32A-164 The Commonwealth of Massachusetts
.�- Department of Industrial Accidents
. -
" Office of Investigations
600 Washington Street b
' B MA 02111
' '_�` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 4) ' Pc �� 6 (4 1 Rv' (1 i I
Address: /D ¥/ .4(...-/L .7 4rr' F
City /State /Zip: (% - L /1 f4 0 OM ,,( Phone #: W3 — 567 -3o Sc
Are an employer? Check the a propritte box: Type of project (required):
1. am a employer wiith t f 4. El I am a general contractor and I
( 6. 0 New construction
employees (full and/or part- time).* have hired the sub- contractors
I listed on the attached sheet. 7. [Kemodeling
2. ❑ I am a sole proprietor or partner-
These sub- contractors have
ship and have no employees 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. E 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 12.0 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 h 1-e r , <2( Z-11
Policy # or Self -ins. Lic. #: PpOC e31 y6 Expiration Date: 8 /p/ /P,/ 3
Job Site Address: ( a > w P 4 ,, 4`.0 I City /State/Zip: (! /'!y /
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 certify and •r thep' ns and penalties ofperjury that the information provided above is true and correct
Si to ature: L / Date: ?i - Z
Phone #: (113 S $7 31Q5 & .
1l Official use only. Do net-write-in-this-area,- to be commuted by city or town official II
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION Si, COh1STL UCTIOWS.ERt ICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License [ ense Holder : d ON � • I frN p Y v CS7 9‘
License Number
/ 0 4-f ;V. ELF,, 3 /�i / °'K
Address Expiration ate
Signature Telephone
( q . 17 3 a5 0
• - - Not Applicable ❑
icw4-? 9 7 s- i -/ j� E ( /� c /5•//t, -
Comp ny Name, Registration Number
Address - Expiration a te
Aiu 4/4 of gto Telephone ? -75g 7-.1
SEC7IQtl r O K 01111PE 130 , Ill t l N AF t iD .41440r
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 buildi permit.
Signed Affidavit Attached Yes l No ❑
The current exemption for "; , ..eowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to • gage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth ' • ition Section 108.3.5.1.
Definition of Homeowner: Person (s ho 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 fame , dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more an one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Buildi. ; Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed unde the building permit
As acting Construction Supervisor you .presen = the job site wil . ` from time to time, during and upon
completion of the work for which this p i, is t is e.
Also be advised that with reference to C ter 52 ' Cot sat .n and Chapter 153
p �o ers p ) p (Liability of Employers to
Employees for injuries not resulting in r ea ) the Mass • .usetts eneral Laws Annotated, You may be liable for person(s)
you hire to perform work for you under 's p .'t.
The undersigned "homeowner" certifies d assumes responsibi .% for compliance with the State Building Code, City of
_
Northampton Ordinances, State and Local Zoning Laws and State .. Massachusetts General Laws Annotated.
Homeowner Signature —
•
9
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 L____ 1 1 11 _ / 1
Frontage ----- -- 1 -- -,.._. I ! _
Setbacks Front L_^.. , i
Side L :1 R:( L:L _... i R: .... _._. ,
Rear 1 1 1....___1 I.
Building Height = _ € ..--....,_
Bldg. Square Footage - - % 1 ;--11
Open Space Footage %
r� � �� ���
(Lot area minus bldg & paved n A 1 .
parking)
# of Parking Spaces i
lik
.. % 1
A 1
Fill: ; ,.. _ ..
S
(volume & Location) i i
A. Has a Special Permit /Variance /Finding ever .een issu= � fo , /on the site?
NO 0 DONT KNOW 0 i/ YES 0
IF YES, date issued:I 1 1
IF YES: Was the permit recorded at th egistry of Deeds?
NO 0 DONT KNOW ® YES 0
IF YES: enter Book Page F and /or Document #
4
B. Does the site contain a brook,,body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit beer, need to be obtained from the Conservation Commission?
Needs to be obtained/ 0 Obtained ,Date Issued:
C. Do any signs exist o /the property? YES 0 NO
IF YES, describf�size, type and location: ? � � � ____
D. Are there any roposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, scribe size, type and location:
E. Will the nstruction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that wi disturb over 1 acre? YES ® NO 0
IF Y , then a Northampton Storm Water Management Permit from the DPW is required.
I ..' -,,,,, '.,'',,?: ' / •••i- 4 17^- 1-2 :: ;•••
; 41. 4.$.• ^ ' ' 1.?IsAV....A4,1,1 .LL .,- 1 .....:', , ° .'" 1.,,,,,,....0 -.4 ,„,' ,, '' ,* ,
'' ' '; '' 'Z' ''.:" ng;;Af",ri. ?"°'•••*-'' 4 .t,,,,, .4, , I• ' exa7 , A 4 SI".$, 7 ",- 7 .!N. , ;;4• - .,;.
'.- .,g ' ,,'., : -. , :,,,. - ,44':::er -.,,!: , ',...: ."1 ,-ick ".,,,...- ;y , , , , ^i •
New House E3 Addition 0 Replacement Windows Alteration(s) a Roofing ED
Or Doors 0
Accessory Bldg. E3 Demolition Er New Signs 0:11 Decks DM / Siding OM) Other [C]
Brief Descriptio' lolf roposed / 115-1411 c '` . ' / 4 '4 4 ' 4 7' -. - - -- -- - ' 7
wok ./ i I a
a•-i ( 146.0 5 € - / r..KI 'C ec 1 " dx-ckra, v."- , 71 v i e ' A
14,, er.,1
../- 0.0,5(
Alteration of existing bedroom Yes No Adding new bedroom 1 / 4 r Yes .,- No
Attached Narrative Renovating unfinished basement 'iv Yes No
Plans Attached Roll - Sheet
,-- -
---
a. Use of building : One Family T 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
1. ,----
,,..
e. Number of stories? „----
f. Method of heating? _-- Fi aces or Woodstoves , Number of each
g. Energy Conservation Compliance. ..7 fr s 4 check Energy Compliance fprm attached?
...--"-----
h. Type of construction
i. Is construction within 100 ft. of<vetlands? Yes No. Is construction within 100 yr. floodplain Yes No
7 7
j. Depth of basement ollar floor below finished grade
k. Will building 9711form to the Budding and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
__, _____„_" • ^"
secncoN ra .? .,„„„,- , f .,,= ' 4:- ' 4 .,:, . 4 4 - ,.,* *:,,FIrtie,pk
OWNERSAGENTOR-. ''''' "* "r—'-.7 7 :1 g 0 ' - ' ' e‘ ' ',...,^:, ro .:..ol 0 1 ;e, - Mkt*"
. %.'
1, ---. "r( 11 1 'fel .'N S , as Owner of the subject
property
hereby authorize 57),- It v.., /..-44.041
to a on my be ilf, in all ma - relative to work auth by this building perrnit application.
Signature of Owner Date
I, t ; 'Ck re A 4e i IA_ as Owner/Authorized
Agent hereby declare that i e statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pai and penalties of perjury.
— 4 t 611- Urr--IN S4
Pril:rne
Signature of Ovmer/Atient Date
RECEIV
DEC - 5
OF BUILDING INSPECTIONS
GR AM PTON, MA 0106 Cit of Northampton
Building De p a rtment
212 Ma Stree
Roo 100
Nort hampton, MA 01060
phone 41 -58 -1240 Fax 413 -587 -1272
APPLICATION TO CON5 ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLI
SECTION I , ,, ∎ � ;'.
�, a _ „_. -,_ .,c_. ;' &:eta' � s, k ,.
1,1 Ptr+ t frty Address: ,
/7a K/ f e �� aTN f a
2.1 gwnergf R.ecQtd: (! / / I f /73V3
; x - ° ! id i s t I / t 3 q �� C J Yt (' ! 1{ v�nl 14S,r 7j4
Name (Pant) Current Mailing Address
/ -7777
,,42 '' .- `" Telephone
si
2.2 Authorized Affet:
(
Name (Print) Current Mail n Address:
/ , DY
Signature i Tele
ES tlmated Cost p allars) to Heart b :4- 4: � as `� use th►hy
tl licasrt
IgiNINIMIN * 1. Buitding � � Q G � � � < �, r« �, , � � r A "
2. Electrica ,,,, ,-. -- i7. , . • �
- gyp ,
3. Plumbing } F
4. Mechanical (HVAC) r 0
5. Fir Protection r c
Total= (1 + +3 +4 + 5) 6 CO
Bu tIding:; Pe rmit Number ` - '
'yX . y 4 t. 1
Plature: Rx, v 4 ... ° d� „ ' dY f s . , 7 , s.' �
`4 ti 7 3 µ ' ,. U r die '' " Y`et a4. � ~}R r ,. '"?
File # BP- 2013 -0623
APPLICANT /CONTACT PERSON JOHN LANDRY
ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413) 204 -9880
PROPERTY LOCATION 61 HAWLEY ST
MAP 32A PARCEL 164 001 ZONE URC(99)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out `l �g
Fee Paid fin
Typeof Construction: CONSTRUCT BASEMENT BATHROOM/LAUNDRY,INCLUDING EGRESS WINDOW,
2ND FLOOR BATHROOM & REMOVE CHIMNEY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 093450
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
r 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
De p glition Delay
/
i ���
Si na re 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.
61 HAWLEY ST BP- 2013 -0623
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 164 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0623
Project # JS- 2013 - 001011
Est. Cost: $100000.00
Fee: $600.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN LANDRY 093450
Lot Size(sq. ft.): 9016.92 Owner: ORENSTEIN LISA
Zoning: URC(99)/ Applicant: JOHN LANDRY
AT: 61 HAWLEY ST
Applicant Address: Phone: Insurance:
104 NORTH ELM ST (413) 204 -9880 WC
N O RTHAM PTO N MAO 1060 ISSUED ON:12/11/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT BASEMENT
BATHROOM /LAUNDRY,INCLUDING EGRESS WINDOW, 2ND FLOOR BATHROOM & REMOVE
CHIMNEY
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 12/11/2012 0:00:00 $600.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner