38B-115 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
.= t 1 Congress Street, Suite 100
= Boston, MA 02114 -2017
a www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): �i9 clt 0`07kJ3 5w -T-
—
Address: \l' 1 20. ■. � ZQ��
City /State /Zip: )3. 1 kkc 1A AcaS OIO (do Phone #: lit 3 -230 -
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and /or part - time).* have hired the sub - contractors 6. n New construction
2.7:1 I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling
ship and have no employees These sub - contractors have 8. LI 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. LI We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 1117 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
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:
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 cert; "' under IK, ains and penalties of perjuty that the information provided above is true and correct.
S i i nature: ' .4111/Za-- Date
/a/I
Phone #: l il3 Z r _ 71170
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 #:
o r,r o City of Northampton
•
Massachusetts ,.
DEPART OF BUILDING INSPECTIONS
•
212 Maier Street •Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck
E E " 'Fax: (410) 587 -1239 - Chuck Miller
Building Commissioner - Fax -- 1 (4 F3) 587 -1272 Assistant Commissioner
52012
NORTHAMF .. A 01060 -
FAX THIS TO: 413 -587 -1272
REQUEST FOR PERMISSION TO VIEW RECORDS
OR HAVE COPIES OF DOCUMENTS MADE
*PLEASE KEEP THESE DOCUMENTS IN CHRONOLOGICAL ORDER*
DATE: f MAP: Lg 223. BLOCK:
FILE ADDRESS: I S.; jai
NAME: i3J
ADDRESS: 15
PHONE #: �( q34 e
UNDER MASS GENERAL LAWS WE HAVE THE RIGHT TO MEET THE
ABOVE REQUEST WITHIN TEN (10) DAYS OF THE ABOVE LISTED DATE.
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��y� DEPARTMENT OF BUILDING INSPECTIONS 44 5. �_
INSPECTOR 212 Main Street • Municipal Building Vigir
Northampton, MA 01060 .
N
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.14 to
act as his /her construction sup . isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends 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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the, home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and i egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour). a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection.;The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, CM z (S /A t` 1 (A k -1 PC understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date ID / � /0)
Address of work
location S (�
No PL T I-1 A e 1 o I - 1
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- DEPARTMENT OP BuiLarNc INSPECTIONS 4 -
212 Main Strcct - Municipal BuIdr .
Northampton, Mass. 01060 . 11•11 '
WORKER'S COMPENS/VH.0N . ENISURA_NCE Ai Fum...va
. .
■ .
I., __ _._.__. .
(licens-Jpc-rmittec)
with a principal place of business/residence at:
! . (phonei)
(scr=ticity/staidzip)
do hereby certify, under the pains and penalties of perjury., that
. - .
( ) I arn an employer providing the followine, .\.vorker's compensazion coverage for iny
employees worldng on this job:
,.,
. • ..
-
(Losunn= Co (27 7) . (Policy Nurzbcr) (Es:pima Daut) .
( ) I am a sole proprietor, general contractor or homeowner (cL one) and have hired
t_he contractors listed below wbo have the follow-in worker's cocriberLsz6on policies:
_
a.ruc of Contrac (Insur CompanyiPoitcy Numlx:) (F_:piratton Datc)
. .
---
(Namc of Cot' cac (1.n.suranc....-. CompanyiPoLicy Num (likpiration Date)
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(Name
of Coo;; (Lasurancc Company/Policy Namkr) (Expiration Datc)
. . . .
•
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(Name of Coatramor) . ("Losuraa Compauy/Poticy Numbc.r) (Expiradou fiatn) .
(.,:t=th =i-tit:c.c..' t±rc . i/noca.a.r to 'ancl.l.s4 inforta.Eoo pc-t.laing to ..1.1 cc-.0) .
( ) 1 arn a sole proprietor and have no one woridng for me.
I an.a. home owner perforrning all the work myself.
NOTE: p1=4.4.- bc .vr th e. wirik be ,...1b. , p,„,„ L d , ,c, =-. -- .:.c.roo a" rc;air work co . dwtth of
not (norm thf_n L...c.: =its in wbich the omoowocr rcrict.= or cc the roucc13 2.9pcartc them ...-c oo( g=...--11y coorrie..--oJ to bc
cuiploya-s ■,,,',-- the waitc?-4 coccp...,..aico Act (GLq52-...ral(5)), ..pplicarEon by • bocncowoc for . ti=_-‹ a permit rr...ty c-vidcocc the
cipd ata-nas of co c=ployac uncial- ciao orkoea Cocopooaarto.a Act-
1 wa4c that a copy of thi. co_tocoost 011 y ba. foc".-..re...d to the opartmooa of J. Am■a.. ( : )15 .". a L.----- far d''
v,--t 6 - vcriGaaicx3Aaci th.t.t f.:11t.vc to soca= 'covcre..Ec track section 25.A of MOL. 152 Catilc.4 to the impositioa of aiminsl pcoallica
coccaiag of . floc °Cup to S1.500.00 anclfor iszpriscuroc= of up to coc yr-mr Lod civil pco.itict in tbo focal of . Stop Work. Ordc- aaxi a
rir. o(100.03 a by a.gx.iast ax.
--------- ----
For dcp.rtor -.-.‘.,-.,-• .1 Lt..c catty -
-, ' Pcrmit Nunalacr
?aL6i'Al Date
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. i gnaturc of Lio=nscr/Pc rrni ucc - . i E
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SECTION 8 - CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9., RegistereifHom4 .lmpFaveriientConticto ' 77 ` ` ' ' - "a Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G.L. c.-152,
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 ❑
11-: - OR a : ner dx ipat on
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 -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 this permit.
The undersigned "homeowner" c -rti ; s and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, S . e . cal Zoning Laws , to of Massachusetts General Laws Annotated.
Homeowner Signature
r
i
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House E Addition Replacement Windows Alteration(s) Q Roofing E
Or Doors El
Accessory Bldg Demolition ❑ New Signs [D] Decks [El Siding [D] Other [D]
Brief
Work: Description of Proposed k i L L o i �� i 0 0 L E 0 () g (,,,19� ss 5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a (t -rs1 hoc se an o r dctiitla : tai -6WiincC4aactsii Or 6tefe*ih al aiiir c :
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, , 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
1, , 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. r
Print • e�y F ,
4 Signature of Owner /Agent Date
Section 4. ZONING All Informatibh 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 4,7"- 9 fib I
Frontage I I ' F
Setbacks Front i
Side L:'` . R:' 'L: 1 R: / '
y"
Rear . L
Building Height
L
Bldg. Square Footage t % f E
Open Space Footage , %
LS
(Lot area minus bldg & paved L____I 1 i C4
parking)
r -
# of Parking Spaces '
Fill: r t
(volume'& Location)
i1
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::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued: 1
C. Do any signs exist on the property? YES 0 NO 0
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 O
IF YES, describe size, type and location: I
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 0 , NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Ity` 4orti ampton tr of °Psunt
l�ilmlig department Cui� Cat [3v eixni
212 Main Street seers of �� ,
Ro di n 100 e r/We ail r Ti {
Northampton; MA 01060 Tea S eIs i i st i u lay ,, , ��
phone 413- 587 -124Q Fax 413- 587 -1272 PI fa ���
l atherks ire, "1' � m
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This secti to be completed byoffice U
1.1 Property Address: i ( on `
v+ ��� T `�.� i-Ne Map Lot + + nit
t i lo t � Zone verlay O rstnct
\ ti l
Elm S t D CB Distr
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
04-1 S I j N- c A ` i PE S ox
Nam n (/.:__NI Current Mailing Address:
n _�L Telephone __ Signature �" C�
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 / t t S J (9 (a) Building Permit Fee
"
2. Electrical t)° (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) Check Number
Th Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspectorof Buildings Date
File # BP- 2005 -0442
APPLICANT /CONTACT PERSON CAMPE CHRISTIAN
ADDRESS/PHONE 152 SOUTH ST NORTHAMPTON () 586 -4429 0
PROPERTY LOCATION 152 SOUTH ST
MAP 38B PARCEL 115 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid X5370 �o
Tvpeof Construction: CONSTRUCT (3) 8 X 8 SHEDS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Co ' n
ilf A. " / CO/
Signature of Building 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.
152 SOUTH ST BP- 2005 -0442
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 115 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Budding DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2005 -0442
Project # JS- 2005 -0586
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 17075.52 Owner: CAMPE CHRISTIAN
zoning: URB Applicant: CAMPE CHRISTIAN
AT: 152 SOUTH ST
Applicant Address: Phone: Insurance:
152 SOUTH ST 0 586 -4429 0
NORTHAMPTON MAO 1060 ISSUED ON:10/21/04 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT (3) 8 X 8 SHEDS
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: Receipt No: Date Paid: Check No: Amount:
Building 10/21/04 0:00:00 2556 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo