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36-078 (4) The Commonwealth of Massachusetts Department of Industrial Accidents to : • • M• : ' Office of Investia moons - if " a 600 Washington Street -r_. y _ � el Boston, lI14 02111 _ ' . www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectrician.s/Plumbers • Applicant Information --7 Please Print Legibly Name ( Busincs P.h +1-e r• d ) /44- 9 - . Address: 1 t), go) `f y 8 - - City /State/Zip: 1, �> t 1f 0/ 0s . � Phone. #: tit 3 " Z Are you an employer? Check the appropriatebox: .- 1 am a general contractor and I Type of project (reps ed): El 4 1. I am a employer with ❑ g - . employees (full and/or part time)." 6_ ❑New construction have hired the sub-- contractors 2_ I alit a sole proprietor or partner- listed on the attarhrd sheet 7 - El Remodeling !! �- ship These sub - contractors have - have no Ioy a S. S ❑ D etro i htron - working forme in any Capacity. ennloyxs anddhave workers' .. • [No woe s' comp SuiZdm, adCiiuon ed] 5. ❑ We are a corporation and its 10.C repairs or additions officers have 4xercised their - ❑ mg repairs or additions - 3. ❑ I am a homeowner doing all work . j ; 11. Plumb' • myself [No workers' comp_ right of exempt pe r MGL 12. .Roof repairs - instrance required-] t - . C. 152, § 1(4), and we have no • employees- [No workers' 13.1:1 Other comp. insurance requsrd j. • Any applicant that the ss •box #I must slso fill out the section bdawshowing theireforkrrecornpensation policy information: - t Homeowners who submit this affidavit ind>ating they are doing all work and then hire outside txxaractas Haut submit a new affidavit indicating such. ICouuacUas that check this box mmstattached an additional shot showing the name of the sub comtnetors arid state wbetberornotthose entities have employees. If the sub- contnci rs hive employees; they nustpravide their wcakeis comp pohcynumber_ : - I am an employer dear is p workers' compensation insurance for my ernplayees. Below is the policy and job site information. Insurance Company Name: . . Policy # or Self-ins. Lic. #: Expiration Date: - Job Site Address: City/State/Zip:' - Attach a copy of the workers' compensation policy declaration page "(showing the policy number. and expiration date). Failure to secure coverage:as required Mier& Sectrdh 25A of23IGL - c 152 can lead - to the miposrtion of criminal penalties of a fine tip to S1,500_00 anri /or one -year imprisonment; as well as civil penalties in the form of a STOP WORK -ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of afaiitzations ofthc DIA for'msurancc coveraie verification. _....:;:_ I'do hereb •ecru u _ y fy • _r thee' ' �p „ ' . • ofperjury that the rnf provided.abave rserae_aadrarrPrt ` - - Si . • Lire: ' ?' i ate. - - . P -= hone #: i (,5 - -Cr 4 g L�- v " - - . Ofri'i/ use only. Do not write in this area, to be completed by city or town - officio! City or Town: -- Permit/License # • - Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. Cityflown Clerk 4. Electrical Inspector 5. PIrrmbing Inspector 6. Other i- Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. / , Not Applicable ❑ e Ij r Name of License Holder : � v • (.7 $ d i ( _S 1 3 C 6 c� ! Licensee Number 4 / 4.1..--1/6,- . /Z-a 1, L A4.11 of Psif 7- L'{ - exit/ Address 1t' Expiration Date S' ure Telephone 9Register'ed:Home°1m Y ovemetrtConttactor , .M �� `',,4a g,., .Not Applicable ❑ e�� �• 1-7 14 l 3L 677 Com any Name Registration Number 7t X40.4.-- / L-e t' / .A.1). d `? f J 8 - pi . z-o / z Addre /3 c� p Expiration Date • � t /1 Telephone S a 7 '/ , / L 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 No ❑ 1 - 1w t1 om ' e xemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings 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 10833.1. 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-vear 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 building 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 thispermit. 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) ! ) Roofing I Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [ Other [D] Brief Descripti n of Propose' r ' N - �� /0 �� �/ AN,(4.0 J/& / Work: 4 /15 1 s•d U v -c Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes 1-No / A. - « - • Narrative . Renovating unfinished basement Yes // No • Ians Attach - • • o - Sheet ✓ re •t.l . z.�Xc'•��s: --�: � _ �,�. _ ,��a� -•sue'. �.� -,.. � ..�:��- sar'faiga � il nc �.tOr_- adaItrOTIW rSi act Mo igiltr o rag t W011'Owmq: 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 stories? 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. floodplain 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, b /4V ,•.1 v- / ` / "L. get , as Owner of the subject property /� ) - hereby authorize /f; , L N H k of to act on my behalf, in relative to work authoriz by this building permit application. nm Signature of Owner !�- 'kW ....• I, O rL /'L I" , jf' /"' �- , as ONe�sr/Authorized Agent he - • y declare that the statements an Information on the foregoing application are true and accurate, to the best of my knowledge and belief ab Signed under t¢e pains and p nalties of perju� vs, h.. 1,- y Print Ve 11--- - S T/ Si at re of Owner! gent / Da te Section 4. ZONING All Information Must Be Compteted. Permit Can Be Denied Due To Incomplete Information Ex Proposed Required by Zoning This column to be filled in by Building Department Lot Size s t" [ s Z • • � *.1''r ; i Frontage 1 '117 1 i '�J' ( i Setbacks Front 1M i ; Side L:lif t S i R: L:� � R :' ` ? s i Rear � /� 1 i• Building Height l G•� i = 1 • 1 .. Bldg. Square Footage e s� 1 3 1 % 2' . { 1 ) ,. Open Space Footage % �� + t (Lot area minus bldg & paved � Ot'1i�• �_ ! ! PC / I 3 parking) # of Parking Spaces i — . 1 Fill: ! /10 n<- i /Volt C, (' 6 (volume & Location) _ { A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:1 I ' r IF YES: Was the permit recorded at the Registry of Deeds? . NO Q DONT KNOW 0 YES 0 IF YES: enter Book f Page! and /or Document # _ __A__M B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained Q , Date Issued C. Do any signs exist on the property? YES 0 NO )6, IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO i ®p IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, xcavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Managem nt Permit from the DPW is required. `'G f ,,`Department u only • � i City of Northamp Status�ofPermit ' - _7,w�`1 : uilding Department Curb uf/Dnveway ',. nit .. x . . s T� r a4 212 Main Street _ ptic akc I } -. a 'F` ,- - '+ r r� • o` ,G \ vNi Room 100 N ell : i fab i t o FeOP�ne� ° � ' ' Northampton, MA 01060 Two o fStni . ' =n xr �� �� ���N: phone 413 - 587 -1240 Fax 413 - 587 -1272 FIoUSde ,la s ' � -1- ' 5 10, 1 '. - - � ` (the ' ' pea * ,: APPUCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION -1 - SITE INFORMATION 1.1 Pro a Address: This section to be completed by office 3 4/0 ��A -,, p / Ma p Lot Unit r ile-vt-tf---- e OverlyDist °`Elm Stfiistrict CB "District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Tau ; 1 Vic �., 3 Vb �� f Name (Print) Current Mailing Address: 111 -; - 6 - x6 — 2 b Z 7 pNi� --- Telephone fp nature 2.2 Authorized Agent: Kt4 - 4 14- Po. 090 �y� uaa 1, ono S`� Name (Print Current Mailing Address: .�___ _ X13 —s-a" y- 921 921 1--- Sign. i re Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only comp leted by permit appl 1. Building � I$ 5 (a) Building Permit Fee 1 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection !� • i 6. Total = (1 + 2 + 3 + 4 + 5) +a (� r Check Number / 3- - 1 This Section For Official Use Only Date Building Permit Number. Issued: Signature i7 , M „ � • �� 77 Date Building Commissioner /Inspector of Buildings 340 WESTHAMPTON RD BP- 2011 -0915 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 078 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2011 -0915 Protect # JS- 2011- 001495 Est. Cost: $18500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KENNETH LYNDS 013668 Lot Size(so. ft): 108900.00 Owner: NELSON DAVID Zoning: SR(100) / /WP/WSP II Applicant: KENNETH LYNDS AT: 340 WESTHAMPTON RD Applicant Address: Phone: Insurance: P O BOX 448 (413) 584 - 9282 LEEDSMA01053 ISSUED ON:5/9/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING 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: 3/( 7., b _ /(Ce' ' THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REG . fo S 16464 Certificate of Occupancy Si gnature: A400. k 004 FeeType: Date Paid: Amount: Building 5/9/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner