23D-086 'F, The Commonwealth of Massachusetts
Department of Industrial Accidents
- '° Office of Investigations
i 600 Washington Street
' ''= Boston, M4 02111
; * % www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
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Name ( Business /Organization/Individual): f1 � , - MA Z, _.j -... �1 / Aev / i J'»
Address: .
J Ye /e.1 i/'r.` i < ,' - /
City /State /Zip: / � i/f7 , m4- e) 0 67 0 Phone #: 1 /`/Y. - -1 V - 75 2 —
Are you an employer? Check the appropriate box: Type of project (required):
1.174 I am a employer with ) 4. ❑ I am a general contractor and I 6 ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
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 10.0 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. Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Other t f `Jt) U 1
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.
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: /4 :1� /f X1 �-/ � i'�L ( � —
Policy # or Self -ins. Lic. #: (4) (/ -- /)G.1 `% �' / c' Expiration Date: 2� /
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Job Site Address: 3b L(fl e X 5+ City /State /Zip: I- Cdren CQ, fl Oi 0(
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c' +'r i' -tern rains and enalties p r9' that the information provided above is true and correct
� l /l G � /�, ,_./ Date: < ti.� 7
Signature: I / iB
' �
Phone #: 4 //5 -- .-5 -1 5 4 `,% J 2 7
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Cr Not Applicable ❑
Name of License Holder: J Sht$f -k (.0Q
License Number ,
3 +htve stile hr. Aare MA- ctcx0 gpd-ii`f
Address Expiration Date
qi3 • - '75� ..
Signature Telephone
9.'Renistere , dome Improvement Contractor Not Applicable ❑
Vaalp`l4 None =m Aeme,ryt i C55'&3
Company Nine Registrati n N tuber
3 v t'�►ver ( cle 7 != lv re rice MA v�c�t� �- ��� i '4
Address Expiration Date
Lit 3 _
Telephone 513q ' 75 ✓.
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
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) ❑ Roofing ❑
Or Doors l J
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [01 Other NC
Brief Description of Proposed
Work: Ir4 )lade -e - u 1\s i" � I cell Jlc�s Co rod / pdy an 0 rcutl15Pc10E 1 ?Y S 2/cde -% �
\/ 1
Yes )( No � ( 7'/,� "ce /Jo/
Alteration of existing bedroom Yes )C No Adding new bedroom
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
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, Mart L.-()U (A Al <
l] , as Owner of the subject
property
hereby,u n t
t orize r `� ei son S h 4 f je. :H
to act n behalf, in all matters relative to work authorized by this building permit ap 47/,3 ion
` 2
4 �.� /V
Siynatur Own Date
NeASOn Shl - i-1e:{t , asOwner/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.
A)thn Sh1 -i 2-
Print me
gi /
Signa 1 o b - /Agent ) f Date
l'
File # BP- 2013 -0821
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 BOX 60627 FLORENCE (413) 584 -7522
PROPERTY LOCATION 35 WARNER ST
MAP 23D PARCEL 086 001 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 at,
Fee Paid 7
Tvpeof Construction: INSULATE WALLS & FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ( 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
Demolition Delay
- . + e of Building Offici. 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.
35 WARNER ST BP -2013 -0821
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 086 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0821
Project # JS- 2013- 001414
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sq. ft.): 29403.00 Owner: WITTIG MARY LOU
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT: 35 WARNER ST
Applicant Address: Phone: Insurance:
P 0 BOX 60627 (413) 584 -7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:3/15/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE WALLS & FLOOR
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 3/15/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner