Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
12C-069
The Commonwealth of Massachusetts Department of Industrial Accidents l_.- Office of Investigations 1 Ira-_ 600 Washington Street =. , -,, Boston, MA 02111 4. tip,f• : V = ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Rosemund, LLC Address: 23 East Hadley Rd City/State/Zip: Hadley, MA 01035 Phone #: (413) 695-8795 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction 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.t required.] 5. ❑ We are a corporation and its 10.n 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.n Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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. 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: Main Street America Assurance Co Policy #or Self-ins. Lic. #: MPF659979 Expiration Date: 5/26/2014 Job Site Address: 52 Carolyn St City/State/Zip: Florence, MA 01062 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ` (31- ,..&Q Q) kAkkit Date: St k 1113 Phone#: l S j 1 C{ 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: E k Not Applicable ❑ Name of License Holder: GY Qlr E C) L.,( I V C '2 C License Number 1%) 3 04,C i 4011 hnA 017 091 ao t" Address Expiration Date Lk 3 —Clef C Lk \ (----I a_ Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi g 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 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks [q Siding[0] Other[0] Work:Description of Proposed ( .--k- r©0 Work: r��C) .Q C� � 1f� / Alteration of existing bedroom Yes k No Adding new bedroom Yes v 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: 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 TRACTOR APPLIES FOR BUILDING PERMIT I, Qty _ C drl�d <� , as Owner of the subject property hereby authorize cyS ew\\X & LL 1 C, C-Q -ik k � ' to act on my behalf, in all matters relative to work authorized by this building mit application. Signature of Owner Date I, (:)- C-)1-)Q\' • X\ \& G., r (-4u k. \ 1 , as Owner/Authorized Agent hereby declare that the statements and information on th rego ng application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penaltie of perjury. G\4C-C QU I Print Name ( • Signature of Owner/Ag'.,t II ate 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 % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Spe at Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 g l DONT KNOW 0 YES 0 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 V IF YES, describe size, type and location: CVD. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, ex ation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: _- ' -' --- Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability 6 2013 Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of Structural Plans OFB�tIDlNG�NSP pit',: e 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans pEFTRntpTON►� 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 5 a C r('O'b\ 'j.t Map Lot Unit O r V1 ct I MA 010 (7, 4- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: L�1 r t 5 ?0:1/4"( t C,\u. \--\vkc\ \Y\c S O.i ' -... C15 ? ropi2104,i Name q.r.int I Current Mailing Address: 41 w',af t— Telephone Signature 2.2 Authorized Agent: ` i Q.osewAK\e\(9, L c, Gr E k\ 1 c)3 E- �G.G1 0 t 1�a1�\-Q ki A Name(Print) Current Mailing Address: 0103 c C Lk (gS-LWkS Signature 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, Lao .- 2. Electrical (b) Estimated Total Cost of Construction from(6) 3. Plumbing -Q - Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �, 6. Total=(1 +2+3+4+5) i gg DS1 0(Do - Check Number dVO6 (ti SC This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-1097 APPLICANT/CONTACT PERSON GREGORY QUILL ADDRESS/PHONE 23 E HADLEY RD HADLEY (413)695-4195 PROPERTY LOCATION 52 CAROLYN ST MAP 12C PARCEL 069 001 ZONE RI(100)/URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ?fa ,jk �5 Fee Paid `�`7�`�'`�' �E' Typeof Construction: REMODEL BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 105857 3 sets of Pla•: Plot Plan TH FO - OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN"I 'I 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 i •liti•• •- 410 . Siglirre of Building 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. 52 CAROLYN ST BP-2013-1097 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-069 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-2013-1097 Project# JS-2013-001813 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GREGORY QUILL 105857 Lot Size(sq. ft.): 13155.12 Owner: HUTCHINS PATRICIA A&CHRISTOPHER P HUTCHINS Zoning:RI(100)/URA(100)/WSP(100)/ Applicant: GREGORY QUILL AT: 52 CAROLYN ST Applicant Address: Phone: Insurance: 23 E HADLEY RD (413) 695-4195 WC HADLEYMA01035 ISSUED ON:5/16/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM 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 5/16/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner