24A-030 (5) e _ t,� ' office of In c4ggatcu rs_ '
�.. 600 Washington Street •
a ,(; Boston, MA 02111
www.mass gov /din
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
' r /.. -1 Z4. / - 3/c '
Name (Business/Organization/Individual): �I• ,% [" / / j c„L i C 0C—
Address: r t �J G e ",.o ( . ..; (-. ( / /t.. '
C i t y / S t a t e / Z i p : ,/ ° / f e 4) r/, ' /t-_ Phone #: `i 2 `f e' / `r
Are you an employer? Check the appropriate box: Type of project (required):
1. (J 'I am a emp10 with / - 4. ❑ I am a general contractor and I 6. ❑ New construction
employees ( (1),and/or part-time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- - listed on the attached sheet_ 1 2 ' ❑ Remodeling
ship and have no employees These sub - contractors have 8_ ❑ Demolition
working for me in any capacity. worker' comp_ insurance. 9_ ❑ Building addition
[No workers' comp. insurance 5_ ❑ We are a corporation and its -
-)
officers have exercised their 10_0 Electrical repairs or additions
required]
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself [No workers' comp_ c 152, §1(4), and we have no . 12.0 Roof repairs
insurance required] f . employees- [No workers'
13.0 Other
comp_ insurance required]
*Any applicant that checks box #1 must also 511 out the section below showing their workers' oompensatioa policy infomtatiod
t Homeowners who submit this affidavit indicating they arc doing all work and then hies outside contractors must submit a new affidavit indicating such
'Contractors that check this box must attached an additional shod showing the name of the sub - contractors and they workers' camp_ policy information.
t am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information.
[ nsurance Company Name: / S D<</ - � //(e yy`)jS --L�� C " °
'obey # or Self -ins. Lic- #: 5?'O Oc') Ye)/ -{) /„9—. Expiration Date: 9/3/ 3
'ob Site Address: 7S' D L.. e - - ) , ) - t' e> o j - L - Ciry /Stateizip:A10i2r/i P2?`>,. " 4- p e
kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
'allure to secure °overage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
, f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
avestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
it lature: (( -- Date: 5/a '7/-3
hone #: Y -3
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 Su peervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signatu Telephone 2- /Z3'// `>
9 :.:Registere ,Home lni.provement.Contractor _ ,,, ,. , .. Not Applicable ❑
p //2 //. y / ± ?/ 5R7 / -i / D =lx
Company Name Registration Number
5 4 / C' c /3
Address Expiration D ate
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 No ❑
Lhe_ curr ent _exemption for "homeowners" wauxtended to include Owner 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 1083.5.1.
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, von 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
ampton tI r • mances, a e . I . .1 - • ° • • - F - s-General- Laws .Annotated.
Homeowner Signature
4ir
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ - - . • - ment Windows Alteration(s) ❑ Roofing ❑
Or Doo IC
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Brief Description of Proposed ,, K' " e ez..e.9
Work: /C' C- 1"G 1.4- y. '7 ., csQS 1 `'c,2c-It' 7-v neo4-e_i :
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
5a If fsi i rrm house:arid oeidditiori to existinci tiousinc c oinptete ttielfotio uil ci:
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 FO R BUILDING PERMIT
j c - .., 5/e7 , as Owner of the subject
property
hereby authorize J <0 r •fw /{ /' L-� r i �_si /
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I Vic= (t',' -) 771 j - ..--T / ,-' 5/e.., / , 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.
- c /,fr r/- ".--t i 1/ , - r.s/c/
Print Name
�,` I 3f z7A?
Signature of Owner /Age Date
t
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 3 % r
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 0 DONT KNOW 0 YES
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 #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0 NO
IF YES, describe size, type and location:
are there any proposed cfianges to or a >tioEa intendia Thi tfiie property ? YES 0 NO 0
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 0
IF YES, then a Northampton Storm Water Permit from the DPW is required.
liftr
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City of Northampton 5tamrrr
R�(iE�r`� Bui ding Departmentur01Drlrrer�rayax� =
12 Main Street se = i ep lab
Room 100 a e la ® t 'ih , 44
NIB 2
l ��3 ort ampton MA 01060 T . e af` la ns r m t
• hon e 4 3 -5 7 -1240 Fax 413 - 587 -1272 �i e., ans46 � ' g is Wit. :
DEPT OF BUILDING INSPEC ae I`1e ` } g
NORTHAMPTON MA ' . ., .... ,...,
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:
7,s- / / - a.sco -x' , Map Lot Unit
/t/al OM /rr 1 /Y d- e , 6 v Zo " " Overlay District
" °EImSt. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
fti_ i G c G v r) 5/C i 7 g , l>G c ,...sv -rte 7" orb
Name (Print) Current Mailing Address: y , G V C c. ,
T
elephone
Signature
2.2 Authorized Agent: op ca3.1
■ /f /-i - / l l A--i $/C ( CF GJ er) c 2 Dec i 0 6 -` c: / ic /: ` /ec. ,6 sm''YS�
Name (Print) Current Mailing Address:
{„- _ ( w- --- V/ 3 — .-- Y7 'iv , `i
Signature V Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /8 0 D cx> (a) 'Building Permit Fee
2. Electrical (b) !Estimated Total Cost of
Construction from (6)
3. Plumbing . Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �
6. Total= to (1 +2 +3 +4 + 1f 0 � C heck Number 96 .5"
This Section For QfficialUse Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
l
78 RIDGEWOOD TER BP- 2013 -0875
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 030 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2013 -0875
Project # JS- 2013- 001497
Est. Cost: $1800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN ZIEMINSKI 017889
Lot Size(sq. ft.): 7535.88 Owner: GONSKI 2009 IRREVOCABLE TRUST
Zoning: URA(100)/ Applicant: JOHN ZIEMINSKI
AT: 78 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:3/27/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT DOORS
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 3/27/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner