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Pinuoe,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
�rp1 600 Washington Street
Boston, Mass. 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual) : DA Sullivan & Sons, Inc.
Address: 82 -84 North Street
City /State /Zip: Northampton, MA 01060 Phone #: 413- 584 -0310
Are you an employer? Check the appropriate box: Type of project (required):
1. Xl I am an employer with 4 0 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part time).* have hired the sub - contractors ❑Remodeling
7. 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
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 perm MGL
insurance required] t c. 152, § 1(4), and we have no 12. N Roof repairs
employees. [no workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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: AIM Mutual Insurance
Policy # or Self -ins. Lic. #: MCC 2 0 0 0 0 9 3012 012 Expiration Date: 7 / 1 / 2 013
Job Site Address: 82 -84 North Street City /State /Zip: No rthampton, MA 01060
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the ains and penalties of perjury that the information provided above is true and correct.
Signature: / Date:
Print Name: Mark Sullivan Phone #: 413 - 584 - 0310
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 Heath 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 : tiAA)( G. Sul.l.lyrd cs • c).3 66
License Number
S3 R'4" NakyrrfA 1/q Lobo a .17 • .zD/ 3
Addres Expiration Date
Signature ` a�
y /3 lip ca"
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 building permit.
Signed Affidavit Attached Yes d No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess 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 he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site 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 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts 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 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) v" Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [❑] Other [0]
Brief Description of Proposed
Work: REIWOY4fPA( OF K1rG#£N / D/M/4 /MI S
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet SEE 411011 -1)
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, DoA1/1L SULLI , as Owner of the subject
property
hereby authorize 0.A. S uw / ? S OAI‘ INc.
to act on my behalf, in all matters relati to work authorized by this building permit application.
j
Signature of Owner Date /•3/. /
I, D.A. SJLIAMAl s SOnfS 14c. , as Owner /Authorized
Agent hereby declare that the statennents 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.
14A Solo S. A/
Print Name a
Signature of Owner/ t Date /• 3/./3
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
Frontage
Setbacks Front
Side L: R: L: R:
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 /Finding ever been issued for /on the site?
NO V DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page, and /or Document #
Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES l
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO it
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO g
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
`
212 Main Street Sewer /Septic Availability
r ` — _ .. Room 100 Water/Well Availability
f N rthampton, MA 01060 Two Sets of Structural Plans
FE6 ~ . n ' 41 - 587 -1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
-- _ - PPLIDAARTOqiGON RUCT, ALTER, REPAIR - ENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
SL 6LicK6sRRy IM£ Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
DsilliLis Suu.wj / 31, ALA i(y 4
Name (Print) Current Mailing Address:
o - j w" ` `1 (1!`---) Telephone
Signature
2.2 Authorized Agent:
OA SVLtwyN i Soft, )Nc 8A - By i4h r, Sr
Name (Pint), Current Mailing Address:
,,b�A /�ynL, ( S8 y 0 3to
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee �` / /000
3 o bob
2. Electrical (b) Estimated Total Cost of
l S .2oo Construction from (6) .?3`d• stv 3q,700
3. Plumbing Building Permit Fee
9, Soo $ 232. ao
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) X 39 70o Check Number /Si 4/ eit ,- � c? )
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0742
APPLICANT /CONTACT PERSON D A SULLIVAN & SONS INC
ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413) 584 -0310
PROPERTY LOCATION 86 BLACKBERRY LN
MAP 18C PARCEL 127 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out J Q ) i // old 2, as
Fee Paid / /
Typeof Construction: RENOVATE KITCHEN/DINING RM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 53667
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
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
Signature of Bui ng • fficial 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.
86 BLACKBERRY LN BP- 2013 -0742
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 127 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 -0742
Project # JS- 2013- 001269
Est. Cost: $39700.00
Fee: $238.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: D A SULLIVAN & SONS INC 53667
Lot Size(sq. ft.): 19384.20 Owner: SULLIVAN DONALD A
Zoning: URB(100)/ Applicant: D A SULLIVAN & SONS INC
AT: 86 BLACKBERRY LN
Applicant Address: Phone: Insurance:
82 NORTH ST (413) 584 -0310 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:2/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN /DINING RM
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 2/7/2013 0:00:00 $238.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner