24B-002 (2) The Commonwealth of Massachusetts
—,�— Department of Industrial Accidents
JAI= Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
• ,i i c.n o ii .a ;: • .eau%
Name (Business/Organization/Individual): xt--�� (- A/
Address: 96— c//
City/State/Zip: /L c'. Mt,/j,/,> I'd A i, //A.e,eeoPhone #: 7
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Are you an employer?Check the appropriate 'ox: Type of project(required):
1.❑ 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. workers' comp. insurance. 9. ❑ Building addition
<. ,' 5. ❑ We area corporation and its
equired.] officers have exercised their
10.0 Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
4 h comp. insurance required.] 13.0 Other
*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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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.
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• do he eb ce of u de t •pa ns •n•pe al ies of leg ry th• th• i or a 'on pr s vi i•d •bo•e ' tr`e • d or ec.
Signature: Date: /-7< ZCS"3
Phone#: 5S-6 --ZS-7 y 7
OfrciInee I I, n•t it<in i• Ir:1 • 1 • i•• ••
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 icensed Construction Supervisor: Not Applicable ❑
Name of Licen older:
License Number
Address •ration Date
Signature Telephone
9.Registered Home Improvement Contractor; Not Applicable ❑
Company Name Re.': ation 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 ❑ 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 oning Laws and State of Massachusetts General Laws Annotated.
> Homeowner Signature !'^
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteratii•n(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q iding[El] Other ED]
Brief DeAgription of Proposed
5 tree C/ hey: � L C //
Work:
H 4(
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. ew house and or addition to existing housing, complete the following:
a. Use of bu ;41. :One Family Two Family Other
b. Number of rooms in _ h family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constru Dimension
e. Number of stories?
f. Method of heating? N1.41 aces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck -,ergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of ands? Yes No. Is construction within 100 oodplain Yes No
j. Depth of basement • ellar floor below finished grade
k. Will build'•. conform to the Building and Zoning regulations? Yes No .
I. -ptic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
o tf ubject
property
hereby authorize
to act on my behalf, in all matters relative to we • . • ed by this building permit app -
•
•
�.,.
I, !C �" 1 -� , a• Owner/ uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the e- • my knowledge
and belief.
Signed under the pains and penalties of perjury.
%lc`A/ L 4-1
Print Name
Signature of Owner/Agent Date
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:
1
Rear
Building Height
Bldg.Square Footage �}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 DON'T KNOW YES
IF YES, date issued:
YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book Page and/or Document#
t 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 0 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 I0 NO 1,
IF YES, describe size, type and location:
k. 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.
'ti \1 k:1‘) Department use only
l City of Northampton Status of Permit:
,�„`.� Building Department Curb Cut/Driveway Permit
pQ� 2 �W 212 Main Street Sewer/Septic Availability
S�EC�o�s Room 100 Water/Well Availability
F BUti�o�NO`�P o��° orthampton, MA 01060 Two Sets of Structural Plans
DEPNpPSHPMPS�N 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
1.1 Property Address:
This section to be completed by office
CIS 23cti-f-k-
7
/
S Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT /
2.1 Owner of Record: /$ 73t i /4 7 / v/
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Name(Print) Current Mailing Address:
7
,-, Telephone
Signature
2.2 Authorized 'q
Name(Print) Current Mai ing •..
Signa' ure 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
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number )d5c2 'st..
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: � ---- / ( c/
f3
Building Commissioner/Inspector of Buildings Date
95 BARRETT ST BP-2013-1000
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B-002 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-2013-1000
Project# JS-2013-001676
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 92695.68 Owner: TOFINO ASSOCIATES INC C/O KEN&VERONICA LAP
Zoning:URB(100)/ Applicant: TOFINO ASSOCIATES INC CIO KEN & VERONICA LAP
AT: 95 BARRETT ST
Applicant Address: Phone: Insurance:
95 BARRETT ST
NORTHAMPTONMA01060 ISSUED ON:4/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK WATER DAMAGED KITCHEN
WALL
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 4/26/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner