38A-041 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
1 _ 1 E '� Office of Investigations
•.'�r`� 600 Washington Street
�� Boston,MA 02111
.. °'` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organi7ation/Individual): y-.-rim - -0' c�s-�r-- � r
Address: Lt(,,k4 l i} :xA + Vcc .4 0�
City/State/Zip:S4VIA er>liA.:\.' 1)\(k 6 k3-)2 Phone#: `-k.1 Z, Z 5 ci — i 6'1V .
Are you an employer?Check the appropriate box: •Type of project(required): ,.`I
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. 11 New construction
2 I am a sole proprietor or partner- listed on the attached sheet. 7.t.�..Remodeling
ship and have.no employees These subzcontractors have g_ ❑Demolition ,
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers'comp.insurance comp.insurance.t
10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
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 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.
tContractors 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:
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.
I do hereby certify under the pa s and penal • s of perjury that the information provided above is true and correct.
Signature: r% .v., <r. C% `E. Date: L/
�
Phone#: /7J 2 c1. /O y
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: Not Applicable ❑
(,
Name of License Holder: l,(WIN L Y s
il sJ License Number
LRAL C� 8)(, 5 q CS 0626 5-0g
Address G�I e s 1, 0 1 O `7. Expiration Date
Si nat re v �( elephone I I 2 Z /Zci r
/1/ 25"9.,je 4l
•.
9. uistered Home I •rovement Contractor: Not Applicable ❑
ck�� 2)Cow
Company Nam Registration Number
Lc i
Address Expiration Date �{
iti:.:: c-cluv i Telephone 2'; 1_ I cq`f
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 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,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 D Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [DI Decks [l Siding[D] Other[D]
Brief Descriptiort,o Pr+posed [�
Work: `. .. ...-�. J i , tC I .r' rC
1\
Alteration of existing bedroom Yes X No Adding new bedroom Yes 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, .rb&e-q UJ eye ,as Owner of the subject
property
hereby horize k .. —L.Adi S
to act do y behalf tin a I - ers relati e ,: work authorized by this building permit application.^
Signature of Owner Date
I, R c l4 ficg""'/ c� ,as Owner/Authorized
Agent h eclare that e statement d information on the foregoing application are true and accurate,to the best of my knowledge
and beli f.
Signed under the pains and penalties of
perjury.
. fl - JV� . eQl,�`
Print Name '
r J 1/ -1 /
Signatu Jr'r*..1 rAg-nt Date
tk
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
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
�� �-� Map Lot Unit
1�k i 01,} p Zone Overlay District
fit aod Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�� • • Ca, t!V ee a° 7S t/C C;4 C t \>+.-(}-L L ak L 6c 0
Na ; n}t) I t r Current Mailing Address:
( eL 1r1 4,2A l '�` 1 '1 - Telephone �-4 l 5 C.-, 2 C:) . 7 O
"� Signature
2.2 Authorized Agent:
-- ebb- --1- Poe 5 a Sti v:4esbLrc nAccOto7Z
Nam •nt) Current Mailing Address:
apn h 413 —ed
atu Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z1 3- o `� (a)Building Permit Fee
2. Electrical G— (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee /eF
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) _ Check Number
This Section For Official Use Only
Date
Building Permit Number:_ : Issued: - -7/3
Signature: / 7
�� . i.
Building Commissioner/Inspector of Buildings Date
18 LAUREL ST BP-2014-0043
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-041 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: GAS BUILDING PERMIT
Permit# BP-2014-0043
Project# JS-2014-000074
Est. Cost: $28400.00
Fee: $168.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RYAN REGAN-LADD 060508
Lot Size(sq.ft.): 5009.40 Owner: WEENE BARBARA J
Zoning:URB(100)/ Applicant: RYAN REGAN-LADD
AT: 18 LAUREL ST
Applicant Address: Phone: Insurance:
P O BOX 59 (413) 259-1149
SHUTESBURYMA01072-0059ISSUED ON:7/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE KITCHEN
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 7/18/2013 0:00:00 $168.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner