16D-008 (2) The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
A , ., Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114 -2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information ��`' Please Print Legibly
): �r�
Name ( Business /Organization/Individual 4,0 �Q�,� L J•�.�G�( �/V f 1 AdC —
Address: Q t cP t Qc," k cfT
City /State /ZipL 4 r 0 0 / Phone #: 5 — ' c
Are yo an employer? Check th • appropriate box: Type of project (required):
1. I am a er with employer 4. n I am a general contractor and I
p y / * have hired the sub contractors 6. El New construction
employees (full and/or part- time).
2. 11] I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling
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. El 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' 13.111 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
± 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 an: an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. Co Insurance Company Name: • ` L 2-/ a . o
Policy # or Self-ins. Lic. #: GQM ?I P () 6 O / 0) Expiration Date: l3
Job Site Address: l P 6 /V • 1t t 44 AY S' City /State /Zip: /tl0 i y 4/4- 0/060
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 S250.00 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 certi der the pai : and penalties of perjury that the information provided above is true and correct.
Signature: = Date: /1 2eh/
Phone #: 0 S ` �9 0Pe
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 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : DOA, 4 , . 1 ea a CI C S .... "' 7 7/
/ / License Nu ber
Addre s Expira on D
((l y/a — fe3
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
�era Co - 04 .i -. /05
Compan ame Registration Number
01A 8' 1 ■ S<r, 8// /�o/y
Address //�f Expir ion D to
e'er+, kt*. 0/04 Telephone 5//3-5
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 ❑ No ❑
11. - Home Owner Exemption iv /!¢—
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 fancily 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, dining 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 n Addition ❑ Replacement Windows Alteration(s) Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Ip Siding [0] Other [0]
Brief Description of Proposed
Work: ge ry o v Bo* R 4-ck. .4 ►v D Secomo ,PUL A e D 9.00v%-r
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 to existing housing, complete the following: Ni
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
p4 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, LA SePAII � - --77- i ThRF , as Owner of the subject
property
hereby authorize 1: Z, - rt4Eg No PQ &S. /ea 9. Am CO,J 'r co Ci -- NC
to act on my beh If, in all matters relative to`Work by this building permit application.
(�_ /, 2//3/20/ 3
Signature of Ow r Date
I, DOA, 4 Vi 3 • I pa_ 4 /U O fu` -"' C. , , as Owner/ thoriz
en hereby declare that the statemert 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 n� perjury. ,l
Print a 4.Lb �. I C� V
�l i �/ 44 /,? 10/3
Signature of pwner�.}'. �'" a Date
is
.)res -I-t^' S No eL i' e-
Section 4. ZONING All Information Muct Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be tilled 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 Q DON'T KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES (3 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (,) NO t
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, 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 Northamp S tatus of Permit:
201 Building Department Curb Cut/Driveway Permit
` 212 Main Street SewerlSeptic Availability
t tioNS Room 100 Water/Well Availability
p.S p �
UT U PON 4;No Northampton, MA 01060 Two Sets of Structural Plans
oE� NOptHP`nP phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/ e9g N . /14v41i 4 37 Map Lot Unit
ri- ...,..4BN Ik Zone Overlay District
__
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
L4 e HMI) A T I Ffl1- /94 N MA-/P1 T j ,RCJ c c- Oft 2--
Name (Print) . Current Mailing Address:
ail3 - YTS - 04'37
3
_/ 1/ A ,_ i - Telephone
Signatur =" /
2.2 Authorized Agent: ok, )4, Tr i c..--11 /P . 11". DoN4L13 S. 1 A., O /�" 140(J- 0#0/0
Name (Print) Current Mailing Addres:
Lett" yr — syf-
Signat 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
3 y oe b. —
2. Electrical (b) Estimated Total Cost of
8 Gm 0. " Construction from (6)
i
3. Plumbing Building Permit Fee
te e
Ooa.
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 50,000 . '-'— Check Number 44r /5 _ c3��
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
k
File # BP- 2013 -0759
APPLICANT /CONTACT PERSON TEAGNO CONSTRUCTION INC
ADDRESS/PHONE 228 TRIANGLE ST AMHERST (413) 549 -0803
PROPERTY LOCATION 186 NORTH MAIN ST
MAP 16D PARCEL 008 001 ZONE URB(100) /WP(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / d 3 $36
Fee Paid
Tvpeof Construction: RENOVATE KITCHEN & 2ND FLR BEDROOM �
New Construction 2 d" t
Non Structural interior renovations giji
Addition to Existing
Accessory Structure
Building Plans Included: i/e
Owner/ Statement or License 034716
3 sets of Plans / Plot Plan
THE FOLLO ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved 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
A i
4s.: 'tip.: elay
5 /.5 /
Si_ ature of : uil. mg Officia
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.
186 NORTH MAIN ST BP- 2013 -0759
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16D - 008 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 -0759
Project # JS- 2013- 001306
Est. Cost: $50000.00
Fee: $300.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TEAGNO CONSTRUCTION INC 034716
Lot Size(sq. ft.): 7579.44 Owner: PETTIFORD LASHONDA & SARA P ROWAN
Zoning: URB(100) /WP(0)/ Applicant: TEAGNO CONSTRUCTION INC
AT: 186 NORTH MAIN ST
Applicant Address: Phone: Insurance:
228 TRIANGLE ST (413) 549 -0803 Workers Compensation
AM H E RSTMA01002 ISSUED ON:2/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN & 2ND FLR BEDROOM
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 2/19/2013 0:00:00 $300.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner