?
f Method of heating? Fireplaces or Woodstoves Number of each
g Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. ffoodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
I Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, / )! Z i )/ L i //I ) , as Owner of the subject
Pr rty -- --
t j i f j
hereby i/ I, L , l / f / l f 1 / c l ∎` C 7.."t 5 _ ! ° (4 ,,�J4 Stj /
to act do my half, in all tters relative to irk ath�ized by this building permit ap licatio� 7
7 t 1
J
4 Li )r ii ,,G( 3 i l - C ?
Signature of Owner Date
t
I, ; // Z' ,f J / 1 / L[i� r it t- l rr .e , as Owner /Authorized
Agent hereby declare that the staterhents and information on th4 foregoing application are true and accurate, to the best of my knowledge
and belief. �f
Signed under the pains and penalties of perjyty. /
Print Name if f „.
Signature of OwnertAgent ' Dom"
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Suction 4. ZONING AR information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
l:rontae
etba+ ks F t °] l
Side L: -y- R : {.__. I
Rear _...... �, ....W. I_. _..
130i/ding Reight
Eldg. Square Footage I,. %
Opeh . F+ootage I
(Lot area m I
intis bldg & paved I .w.,_ _._.. [._ .__.I
P"
+ f,arla
Fill:
( i & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES i
IF YES: enter Book L Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained (3 Obtained ,Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (3
IF YES, describe size, type and location:
E. Will the construction activity disturb (ci aring, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
6/25/12 1 (2560x3259)
r
R EC ti t:: i t apartment use only
_ _ ' City of Northampton Status of Permit:
Bui ing Department Curb Cut/Driveway Permit
t 2012 2 2 Main Street Sewer/Septic Availability
Room 100 WaterlWell Availability
L_ Northampton, MA 01060 Two Sets of Structural Plans
phone 413 -587 -1240 Fax 413 -587 -1272 Piot/Site Plans
Other Specify
APPUCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Proaerty Address:
1 1 4 /. ?6 e A y / 1 Map Lot Unit
(C �C k � �/ �rt:.e fin O /Ob0 Zone overlay District
Elm St. Dlebiet CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
7
c– v7 JL ; e o-r-
Name (Print) C unt 7 7 ‘.‘ei r " r .S G
Telephone
Signature
2.2 Authorized Anent: .
!
Na f� si4 � 11/ /V _ , J i 1 Current S Y1 J UyJ _5 /- t
.4;� '/ �1 �P Mailing fess:
S i g : 0 Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b it applicant
1. Building 0 Q--- (a) Building Permit Fee
2. Electrical e2 t (1 D (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection v V
6. Total = (1 + 2+ 3 +4 + 5) 0-0 Check Number
This Section For Official Use Only
Date
Building Permit Num. - Msued.
Signatu Jam/ /�� /Iii/ — /
Balding Commissionedlnspector of Buildings Date
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496 ELM ST BP- 2012 -1171
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 023 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2012 -1171
Project # JS- 2012- 002000
Est. Cost: $2300.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AWL MAINTENANCE SERVICES INC 104039
Lot Size(sq. ft.): 4007.52 Owner: LANG MONNA
Zoning: URB(100)/ Applicant: AWL MAINTENANCE SERVICES INC
AT: 496 ELM ST
Applicant Address: Phone: Insurance:
52 UNION ST (413) 529 -1936 WC
EASTHAMPTONMAO1027 -0865 ISSUED ON:7/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: Demo 1 car garage
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/3/2012 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner