18C-057 Mar 30 10 10:38a P.3
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
" 600 Washington Street
;+ Boston, MA 02111
www.massgoy /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): f �r r . _
Address: ld V /Norm gw 5 'i l0or ,. 07 7 4 - 01061
City /State /Zip: Phone 50
Are you an employer? Check the appropriate box:
� Type of project (required):
1. t J l am a employer with 4. [] I am a general contractor and I
Y have hired the sub contractors 6. ❑ New construction
employees (full and/or part- time).
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance.+ 9. El Building addition
[No workers' comp. insurance p
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. El 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 them 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
etnployees. 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: ' ' -
v � o
Policy # or Self -ins. Lic. #: goo r a i`// T? Expiration Date: $ ,3
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 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 hereby certify under the ains and penalties of perjury that the information provided above is true and correct.
Signature: 1 - Date:
Phone #: 4 6 3 58 - jeSo
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 #:
SECTIONS CONSTRUCTION SERVICES':: ,
-
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ,T01.." Ley y e 5- ' 5 0
{ License Number
I / i A 1 1 ; t
Address Ex P it i on e
X13 eo Y & 0
Signature Telephone
f _ t ' Not Applicable ❑
'9Re �s'� ec`e`d�'�oe m ouemen •�La tracto :" .f.,�, �n •� ;. � ��, . � � ,�° PP
P� : _ R - � /
Company Name j / Registration Number
Mr Address Expir tion to
Telephone y/l7 do y ew
rte=, x j w , ,
SECTION '}0 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.O L c :4$2 § y 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 ❑
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 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 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, von 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
r •
?t
SECTION 5 DESCRIPTIt�. N OF PROPOSED'WORK.(check:al {applicable)
•
New House [J Addition ❑ Replacement W' Bows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. n Demolition ❑ New Signs [D] Decks [El Siding [DI Other [D]
Brief Description of Proposed �r
Work: Fear / C P �f~ , I4 », r- A0 . kcr
Alteration of existing bedroom Yes �No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll - Sheet
I T[ew f obis i�d o tl# #o1 o exls`tlnq , ou t#�q comet= e fi faI vu nq:
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? / Fire aces or Woodstoves Number of each '
g. Energy Conservation Compliance. scheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? es No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished . rade
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 BECOMPLETED WHEN
OWNERS.AGENTOR.CONTRACT APPLIES FOREilhlt='DINGRM1T Y
6. VA v ,LL,. e / • _ as Owner of the subject
property
hereby authorize k .. L,Sey
to act on my behalf, in all matters relative to work 46thonzed by this building permit application.
Signature of Owner Date
I, t� , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owne tent Date
•
Section 4. ZONING All 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
r l-- I
Lot Size 9
Frontage
Setbacks Front i ! r
F
Side L: ' R: L:' . R _ ,
Rear = 1
Building Height _ i ,
Bldg. Square Footage [ i € % s i
Open Space Footage %
(Lot area minus bldg & paved ; _7 !
parking)
i
# of Parking Spaces
Fill: i �`
(volume & Location)
1 0111.1.- `
A. Has a Special Permit /Variance /Finding e er been issu•;) fo on the site?
NO 0 DONT KNOW 0/ YE ik
IF YES, date issued:. I /
IF YES: Was the permit recorded at t e Registry of Deeds?
NO 0 DONT KN 0 YES 0
IF YES: enter Book Page E and /or Document #1
i
B. Does the site contain a brook, . •dy of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been %r need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on t' e property? YES 0 NO 0
IF YES, describe s' e, type and location: i 1
D. Are there any pro changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, desc 'se size, type and location: 1
E. Will the const ction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
`� �" D ®artrn t•t , . ,
City of Northampton S S. us ® 4``0 �• - .
Building Department 0 °,
212 Main Street • e er e. 1 A vat hilt _ .� ' . ��- , � 4 „
` A 241
Room 100 ta® �_
ko, 1 or MA 01060 e f 4., F ° �,4 fiv
�
' .
ne 4 3- 587 -1240 Fax 413 - 587 -1272 'P t . 4 .44 1 # gi ,
tioso
. 1_ 'r BU . .. ::,+ Pr, i Rt t ► '"mow +, ' " , it4N41 RA;-i � 11t i., x3 a i
CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
•
SECTION 1 :SITE INFORMATION
1.1 Property Address: E:g . ' t k:g This Bect on tob
y e tompleted y offi i -
7/ peg 4 ke . nre . ya ,,• w'� x-: �. i a�` AN ' r � l , v
S 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: / l // e / rj 2 I J -
P i Ka /fh Pet krtw?v�e'�, 5 ✓L 6C /ti, h igk / �rc 1 ,1'I( /J Jt. 7�� 1 w4
Name (Print) Current Mailing Addres
Telephone
Signature
2.2 Authorized Agent: /
Name (Print) Current Mailing Address:
/� y /3 - 587 -3oSo
Signature / Telephone
�.._
SECTION 3-- ESTIMATED >CONSTRUCTION =COSTS ,
Item Estimated Cost (Dollars) to be Official Use On(
completed by permit applicant
1. Building '�/� G' f(a)4Bu►lding,Perm►t-Fee y
2. Electrical (b)"Estimated Total Cost of
. .Construction,'from (6)F a V .._
3. Plumbing Per
Building mit Fee'
4. Mechanical (I-IVAC) { u
5. Fire Protection
6. Total- (1 +2 +3 +4 +5) Pery OCR Check Number � �
. This Section For:Official ` Use On y .
Bu P ermit Numbe �s sued. ste
" is ,: ", ... . ��:, _
S ignature
Building Commi /In o f B uilding s ' Date
142 PROSPECT AVE BP- 2013 -0166
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 057 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2013 -0166
Project # JS- 2013- 000274
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN LANDRY 093450
Lot Size(sq. ft.): 39900.96 Owner: CZELUSNIAK JAY
Zoning: URB(100)/ Applicant: JOHN LANDRY
A T: 142 PROSPECT AVE
Applicant Address: Phone: Insurance:
104 NORTH ELM ST (413) 204 -9880 WC
NORTHAMPTONMAO1060 ISSUED ON:8/14/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE ENTRY, BATHROOM & GARAGE
DOOR
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 8/14/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner