31B-111 Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confii irration of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self - insured companies should enter their
self - insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114 -2017
Tel. # 617 - 727 -4900 ext 406 or 1- 877- MASSAFE
Fax # 617 -727 -7749
Revised 7 -2010 •
www.mass.gov/dia
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
� � 1 Congress Street, Suite 100
*ft Boston, MA 02114 -2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address: \ r`C\t\`''�
City /State /Zip: N\ Phone #: `k \ �-� `1 C) 6 t
Are you an employer? Check the appropriate box: Type of project (required):
1. n I am a employer with 4. 111 I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. n New construction
2. [ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling
ship and have no employees These sub contractors have 8. n Demolition
working for me in capacity. employees and have workers'
g any p y 9. n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. El We are a corporation and its 10. Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11. n Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. n Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
13.1 Other
employees. [No workers'
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:
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 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 pains and penalties of perjury that the information provided above is true and correct.
Signature: ` V,./■ L Date.
•
Phone #: ct 7
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 #:
i n, Commonwealth of Massachusetts •
100155838
Li Asbestos Notification Form ANF -001 Decal Number
B. Facility Description (cont.)
PAUL ROCHA 11 BRIGH T ST
5. a. Name of General Contractor b. Address
NORTHAMPTON 01060 4132970031
c. City/Town d. Zip Code e. Telephone Number (area code and extension)
f. Contractor's Worker's Comp. Insurer g. Policy Number h. Exp. Date (mm/dd /yyyy)
6. What is the size of this facility? a 2
a. . S Sq quare Feet b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos - containing material from site to temporary storage site (if necessary):
PAUL ROCHA 11 BRIGHT ST
Note: Transfer a. Name of Transporter b. Address
Stations must NORTHAMPTON 01060 4132970031
comply with the c. City/Town d. Zip Code e. Telephone Number
Solid Waste
Division 2. Transporter of asbestos - containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000
a. Name of Transporter b. Address
c. City/Town d. Zip Code e. Telephone Number
3.
a. Refuse Transfer Station and Owner b. Address
c. City/Town d. Zip Code e. Telephone Number
4. NORTHAMPTON LANDFILL
a. Final Disposal Site Location Name b. Final Disposal Site Location Owner's Name
NORTHAMPTON LANDFILL NORTHAMPTON
c. Final Disposal Site Address d. City/Town
MA 01060
e. State f. Zip Code g. Telephone Number
■ 0
�� o
D. Certification
The undersigned hereby states, under the PAUL ROCHA Paul Rocha
z= penalties of perjury, that he /she has read the a. Name b. Authorized Signature
Commonwealth of Massachusetts regulations OWNER 8/14/2012
for the Removal, Containment or c. Position/Title d. Date (mm /dd/yvvv)
Encapsulation of Asbestos, 453 CMR 6.00 and 4132970031 SELF
310 CMR 7.15, and that the information
contained in this notification is true and correct e. Telephone Number f. Representing
° to the best of his/her knowledge and belief. 11 BRIGHT ST
g. Address
NORTHAMPTON 01060
� h. City/Town i. Zip Code
Z
U anf001 an.doc • 10/02 Asbestos Notification Form • Pane 3 of 3
..............................
LI Commonwealth of Massachusetts ■
100155838
Asbestos Notification Form ANF -001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
0 1500
a. Total pipes or ducts (linear ft) b. Total other surfaces (square ft)
c. Boiler, breaching, duct, tank d. Insulating cement
surface coatings Lin. ft. Sq. ft. Lin. ft. Sq. ft.
e. Corrugated or layered paper f. Trowel /Sprayer coatings
pipe insulation Lin. ft. Sq. ft. Lin. ft. Sq. ft.
g. Spray -on fireproofing h. Transite board, wall board
Lin. ft. Sq. ft. Lin. ft. Sq. ft.
i. Cloths, woven fabrics j. Other, please specify: 1500
Lin. ft. Sq. ft. Lin. ft. Sq. ft.
k. Thermal, solid core pipe SHINGLES
insulation Lin. ft. Sq. ft. I. Specify
14. Describe the decontamination system(s) to be used:
DISPOSAL ONLY
15. Describe the containerization /disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
DOUBLE BAG
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name of DEP Official b. Title
c. Date (mm /dd /yyyy) of Authorization d. DEP Waiver #
e. Name of DOS Official f. DOS Official Title
g. Date (mm/dd /yyyy) of Authorization h. DOS Waiver #
N
o 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A —F apply to this project? Yes ✓ No
B. Facility Description
■N
�o 1. Current or prior use of facility: SINGLE FAMILY HOME
0
2. Is the facility owner - occupied residential with 4 units or less? ✓ Yes No
PAUL ROCHA 11 BRIGHT ST
3 ' a. Facility Owner Name b. Address
- o NORTHAMPTON 01060 4132970031
c. City/Town d. Zip Code e. Telephone Number (area code and extension)
PAUL ROCHA 11 BRIGHT ST
4 ' a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address
Z NORTHAMPTON 01060 4132970031
c. City/Town d. Zip Code e. Telephone Number (area code and extension)
1111 anf001 ao doc • 10/02 Asbestos Notification Form • Paae 2 of 3 ■
.... .............. .................
Commonwealth of Massachusetts •
100155838
Asbestos Notification Form ANF -001 Decal Number
Important: A. Asbestos Abatement Description
When filling out p
forms the
computer, use 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner - occupied
only the tab key residence of four units or Tess? ✓ Yes No
to move your
cursor - do not b. Provide blanket decal number if applicable: Blanket Decal Number
use the return
key. 2. Facility Location:
11 BRIGHT STREET 11 BRIGHT STREET
a. Name of Facility b. Street Address
Northampton MA 01060 4132970031
c. City/Town d. State e. Zip Code f. Telephone Number
INSTRUCTIONS 3. Worksite Location:
1. All sections of this OUTDOORS
form must be a. Building Name /Building Location b. Building # c. Wing d. Floor e. Room
completed in order
to comply with 4. Is the facility occupied? ✓ Yes No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of Occupational INHOUSE OR HOMEOWNERS INHOUSE ABATEMENT
Safety (DOS) a. Name b. Address
notification INHOUSE 02108 6172925500
requirements of 453
CMR 6.12 c. City/Town d. Zip Code e. Telephone Number
AC000000
f. DOS License Number g. Contract Type: Written ✓ Verbal
PAUL ROCHA OWNER
h. Facility Contact Person i. Contact Person's Title
NON LICENSED REMOVAL AS000000
6. a. Name of On -Site Supervisor /Foreman b. Supervisor /Foreman DOS Certification Number
NA AM000000
7 ' a. Name of Project Monitor b. Project Monitor DOS Certification Number
a. 8.
Name of Asbestos Analytical Lab b. Asbestos Analytical Lab DOS Certification Number
8/28/2012 10/1/2012
• 0 9 ' a. Project Start Date (mm /dd /yyyy) b. End Date (mm /dd/yyyy)
■•'••••■■ 8AM -7PM 8AM -7PM
c. Work hours Mon -Fri. d. Work hours Sat -Sun.
=-o 10. a. What type of project is this?
Demolition ✓ Renovation
Repair Other, please specify: b. Describe
11. a. Check abatement procedures:
� ° Glove bag Encapsulation
-■ o Enclosure ✓ Disposal only
�- Cleanup Other, specify:
.emu Full containment b. Describe
z
12. Is the job being conducted: Indoors? ✓ Outdoors?
anf001ao.doc • 10/02
Asbestos Notification Form • Paoe 1 of 3 III
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applic
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Co - ctor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
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, 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, �S ` Local Zoning Laws and State of Massachusetts General Laws Annotated.
4__. H o meowner Signature
�N
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors 0
Accessory Bldg. El Demolition 0 New Signs [D] Decks [❑ Siding [IZI] Other [D]
Brief Description of Proposed
Work: removal of asbestos and asphalt shingles
Alteration of existing bedroom Yes n° No Adding new bedroom Yes n° No
Attached Narrative Renovating unfinished basement Yes no No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the folio • q:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathro= s
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 101 . of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement t cellar floor below finished grade
k. Will building * form to the Building and Zoning regulations? Yes No .
I. Septic Ta City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, , 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.
a.0 o
Prin e °. \ t —
Signature of Owner /Agent
Section 4. ZONING Alt 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
Lot Size 7405 Sq. ft.
Frontage 60 ft.
Setbacks Front 12
Side L: 8 R: 5 L: R:
Rear 110
Building Height
Bldg. Square Footage 864
Open Space Footage kh4., ° o
(Lot area minus bldg & paved • 41
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location:
E. Will the construction 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 O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
tt City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
- 4 2012 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
p�;=r.6 .- sr;Pecriorvs Northampton, MA 01060 Two Sets of Structural Plans
Nosr"A""r `' . h�rte 413- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Properly Address: This section to be completed by office
1 1 , ` \- 5 \— • Map Lot Unit
_ON IN � `� 1 v ! V 6 Zone Overlay District
"
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Paul Rocha 11 Bright Street
Na nnt) Current Mailing Address: Northampton, MA 01060
� - Telephone !\
Signature "'� �� L a d�
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 5,000 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) _ 5,000 Check Number 3 I ��
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
P / • C (*1441/0
11 BRIGHT ST BP- 2013 -0249
is #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 111 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2013 -0249
Project # JS- 2013- 000411
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 1263.24 Owner: WAITE HELEN H C/O PAUL ROCHA
Zoning: URC(100)/ Applicant: WAITE HELEN H CIO PAUL ROCHA
AT: 11 BRIGHT ST
Applicant Address: Phone: Insurance:
11 BRIGHT ST
NORTHAMPTONMA01060 ISSUED ON:9/6/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE ASBESTOS & SHINGLES
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 9/6/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner