16B-010 (2) _. The Commonwealth of Massachuse(Ls
------ Department of lndusfrial Accidents
- ,k+ Office oflnvestigations
rn� = 600 Washington Street
.t.{= 3 Boston,MA 02111
f,cE www.mass.gov/die
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly_
- Name dtv dual): UILM1? thUEQ-c
Address: P.O. ?sac 11441(c•
City/State/Zip: GREG,Fiez-b $44. Ot3C .Phone.#: 1413. ?73. a$1O
Are you an employer?Check the appropriate box: of ro'ecf(required):
4. I am a general contractor and I Type project
1.�I am a employer with L- 6. ❑New construction
employees(fall aad/orpart4ime)_* have hired the
2.❑ I am a bole proprietor or minor_ _ listed on the-attached sheet, 7. ErRemodeling
ship and have no employees T have 8. ❑Demolition
worktUg for me in an Ycapacity. employees and have workers'
9. 0 Building addition
[No workers'comp.insurance camp-insurance.
required.] 5. 0 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 .]t c.152, §1(4),and we have no 13 0 Other
employees.[No workers'
Comp_insurance required.] -
*Any applicant that ched=box#1 nest also fill out the section below showing their workers'compensation policy inform fion.
t Homeowners who submit this affidavit indicating they an doing all w mk and then hire outside contractors must submit a new affidavit indicating such.
tCo®nac teas that check this box nest attached an additional slices showing the name of the sub-contractors and state whether or not those entities have
employ if the 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 polity and job site
information.
Insurance Company Name: 112Ametens ' Stk'24gj.
Policy#or Self-ins.Lic.tt Ts-us-3c14/00 t Z_ Expiration Date: 1(zz 3
Job Site Address: id gv2.10tee:0-11 . City/State/Zip: N-414 4 Z
A4tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up-to 5250.00-a day against the violator. Be advised that a copy-of this statement may be forwarded to the Office of
Iuvestiaations of the DIA for insurance cbveratre verification.
I do hereby certify under the p ' -and penalties of perjury that the information provided above is true and correct.
Date: 12A11 3-
Phone##: 413.1'73. 38I0
Official use only. Do not write in this area,to be completed by city or town official
City or Town: - Permit/License#
j Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
r .6.Other
Contact Person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
(LS0�1 License Number Expira on Date
Name of CSL Holder
1 Z S,l c ru(L Si: List CSL Type(see below)
No and Street Type Description
r~ re-13 • a 301 U Unrestricted(Buildings up to 35,000 Cu.ft.)
` R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
(f'3 X773., Yor SF Solid Fuel Burning Appliances
�
1 I Insu lation
Telephone Emaress D Demolition"
5.2 Re tstered Home Improvement Contractor(HIC) /03 eyty I ,724/
`tsor4 Aumbetu HIC Registration Number Ex ration Date
HIC Coriep y ame otr F,�s�Registrant Name
No. Street t� Email address
I14c 6 130 413.'773-5i3lo
City/Town,State,ZIP' Telephone
SECTION 6: 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 1! No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize d /LSa]J
to act on my behalf,in all matters relative to work authori>1./
y this building permit application.
X 1"' '.1 ■4 _A_. l At _ 4/1///-3 _
�rart Owner's -.1 . • Signature) / Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containe 'n this application is true and accurate to the best of my knowledge and understanding.
K 1 U 25 3 __
Print Owne s or Authorized Agent's Name(Electronic Signature) ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.)_ _(including garage, finished basement/attics,decks or porch)
Gross living area(sq.ft.)__ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system _ Enclosed_ Open_
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1VED \
ill 1 (3;j
The Commonwealth of Massachusetts FOR
_ Board of Building Regulations and Standards MUNICIPALITY
o Massachusetts State Building Code, 780 CMR USE
,, Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
lb! i71�Df, ko_ — –
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ p p system
2: PROPERTY OWNERSHIP'
2.1 lOwnerl of Rec d:
Name(Print) City,State,ZIP
101 f rLoee N. 417. 55B.zc1(
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 21/-Owner-Occupied el Repairs(s) ❑ Alteration(s) l Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units _ _ Other ❑ Specify: , _, ♦_ ,' ,12406,
Brief scription of Proposed Wor�C2:_ D 6 )A! txga .tQyL, �4'LC t- TO GE 2. t4-,-1
.W P7L0144 CEWULMSE 1 l - eM
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1q00 1, Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression) ee�
!�Qom_ Check No.�(,Check AmoulK6 Cash Amount:
6.Total Project Cost: $ `t w0 ❑Paid in Full `v'tt ❑Outstanding Balance Due:
File#BP-2013-1248
APPLICANT/CONTACT PERSON DAVID WILSON
ADDRESS/PHONE P 0 BOX 1496 GREENFIELD (413)773-3810
PROPERTY LOCATION 101 BRIDGE RD
MAP 16B PARCEL 010 001 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 -%
Fee Paid (f
Typeof Construction: INSTALL WALL&ATTICE INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 40055
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
D- •liti•I Delay
dr, ,
Signature of Building •f icial 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.
101 BRIDGE RD BP-2013-1248
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16B-010 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: INSULATION BUILDING PERMIT
Permit# BP-2013-1248
Project# JS-2013-002057
Est.Cost: $4900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: Lfcc ;c:
Use Group: DAVID WILSON 40055
Lot Size(sq. ft.): 10018.80 Owner: SNYDER CHARLOTTE D C/O ADELAIDE CAIN
Zoning: URB(100)/ Applicant: DAVID WILSON
AT: 101 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 1496 (413) 773-3810 WC
GREENFIELDMA01302 ISSUED ON:7/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL & ATTICE 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 7/2/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner