30C-052 (3) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
� Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): eZ_(J or., per cm 1! o Li C.
Address: I- t L ' C .San
City /State /ZipbckS � )1c„. C11f)Z1Phone #: (4 52 (52C�C`3
9 •
Are you an employer? Check the box:
I Type of project (required):
1. ' 1 am a employer with 4. ❑ am a g eneral contractor and I
employees (full and/or part- time).* have hired the sub - contractors ❑ 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'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their I I. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.D Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 131aOther 1f \SL) \O v
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.
1 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: B Q,,( 65I C^'f , nFi 3ra fl (Q_ 6r-
Policy # or Self- ins.ftLic. #: ` tcU - (-f -, 3.7?j 01 Expiration Date: i i / L) 1 Z S
Job Site Address: u / O L' City /State /Zip: CL [ r 1. /Y) )6161
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c$tify uun derthe pains nd penalties of per' that the information provided above is true and correct.
; w
Signature: 1 - Date: -J
Phone #:(V/ - 3)S9 ° Uv �(a(�
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 #:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
aK
j �� p �
tl 1A;11 A;11 L--1 Un License Number Expiration Date
Name of CSL- Holder `
ri LA+ St �� � U (i) fSt�YtJY+Q List CSL Type (seebelow)/nS OY1
Add
ress Type 1 Description
U Unrestricted (up to 35,000 Cu. Ft.)
Sig attire R Restricted 1 &2 Family Dwelling
� 3) 5 q • O � M Masonry Only
! RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home mproventractor (HIC)
OZ: y I#r� P ran ment Contractor / �o �o
HIC Com•any Name or HIC Registrant Name Registration Number
Address
. ` (h .S - U ae. x piration Date
Signature Telephone
SECTION 6: 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 ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OW, ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
' 1 , as Owner of the subject property hereby
authorize 1■,. • • _ to act on my behalf, in all matters
relative to work a . rized by this but ding permit application.
Si g ture of Owner Date _
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
.k I, (NV � tl 1 , as Owner or Authorized Agent hereby declare
that the statements and information one foregoing application are true and accurate, to the best of my knowledge and
behalf.
Prin 'r a / %' l
gnature of Owner, orized Age Da
(Signed under the pains and penalties if perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost" 4 A J
•
L SEP - 6 2012- — _ __
The Commonwealth of Massachusetts
DECTOFiT.T,:„.:::',. ,, - s 41:,•,,,, i ' Board of Building Regulations and Standards FOR
MUNIC2ALrfY I
NORTHAMF ; ON MA 4. 1.71 ..' Massachusetts State Building Code, 780 CMR
USE
BUilding Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar Mar 2011
• One- or Two-Family Dwelling
This Section for Official Use Only
— -
Building 'Permit Number:. _ _ Date Applied:
., .
Building Official (Print•Narne) • Signature Date
SECTION i:. $1T1 liNt'ORIiiirillioN
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
i d 5 (.. e ' 1-1 li - q , ..1-(\iv■a_. -.. —
1.1a Is this an accepted street? yes__ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 • Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, ¢54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public 0 Private 0 Municipal Cl On site disposal system 0
Che,ek if yes0
. ., : .,. •• - -. -.• -. - ' - . ' ; - 0j 1 -1''''#0*.; ' :. 1' . ' 0:i.i.t i til ' . , tviji*OtOtto)'. : , -..... :: : ..:-.....;: ...: .:,. ...:.
,21
Owner of Itecorid:
C 1 1 CA e 5 (A )1 . 1..,c ev, Lk_ rf) A 0 / 0 (th-
Name (Print Cit State, ZIP
1 CI S C\ t (.._11.C1._____---5---- `t1 — l` 111
No. and Street Telephone Email Address
544.tqT..::I
New Construction 0 Existing Building 0 Owner 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units_ Other 0 Specify:
Brief Description of Proposed Work i ' , .....* t•t\-\ ta oyl 1
v l.tt. k, n A r Qi,16
, ._ ...._,... . .. ., , .
SCTIf:)N4:.opavoltbicoNmticriQN
Estimated Item Official Use Only
(Labor and Materials)
1. Building $ ;II gninting Permit fee:. $ 1 Indicate how fee is determined
.. .
0 Standard. CitYitOWii:A.ppliCation Fee
. $ Electrical
- --- ---- 0 To'tal l"rojeCt COst 6) x itinfriplier _ _5t
3. Plumbing $ ,._ -
2 Other f e'S: 5
4. Mechanical (FNAC) $ List: _ _
--
5. Mechanical (Fire
$
Suppression) Total All %4. ' $
Check ',/ rf Check Amou05c Amount:
6. Total Project Cost: $ \
0 Paid in ul
i —
0 Outstanding Balance Due:
P
File # BP- 2013 -0257
APPLICANT /CONTACT PERSON MARK LANTZ
ADDRESS /PHONE 180 PLEASANT ST EASTHAMPTON (413) 320 -7611
PROPERTY LOCATION 105 CLEMENT ST
MAP 30C PARCEL 052 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out al?
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102169
3 sets of Plans / Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I ATION PRESENTED:
Approved _ Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
/ • f ► Dela
Or,
Signature o guile mg Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
105 CLEMENT ST BP- 2013 -0257
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C - 052 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0257
Project # JS- 2013- 000419
Est. Cost: $2300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 14505.48 Owner: SCHAESDIG CINDY
Zoning: SR(100)/ Applicant: MARK LANTZ
AT: 105 CLEMENT ST
Applicant Address: Phone: Insurance:
180 PLEASANT ST (413) 320 -7611 WC
EASTHAM PTON MA01027 ISSUED ON:9/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 9/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner