29-514 The Commonwealth of Massachusetts
Department of Industrial Accidents
/
=911-166 .E Office of Investigations
Hbes 47, _ 600 Washington Street
°— °� Boston, MA 02111
s � °` �� www.mass.gov /dia
Mg -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): `f , l/ 6Vc:�,l./t 5v Z ✓ 7tuti
Address: O— 4 -L 64 16 w/ C44... 70 / 1-/ 4 o,:2,. 1
City /State /Zip: 6.'4.1 -10 -c.. I ic),,3 O 1 Phone. #: '7 ( �3 ?/ - O ?8 D
Are you an employer? Check th appropriate box: / '
4. I am a Type of project (required):
1. I am a employer with ❑ general contractor and I g
employees (full and/or part- time).* have hired the sub- contractors 6. [j] New construction
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. [I] Remodeling
ship and have no e loyees These sub - contractors have g. N'Denolition
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 10.0 Electrical repairs or additions
3. ❑ 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. [D Other
comp. insurance required.]
*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.
1 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: /V.aly - 4 / uS 1 ^-, Sv 4.,4 A.. , C.C-- C-0 Al P4, A- Al .
Policy # or Self-ins. Lic. #: i 0 10 1 13 qU Expiration Date: /(2//4/1
Job Site Address: <) 2 7 14a4 i14 6; ae Ge f i v / 2 C - - ■. C F 1 , i 4- City /State /Zip: r l o . ( z e -,., e e; - / / 0 0 6 . 14 .7 .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiation 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 certt ify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: �'�-'(� --- - G an C, ---�- Date: 0 3 k 1 //3
Phone #: 18 ( 3 q 3 . jti 3 9 .
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 #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �t Not Applicable 0
Name of License Holder 1'1 1 Cd 4 L -r, Ci f/i c " 0 ` Q 7 /
License Number
Ot,i✓ C66 ,4 1 - C /4 4.7 —' , A44 . �a�� Il /071 f
Address Expiration Date
� /�� 6/9
76/ . 9: r OY e •
Signature Telephone
IF/— 2 LI3 - 1 . 2 3
9. Realstered Horne Improvement Contractor; Not Applicable ❑
16y ,2 C
Company Name Registrati Number
V/ 6`fv4) 500 0 " i — � � 71 -
Address ) � � 3 73 -! 3 ? Expiration Date
c9 L- &16 4 7/' , M/1- • Telephone lel 9, O?8
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6O
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
The current exemption for "homeowner:' was extended to inchide Owner- occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hie wino does not possess a license, provided that the owner acts
as supervisor. CMR 180, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) wino 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 -veal period shall not be considered a homeowner.
Such 'homeowner" shall submit to the Building Official, on a foam acceptable to the Building Official, that he•'she shall be
responsible for an 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 penult.
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 Aunotatecd.
Homeowner Signature
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SECTION 5- DESCRIPTION OF PROPOSED WORK !check all applicable(
New House Addition Replacement Windows Alterations) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [ 1 Decks [ 1 Siding [ j Other ( ]
Brief Description of Proposed
Work: Op avC L16� ()l,'y44.4 C 1 4;5,4 444A-1i:0- ffeo- boto ge: 7,a ��. S Tv." 7G•Af
Alteration of existing bedroom Yes X No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. if New house and or addition to existlno housino, complete the fallovwlno:
a. Use of building : One Family Two Family y Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? .4/0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
1. Method of heating? 4'3 Fireplaces or Woodstoves /V .0 Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction DE Matt It
i. Is construction within 100 ft. of wetlands? Yes )c No. Is construction within 100 yr. fioodpiain 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, t3 1 j/42A reA Ivfc4t I(/ , as Owner of the subject
property
hereby authorize /`1 t (14/f6-/- -r f?u FO .
to act on my behalf, in all matters relative to work authorized by this building permit application.
05 /0( 3-
Si u caner Date
, as Owner /Authorized
Agent hereby declare that the statements 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.
Print Name
Signature of Owner /Agent Date
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Section 4. ZONING AJI I nformation Mi3 Be Completed. Permit Can Be Denied Cue 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 °o
Open Space Footage 0‘
(Lot area minus bldg & paved
parking)
4 of Parking Spaces
Fill:
(volume & Location)
A. Has a 40ecial Permit/ Variance/ Finding ever been issued for / on the site?
NO DCNT KNOW YES
IF YES date issued:
IF YES Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES enter Book Page and / or Document #
B. Does the site contain a brook, body of water or wetlands? 40 DCNT KNOW YES
IF YES has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES describe size. type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES
IF YES describe size. type and location:
E. Will the construction activity disturb (clearing, gra,,, �•• • , excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Ul•�
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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_
r tr of Northampton
:. folding Department
i MAR 1 20{3 212 Main Street
Room 1 do
. .. " : I t atnpton MA 01060
DEPT, OF BurIDiI.C, fN • 7 ..... _
nmRrMAM N MA ■1080 _5$7 Fax 413587 -1272
rAPPLICAI101I 70 CONSTRUCT. RUCT. ALTW, RI/PM& RENOVATE DR DEMOL1M4 A ONE CR TH° FAMILY Dt111EWNa
.l i t i • WM INFORMATION
1. a . Address; ? 1 K . �. " 9
r � •t �' i 1/4. WV4.. S , , ` '
R zt& e 1 ..-i 4 . Q [ o 60 ' ,. ' ' } ... Y ! 1 fr N 1 41 � 1 °�?' I 1 ,. S';.1' ,� � 4`nf .:11
+
=nowt inwitigenr comeastimmtionan A
z,t orR acota: B j tiwa ,v kq1z ..--)u
) h P AAi lei, /;./ ---,, vvq. , - d 7 1BAR4 c$ c-(A z4. 0ioAI
Name Pant) Current miming Addr s:
/--2-------. //...At:/---- Tetepr<one
i f as . D.. l 1 eJ
Signature '
2.2_i!afftlzed Montt
. �. -1 . a e,i Fca O W-? 1 C4 1 2 — #1 . 4 . s:� i
Name (Print) Current Meilf+g Address:
1a . / i t & r Olga S it- 243 -0;
Slyfnuture _ Tefe one
S 111. i$T T$1 "ft/MM."
Item Estimated Cost (Dnliar,) to bo Mom Use only
_ _____ completed by permit applicant
1. Building ' (a) Witting Permit File . •
2. Electrical (b) Evarnataa 1?sta Cost et '
S, Plumbing . - es
4. Meehaer+IGatl (HVAC) -
E. Fire Prot/cOn
S. IYL& (1 +2 +3.4 +61 - SfiV ert> Gll AekiVritril �. x�
TilLsecson Far a hllM
Buuaing Peardt Number. ,, Mutt - , • - - •
Signature: M
, .SulldtagCornraisstaferAn9 7ui gs • Date
1 of 4, 3/1/2013 9:47 AM
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RECEIVED 1. ik
ay of Northampton �� � �
uilding Department', � �
20( ± 212 Main Street i , < � „,
Room 100
L � �o s N hampton, MA 01060 �� ,� �`� , ' � '
h_ ?, PTON. MA 1060 ° e r �'"" °° "
��io� 41 -587 -1240 Fax 413 -587 -1272 r < �T : < : :t ��� : ?`
APPLICATION TO CONSTRUCT, ALTER, REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
6._ . Address:
This section to be completed by office
cp 7 - A e iRcee Map Lot Unit
Fiev &JC E I /4 4 . o fo 6 (9 • Zone Overlay Distrkt
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: Skov/icily kc 3/0 -3 e5 _ 79‘ a
b4b4zA . roAtilltI� � s a T .� �, 1 �c, 4 'd0 .
Name (Print) /,� e� Current Mailing Address: e.
Telephone
Signature
2.2 Authorized Agent:
M 1 * CH 46 (. "1 (?v Fo 044 C,2664 7( w- y (?Qty -"- 14. 0; 2 0 ). i
Name (Print) Current Mailing Address
j/i./4/1 g21 oeiBo - 7 1-3` -12 3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Budding (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
500,° Construction from (6)
3. Plumbing Building Permit Fee
1.)0c0
4. Mechanical (HVAC)
5. Fire Protection r
6. Total = (1 + 2 + 3 + 4 + 5) 0 �1 ) T6-1) Check Number / d y /( 0
This Section For Official Use Only !!!! h
Building Permit Number. Dsued: 69°
Signature:
Building Commissioner/lnspector of Buildings Date
1 of4 3/1/2013 9:47 AM
File # BP- 2013 -0795
APPLICANT /CONTACT PERSON MICHAEL T RUFO
ADDRESS/PHONE ONE COLGATE WAY CANTON (781) 343 -1733
PROPERTY LOCATION 25 TARA CIR
MAP 29 PARCEL 514 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building / Q�' # 9 4)(v°
Building Permit Filled out "(
Fee Paid
Tvpeof Construction: REMOVE WET DRYWALL & INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 56976
3 sets of Plans / Plot Plan
THE FOLLO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF TION 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
jo r 00. II • lay
I" 5—/--/5
Signature of Bui ding 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.
25 TARA CIR BP- 2013 -0795
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 514 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit # BP- 2013 -0795
Project # JS- 2013- 001359
Est. Cost: $7800.00
Fee: $1 60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL T RUFO 56976
Lot Size(sq. ft.): 14723.28 Owner: FRANKLIN BARBARA
Zoning: URA Applicant: MICHAEL T RUFO
AT: 25 TARA CIR
Applicant Address: Phone: Insurance:
ONE COLGATE WAY (781) 343 -1733 WC
CANTONMA02021 ISSUED ON:3/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE WET DRYWALL & INSULATION
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 3/4/2013 0:00:00 $160.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner