10B-064 1 he Lommonwealtl of.l
r , D epartment of Xndustr.ial Accidents
� - 7 . Office of Investigations
�..,, 600 Washington_ Street
Boston, MA.021.11 •
y -:.,s,' www. ass- gov /dia
Workers' Compensation Insurance Affidavit: Bui.l"ders /,Con_tr_2c" p.r.s. ie,ct. i.G_i : a-n- slgl•umbe-r-s =— j == -=°-
---__ A-ea.l-i =Info - - -"- - - Please Print Legibly
Name ( Business /Organization/Individual): - _., -" .
Address:
1 55 N 5(-
City /State /Zip: 6 1 Ccr) t o id Mq 6 t.�D/ Phone ii: y/J 77,
r
Are you an employer? Check the appropriate box: T of project (required).:
1. [;it I am a employer with i 4 . ❑ 1 am a general contractor. and I 6 New construction
..employees (full and/or part - rime)."
have hued the •ub - contractors
2. 1 I 1 am a sole proprietor or partner- "
listcd.on the attached-sheet. 7. D Remodeling
. ship and have no employees The sub - contractors. have - .g Demolition .
working. for me in any capacity. e mploy e e s and .have..w 9 ". gui addition •
. [No workers' comp insurance comp ins $
VFe area co"at1On d D. repairs or additios. n •
re. utred. 10 EI ectncal .
4 ) '$ D ?P ___.. an its:
3. D. f awn a homeowner doingall work o.fcer , e z iset :their :11:D Pfurnbing repairs or additions
• myself. [No workers' com right of.:-p v4 GL ..
P 12. Roof repairs. • .
insurance required.} t . ... c. 152; §1.(4), ,v ; fa : v
eae.no .
.;employees. [Na workei -s 13.❑ Other
•
comp. insurance required. -__.:._:...._ __._.._._ _ • _..r ---- -..... _.
----- '-tinyapplicanrtbarchccks box #1" mu also fill out,thc "scdion " below: .'. i ■ -" ■ ' ., D=icer =compcasatia "cFpohcyin
-_ _-lioluetw rcirawho-- subrait -is . ay indidntuig they "arc doin aft work" and" ilien'lurc;out must submit.ancw affidavit indicatin• such__
7Contractors that chcck this a ttarhr4p n a rtditionalsh showing thcriamev 'tb ntrac ..rs,a.ti,.. . c cr or not those entities havc
employees. rf"the sub- contractors have employ"ces,: they :must provide th "cii. workcrs i.ot ng,`policy.n.umbtr_
I am an employer that is provid w m
orkers' c oaensalio ' ii suran
ince f or tny :employees
emp - B w elo is the policy a job site
information_
/
Insurance.Company Narife • _ A 6 V r U. f' - . _1 AI c'
Policy 0 or Self -ins. Lic. t{: (,J / A7 9 716( (2 " - 0 Expiration Date: / r�l' r') /- f
Job Site Address: L.a3 WOl. c C A . , . • _ City/State /Zip: U.e8S c1 • O 0'33
Attach a copy of the workers'.compensatio.n policy declaration_ page (showing the policy number and expiration date). -__.
Failure to seethe coverage as required under SecJion_25.A..o.f -MGL c,:I - 52 eat 1 LO -- im post.t ion o�cnminal penalties of a
f ire up Co $7 506 0 and /or one -year impnsoament, 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 advis that a.copy of this •statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der the pains an % penalties of perjury that the information provided above is true and correct.
Si. ature: _ 4 :/ ° -�`L ..& - Date: 41 1i t r
Phone #: • • ''? ? X 700 .
Official use only. Do not r4rile in this area, to be com feted b ci or "towno r
ll y p_ x. ry officio(
. City or Town: . PermitlLicense # .
Issuing Authority (circle "n.e):
•
1. Board of Health 2. Buifdipg Department 3. City/Town -Clerk "4. E lectrical Inspector 5. Plumbing Inspector
6. Other .
Contact Person: . Phone #'
E
8.1 Licensed Construction Sup', ( Supervisor: , Not Applicable ❑
Name of License Holder: D t
Qv f k ' O — bl [� q t �l ` w
5 1 G i n . C ce.� nq Q-',8 i 1 G • 0 tae ( License Number i t l 13t it '3
Address
Expiration Date
Qoj&CJ 4 Y12 — O i 3
Sign Telephone
< >. 1 ifs filta4i 9r : W r i g -- ` g , -,• ,, Not
Applicable ❑
P t - Lc._, matzo Du CV5 / e_ 1 422i q
Company Name Registration Number
c M a't f) ( -x-- . C-1 c e-e n MG 0 V b t ) a � f 3
Address Expiratio Date
0 Q C Cdr Telephone 7 /
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, 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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
New House 0 Addition ❑ ReplacementJdows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [CI Siding [0] Other [D]
Brief A
Description of Prol ,
Work: 11 sKt ` n e? 1 e Rd k�u n(, 1
` ) � 1� (l V s k \ l (b ooc , �,A. t � sa -r f9 (gyp€ n19 .
Alteration of existing bedroom Yes .7 No Adhing new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes v No
Plans Attached Roll - Sheet N 0 ,s c-v ra Ch Gn ' • L( - U q Id e • 21
wE' f` • ,rr I,„5 , : i.,, 91" •ritj jj 6 ' ► , -,,,v B ( Vc :/ 5,. , i''`i ;y,Y, ;i®
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 (1Q i (,l CI? monk •
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 .
1. Septic Tank City Sewer Private well City water Supply
t; � S .pv +✓ ..'9.,,r'�C•1, -);f' < y..;. 1 Yl n
P
V,.Y c ./ . f'' ohs ' -' 1 .0t 9-0 f ' t 9 a �} `i� � �1�q; 1 � �,
_a .
I, Ear I IA gut c)`tQ c , as Owner of the subject
property r- P hereby authorize 6 Lt- U �' ` �-{ J ) I C.
to act on y be alf, in all matters relative to work authorized by this building permit appli ation.
a � —
Signature o Own Date
I,
Da V I D H (Tl 0 1 L A {J�C�
LL a) l�C `N c. , as Owner /Authorized
Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
TDQ.■1 CA ) +-- 1 "
Print Name
`
A. [ q )1 1 ?----
Signature of Owner /Agent 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
Lot Size 1 1 1 1 1 1
Frontage 1 1 1 1 1 1
Setbacks Front 1 1 1 1 1 1
Side L:1 1 R:1 1 L:1 1 R:I 1 1 1 1 1
Rear 1 1 1 1 1 1
Building Height 1 ( 1 1 1 1
Bldg. Square Footage 1 1 1 1 1 1 1 1 1 1
Open Space Footage
(Lot area minus bldg & paved 1 1 1 1 1 1 1 1 1 I
parking)
# of Parking Spaces 1 1 1 1 1 1
Fill: `
(volume & Location) I
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Cr YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO Co
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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212 Main Street
L- 24 2012
Room 100 5Y4l.giOlii.:041!:f.g..,!igs-..;„4--)ill.37..„...,:..:-,:.....„,„....,.:....,,,.:,.:....,.:T.,.,..:::,-:::,,,-,,
rthampton, MA 01060
' i brEpi. • -587-1240 Fax 413-587- 'fa.r..i:EMO.ii.LL-_-.:_-_,:.„.„.._-_,,,, .....• .. - .::
- _ OF BUILDING INSPE 1272
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No- - . MA 010e0 :
APPLICATION TO CON ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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2.1 Owner of Record:
EM r 1 M()unt Qr
Current Maillo?4dress:
Name (Print)
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Signature 1
2.2 Authorized Agent: -
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Name (Print) J
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Current Mailing Address:
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Telephone
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33 WATER ST BP- 2013 -0336
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 064 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 -0336
Project # JS- 2013- 000536
Est. Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft.): 41425.56 Owner: MEUNIER EARL W JR & CAROL D
Zoning: URB(100)/RR(0)/ Applicant: PELLA PRODUCTS, INC
AT: 33 WATER ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC
GREENFIELDMA01301 ISSUED ON:9/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PATIO 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 9/24/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner