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31B-013 • i. The Commonwealth of Massachusetts Department of Industrial Accidents 1 ". Office of Investigations ` °` ' 600 Washington Street y z _ Boston, MA 02111 www mass gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): - q 1 • F \ r Address: /G e( etleh<IL 67 w. 4rep F City /State /Zip: ' , at .444 ,., ie / ' Phone #: V/3 -- 5S7 —34.54 Are u an employer? Check the a s propriate box: Type of project (required): I. L"J 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 e construction 2.0 I am a sole proprietor or partner - ship and have no employees listed on the attached sheet. 7. emodeling e - These sub- contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. [] Building addition [No workers' comp. insurance comp. insurance. re uired. 5. Q We are a corporation and its 10.0 Electrical repairs or additions q officers their 11. have exercised thei repairs or additions 3. ❑ I am a homeowner doing all work ❑ Plumbing eP myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] I *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: 1 hyt°r �;,�, Lid . Policy # or Self -ins. Lic. #: '7‘)0(" e31 W Expiration Date: g/0//,41/ 3 Job Site Address: 5 rt rPr< . Pc - 4t ,AA City/State/Zip: 6J060 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. - 7 do hereby certify and r the p ns and penalties of perjury that the information provided above is true and correct. Signature: Date: //'16 /Z Phone #: & /3 5 07 31Q 4 b2 . II -- O Official use only. D not - in-this-area,-to be completed by city or town official II City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Iieaith 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 : 75-0-11A- r?( C 93 iSt License Number /a q / --H-t_ /w. 5-4- 3 (/a, //D, V Address Expiration Da e f3 - ddy -gam& Signature Telephone 9. Registered FIortie:lgprovementCon dbr:::.`.,. Not Applicable ❑ Z (i- P 5 w0. X„, ( (,r .• /s //o 3 Company Name Registration Number /4 / iz.� S 51-7-* 1 --- s //7 / y Address Expiratio Date be- /1 / 011/4 A em 6 Telephone 1 //3. - ;c7 .- --- -C O 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 permit. Signed Affidavit Attached Yes No ❑ 11. Home O n+e= Exempt ✓ / The current exemption for "homeowners" was extended to include Owner- occupied.I■wellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not posse: 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 h she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detaches tructures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -v: • r period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form . - ceptable to the Building Official, that he /she shall be responsible for all such work performed under the building p • mit. As acting Construction Supervisor your presence on the job s' e 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 (Work: s' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the M..sachusetts 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 assum responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zonin • 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. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief Description of Proposed � Work: ,ke /ac 3 l✓« r J` Q-- too Alteration of existing bedroom Yes ^No Adding new bedroom Yes �No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. if .New house and or addition b existinalioPsina. complete the fOlIo inq: 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. Dimensio e. Number of stories? f. Method of heating? r Fireplaces or W•odstoves Number of each g. Energy Conservation Compliance. Masscheck nergy Co '. ante form attached? h. Type of construction i. Is construction within 100 ft. of wetla ds? Yes No. s constructi,n with 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 wel City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J &L& At-1 , as Owner of the subject property 7 hereby authorize JCS k k / rx vu y to act on my be- -lf, in all matters relative o work aurized by this building permit application. Signature of Ow f r Date ( )CP k'_ ` Ltn&c J r, , as Owner /Authorized Agent hereby declare that the stateme is 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. — 3 7 0 Print Name l iii � , . /C Signature of Owned' g- nt Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning n This column to be fille my Building Departmen Lot Size __ .._w. .. _, ' Frontage Setbacks Front Side L: ° -- dmn. R.l.,._. L Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Findin• ever been issued for /on the site? NO Q DONT KNOW 110 YES 0 IF YES, date issued:, IF YES: Was the permit recorded . the Registry of Deeds? NO 0 DONT OW 0 YES 0 IF YES: enter Book } Page, and /or Document # } B. Does the site contain a broo , body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit be -n or need to be obtained from the Conservation Commission? Needs to be obtaine Obtained , Date Issued C. Do any signs exist •n the property? YES 0 NO 0 IF YES, descr''e size, type and location D. Are there a' y proposed changes to or additions of signs intended for the property ? YES Q NO 0 IF YES describe size, type and location: E. Will th construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that ill disturb over 1 acre? YES Q NO 0 IF ES, then a Northampton Storm Water Management Permit from the DPW is required. �Ps1Sz Cllr of Northampton °reFs 9wl �fY Building Department' '� 16 2012 2 12 Main Street a � QED � Room 100 - r.. � �,,.. ; "N�lort ampton, MA 01060 » « � �� rJ' F; phone 413- 587 -1240 Fax 413 - 587 -1272 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 ct +. 5 ©t Unit. Zone Qverlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: far. ld; - rv. ct ec . f $$rt'e Name (Print) j Current Mailing AddressN�` it/� /060 Signatur J +4 17/1 � Telephone 2.2 Authorized Agent: / I / �0L L 8c /W 7 Name (Print) Current Mailing Address: i 3 Signature / Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building v2066 (a) Building Permit Fee 2. Electrical (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) ;addD . 00 Check Number 0 " ° This Section For Official Use Only Permit Number: Date Building Issued: Signature: Building ! Commissioner /Inspector of Buildings Date 5 CRESCENT ST BP- 2013 -0565 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP-2013-0565 Project # JS- 2013 - 000913 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 8668.44 Owner: MARTYN TIMOTHY 0 & JANET L Zoning: URC(100)/ Applicant: JOHN LANDRY AT: 5 CRESCENT ST Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMAO1060 ISSUED ON:11/19/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE 3 SQUARES OF ROOF 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 11/19/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner