23C-055 (3) o u M al ass Ac a Accidents
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Office of investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
s.t.. wwW.mass.govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name austne rgantzationiinchvidualt:
HOWARD LE DERMAN (OWNLR) - (I Or perm It BP 3
(vi/O
Address: 82 WILLOW STREET
Citv/State/Zi • : FLORENCE, MA 01062 Phone #: 413-587-3145 (H) or 413-221-8954(C)
Are you an employer? Check the appropriate box: Type of project (required):
1. r., ,, i 1 am a employer with 4. i;;;:j 1 am a general contractor and 1
- ;
_
employ oes (full and/or part-time) 6. New construction
.* have hired the sub-contractors - ,...
2. Li 1 am a sole proprietor or partner- limed on the attachod sheet. 7. Ej Remodeling
ship and have no employees These sub-contractors have 8. ,, Demolition
working for me in any capacity. employees and have workers'
9. '' j Building addition
[No workers' comp, insurance cotrip_ insurance.:
10. Tv jElctirical repairs or additions:
required.] 5. :_ We arc a corporation and its
3. L.,' 1 am a homeowner doing all work officers have exercised their 11.Z Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.E Roof repair%
insurance required.)' C. 152. §1(4). mid WC have no
13,E o WINDOWS, SIDING
employees. [No workers'
comp. insurance required.)
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*Any applicant that cheeks box 11 roust also fill out the section below showing thew workers' compensation policy information.
/ Homeowners who saihnut this affidavit indicating they air doing all work and then hue outside conusctors must submit a new affidavit indicating such.
:Contractors that check du* box must attached an addittonal sheet showing the name of the sub-contractors and state whether or not those entities have
employees, lithe sub-contractors have employers. they must provide their workers comp. policy number.
I am an employer dun is providing workers' compensation insurance for my employees. Below is the poky 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 S1,500.00 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 certify ander e palms and penalties of perjury that the information provided above is true and correct.
Signature: a L,----- Date 10/10/2012
ph #: 413-587-3145 (H)
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Official use only. Do not write in this area, to be completed by city or town official
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City or Town: Permit/' Lkense #
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Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
1 , 6. Other ______
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Contact Person: Phone #:
, , .
... City of Northampton Building Department
Re: Howard Lederman Residence (82 Willow Street, Florence MA)
Permit #: BP- 2013 -0345
Project #: 1S- 2013 -000279
Amendment to Building Plan (2012 -Oct 24):
Examination of the 2 -Story structure has revealed that there is an inadequate foundation wall on the
South exposure (front of house) existing structure. Therefore, revisions to the building plan will now
incorporate the addition of (4) Piers, poured with Bigfoot Footing and Sonotube forms. These will be
placed to allow support of a beam adjacent to the existing substandard foundation to support the new
wall and roof loads. In addition, since we are pouring concrete in that vicinity of the overall plan, we will
also pour the piers for the front porch in front of the 2 -story section, which was originally scheduled as a
later task.
Additional examination of the existing second floor has revealed the use of inadequate floor joist
materials. This will be remedied by placing (2) engineered beams and sistering current 2x8 floor joists as
needed. The first floor's floor joists do not run in the same direction as the 2 floor joists. Due to the
specified placement of load bearing beams, (3) LVLs, nailed together will provide additional support to
the existing first floor joists.
All advisement, load calculations, and engineered beam specifications are being performed by rkMILES .
Howard Lederman
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Worker's Compensation Insurance Affadavit (Attachment)
List of Sub - Contractors Hired for BP- 2013 -0345
Job Site Address: 82 Willow Street, Florence, MA 01062 (Howard Lederman Residence)
1. Wailes Construction Company
David Wailes, Owner, with 2 Employees
HIC# 173418 Expiration 10/3/2014
Insured by: Liberty Mutual
Policy #: Coverage ID #1013935
Expiration Date: 10/4/2013