Loading...
49-048 The Commonwealth of Massachusetts Print Form _; Department of Industrial Accidents - Office of Investigations 1 1 Congress Street, Suite 100 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): 1. ((�� l' � Caevon � tA I J ee A C, , Address: / 5o C,c,1f Rocj CJ City /State /Zip: &'ke? rowv. 0 l oo7 Phone #: 913- If 7- E;o3-/ Are you an employer? Check the appropriate box: Type of project (required): 1. [ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time). * have hired the sub - contractors 6. ❑ 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 aci employees and have workers' g any capacity. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ 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. ❑ Roof repairs ' (� insurance required.] t c. 152, §1(4), and we have no employees. [No workers' `1 132 c t5ot� �tn; I(X 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. 1 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 certil under the /ins and penalties of perjury that the information provided above is true and correct. • Si. nature: / Date ' - 1 , - .. Phone #: 1/13- to.-7- R031 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 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : / 1 cc' { )e eCoy1 80 (?-79 I 1 License Number 7 3 6 a Rcd Mi4 0/007 7 - ?8 -13 Address Expiration Date yl� -g od y Signature Telephone 9. Reuistered Home Improvement Contractor: Not Applicable ❑ Dm' rCzt " 6" ) 7 9 Company Na Registration Number 7 (94 Q &I 6wvv P4- otoo-j 9 12 Address y Expiration Date /�� Telephone -0039 SECTION 10- 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 buildin ermit. Signed Affidavit Attached Yes O No ❑ 11. - Home i ner Exemption The current exemption for "home.. ers" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to enga:,:.. individual for hire who does not possess a 1 - • • -, provided that the owner acts as su s ervisor. CMR 780 Sixth Edition ' = tion 108.3.5.1. Definition of Homeowner: Person (s) who own a . cel of land o s ich he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, att. :. or detached structures accessory to such use and/ or farm structures. A person who constructs more than o • • lome in -. o -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Built" _ Official, on a form ac , . ble to the Building Official, that he /she shall be res s onsible for all such work ' • rfo led under the buildin • I ermit. As acting Construction Su e • or your presence on the job site will be require. • om time to time, during and upon completion of the work f• hich this permit is issued. Also be advised th. th reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees fo • furies not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire . •erform work for you under this permit. The un• ersigned "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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. lEr Demolition ❑ New Signs [D] Decks [q Siding [D] Other . Brief Descrip � n of roposed fir/ -.' %1 Work: .' , 4 I , . ��■ arv, � CJ�� �C7 � Alteration of existing bedroom Yes No Adding new bedroom Yes ■ • Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing. complete the following: 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, c 9 1 h 1nNIU' , as Owner of the subject property hereby authorize TI \ f)eC Pcor to act on my behalf, in all relative to vifdrk authorized by this building permit application. q -1 a -1 Signature o Own r Date 1, / �/ lee @ Cod , as Owner /Authorized Agent hereby declai that the statemeirits and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under a pains and penalties of perjury. --- ri cc- n Print Name `� 1 Signature of e A nt 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 1q3 i IMO +i y3, y'f 0 Frontage 5b 5 Setbacks Front 40e ,Loo Side L: R: L: N7Q R: SO'r Rear 300 f Building Height 2q1 Bldg. Square Footage 3000 1.1g % —11593" ` 1.01. Open Space Footage % y (Lot area minus bldg & paved 1 ! 33 ' ° o irgerje parking) y 8.51 IR # of Parking Spaces a" Fill: iVl I P A l A 1T (volume & Location) _ / 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 0 DONT KNOW ef YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: er 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, ex tion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r— Department use only RECEIVED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit SEP I 20I2 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans ° �, NsPEc one 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 Property Address: This section to be completed by office 7 a.7 P a r k M i l l 004 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 54eVIAe * K mb c Dt,40,\ 7» f k H;11 M 4 Name Prin Current Mailin Address: 30 �f JA ( Telephone Signature 2.2 Authorized Agent: II r )3 erovl 730 (. t IRacer Belr '' c kown [ 01007 Name (P ) Current Mailing Address: 1 18-'1?-7- 03 `i Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building / f 7 O6 6 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 3 I:)0 d Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 50 t2 00 Check Number 6 03 / . 0 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0284 DA/L k APPLICANT /CONTACT PERSON TYLER BERGERON 4 ADDRESS/PHONE 7 SCHOOL ST GRANBY (413) 427 -8034 0 r PROPERTY LOCATION 727 PARK HILL RD a td `' ° °v!" MAP 49 PARCEL 048 001 ZONE 4�' N5 THIS SECTION FOR OFFICIAL USE ONLY: 46 PERMIT APPLICATION CHECKLIST Y ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out l r 4 2 ; a Fee Paid (y ✓J O< Typeof Construction: CONSTRUCT ; 42 DET GARAGE New Construction 'Z 3 t7 Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 080274 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required (see below) /( pp p q ( ) � I � PLANNING BOARD PERMIT REQUIRED UNDER: § I 00( ). 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 Demolition Delay 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. File # BP- 2013 -0284 e)4VA APPLICANT /CONTACT PERSON TYLER BERGERON ADDRESS/PHONE 7 SCHOOL ST GRANBY (413) 427 -8034 0 PO PROPERTY LOCATION 727 PARK HILL RD MAP 49 PARCEL 048 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid �1 5 �v Tvpeof Construction: CONSTRUCT 27 X 37 DET GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 080274 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: pproved 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 Demolition Delay Y(ZZ Signature of Building fficial Date g g 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. 727 PARK HILL RD BP- 2013 -0284 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 49 - 048 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: GARAGE BUILDING PERMIT Permit # BP- 2013 -0284 Project # JS- 2013- 000464 Est. Cost: $50000.00 Fee: $235.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TYLER BERGERON 080274 Lot Size(sq. ft.): 443440.80 Owner: DUVAL STEPHEN R & KIMBERLY L Zoning: Applicant: TYLER BERGERON AT: 727 PARK HILL RD Applicant Address: Phone: Insurance: 7 SCHOOL ST (413) 427 -8034 0 WC GRANBYMA01033 ISSUED ON:9/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 27 X 37 DET GARAGE 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 9/26/2012 0:00:00 $235.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner