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42-040 The Commonwealth of illassachusetts ,�, Department of Industrial Accidents tr f - 1 I � ;" Office of Investigations • 1 W —1,..... 600 Washington Street Boston, MA 02111 '�` ,'� www.n ass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Zd -b( p ( n ( o . LL c Address: /' i� 1 t e E �,C�.�l' cs Se !- 4 City /State /Zip . SW\* , ' la V ( " !Phone #: ha ) 529 • 0 ?..S) C3 Are you an employer? Check the • ppropriate box :. Type of project (required): 1. y I am a employer with 4 • ❑ I am a general contractor and I t employees (full andior part - tune). have hired the sub - contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- 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 11. ❑ Plumbing repairs or additions myself. No workers' comp. right of exemption per MGL 12.E Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13 `Other 1(1S11�k\ - - I comp. insurance required.] Any applicant that checks box 41 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: jia 6S ( ` ` ? P 1nSfaca 0 CL / 3 i c s 1 ) p ICYC t`1 pp t ' I) (l Ci Policy # or Self- ins # `f -C.p _ fS ��' — 0 '— _ 1 J � Expiration Date: ) )2... LOf 1 � i X ob Site Address: 1/4,1.; ` �r�; l?ri� r . )1 .1 �� (,� City /State /Zip: �, P 11( ��� � Q\ 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 51,500.00 and /or one -year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 rtify un der the pains nd penalties of per' that the information provided above is true and correct. Signature: f i a Date: (� /2-57 Phone #: �7l . 5-a9 . 0,. 6 0 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) /0) c� ! ` 1 �1� � License Number Expiration Date Name of CSL- Holder List CSL Type (see below) SU� Cr (c/ 1 53 046 a44+ Stre6 i ietsttco,?�n Address / Type Description , , ; L i U Unrestricted (up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling ig ature — M Masonry Only _ 413) 5 21 . CO °° RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) Oozy 14 e Ye4 /hrnn a,., ii-C_, /6a ,)'7 /0 HIC Com.any Name or HIC Registrant Name ' Registration Number fi i `fa a ' tali 1 4///3 AddA )-C;A---.3 6/6) 62/kJ( Sd 9 9. v app, ration Date Signature e — 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 OWrER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, A3 .c ikN IL , as Owner of the subject property hereby authorize C ) )--)04 ,---4.. C r { rr°.h r-(& _ to act on my behalf, in all matters relative to work authorized by this building permit application. R- C '\ v.i 1 i. . k () G 4 i cY" Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 'I I, iNkr\ (\Q. 1---60.\-- ---6 C Z , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print N Signature of Owner or uthorizedt Date (Sinned under the •ains and .enal ' s of ser ) 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 "JK L c) r r6 ' ECEIVED OCT 1 1 2012 VEPt OF BUILDING INS-.E TIONS NORTHAMPTO ; M . • "..!tz.i The Commonwealth of Massachusetts r r Board of Building Regulations and Standards FOR : le Massachusetts State Building Code, 780 CMR MUNICIPALITY E USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One or Two - Family Dwelling This Section, For Official Use Only Building Permit Number: Date Applied: Building . , • a Qffic�al (Pnnt2vauie) Signature Date SECTION 1, SJTI_O12MATION 1.1 Property Address: , Assessors Map & Parcel Numbers '701 we' ht, ors a-61 1.la Is this an accepted eet? ye no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zon District 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 ❑ Private ❑ Check if yes© Municipal ❑ On site disposal system ❑ 21 wner of Reco Name (Print) City, State, ZIP -)() 1 We _- A'0N 441 iii 3- S -5)93 No. and Street Telephone RrnaiI Address ., SECTION 3 DESC IUL OF..P QP•QSD' ORK (chec all a- ._ _.,. L . New Construction ❑ Existing Building ❑ Owner Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ 9 Specifyfl tYi•.���A JVJr `•' • Brief Description of Proposed word: „)' f.., ` tcl • 2� t' <. ; V- t•A.J tt'.,4\\ _'- (• NI) A ate 1 •, 'N/ i SECIION 4 ESTIMATED CONSTRUCTION COSTS Estimated Costs Item O'fficiaj Use Only (Labor and Materials) .. . 1. Building $ 1 Building Permit Fee :. $ indicate how fee is deter ined: O Standard Gity/T*n Application Fee 2. Electrical $ 'M 3 0 Total Prolcct Cost (Item ) x Multiplier x: 3. Plumbing $ 2. Other Fees: `$ n,.. Mechanical (IxVP.C) $ r List: — — 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. ti Check Arnow-46( Cash Amount:_ 6. Total Project Cost: i $ L. © Paid in uIl ❑ Outstanding Balance Due: � '..1i1 _ • File # BP- 2013 -0427 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 180 PLEASANT ST EASTHAMPTON (413) 320 -7611 PROPERTY LOCATION 701 WESTHAMPTON RD MAP 42 PARCEL 040 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filed out �y Fee Paid 7/� �v Typeof Construction: INSULATE ATTIC & AIR SEAL 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: i /'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 la v� � D —1x- Signature of Buildi Of icial 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. 701 WESTHAMPTON RD BP- 2013 -0427 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42 - 040 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 -0427 Project # JS- 2013- 000673 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 37548.72 Owner: ANTIL ROBERT E & CLAUDIA VIELE Zoning: Applicant: MARK LANTZ AT: 701 WESTHAMPTON RD Applicant Address: Phone: Insurance: 180 PLEASANT ST (413) 320 -7611 WC EASTHAMPTONMA01027 ISSUED ON:10/12/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC & AIR SEAL 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 10/12/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner