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06-022 (4) . The Commonwealth of Massachusetts - *�- Department of Industrial Accidents I = = !/. EMI y Office of Investigations �d111- 600 Washington Street ,..T Boston,MA 02111 s"' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): fYij- ai E gcber . 3) 1 l't-±jai WOV' Address: 3, 1 Ru e ssll 5+ J City/State/Zip: OcitiVekj c A- C t O 35 Phone.#: 1/r/3-.530 -- i9:70 Are you an employer? Check the appropriate box: Type of project(required): 1.21 I am a employer with (e 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.# 9. 0 Building addition required.] 5. ❑ 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 required..]t c. 152, §1(4),and we have no 13.0 Other employees.[No workers' comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homdowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors 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:77-e.:h noLC&y _I-0s .. (c(hp(&t1 j Policy#or Self-ins. Lic.#:Twc 333 3 1p I ) Expiration Date: /0 )11 1 020/3 Job Site Address: t-C•X. Pi k.-1... ATLOJJ J 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 i DIA for insurance coverage verification. I do hereby ce/i, under the pains and penalties of perjury that the information provided above is true an correct. 7 Signature: f i� Date: ..--//7- 5 5 Phone#: CLi t 3 O- )1O3 CCc I1 (4(3)5c &44 5 (0-c 'Cc) 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#: 7 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction S ervisor: Not Applicable ❑ Name of License Holder: —, �q, t V J b[��f�A-c-, G� "V q 2 S 7 2 F License Number [[[ "L l /� � ,rte �`t .x--26 Addres A . �� / 1 Expiration Date 0-- 2207 .E `!_ Sig-!'il e%•J -phone 9;...__'stered:H meet ': overne ctor - Not Applicable ❑ C. .an Name Regi3lrationJumber7 l� — , ► . LC * 7 / Address U1 Expiration Date 12f_ SECTION 10-WORKERS'COMPENSATION;INSURNCE AFFIDAVIT.MG.L e. 52,- 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. - vnie vu ter' xe `I- on 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 wiII be required from time to time,during and upon completion-cif theewerk-for-which-this-per 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-DESCRI ON OF PROPOSED WORK(c - k all an$licable) New House ED Addition E Replacemen Windows Alteration(s) [n Roofing n r--� i—� Or Doors Acce3aory Bldg. L._I Demolil:c n _! New Signs (Q) Decks [E) Sit;u;y[Q] Other[0] Brief Description of Proposed ( q Work: c'C.9 14 L t v----1-, 1- 424.i 1de ge_ . ` Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If[`lewliouse'and oradditithao eXWiii g ng�eorr><i to#e_#h .:fo_tiiv+viti�a: a. Use of building :One Family 1"-! Two Family Other b. Number of rooms in each family unit C Number of Bathrooms 1 �� c. Is there a garage attached? LL a- 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. \l 1 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 AUTI-IORLZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 4 I, G S o o .7a..�g ,as Owner of the subject ro rt P Pe Y 1 - hereby authorize i I © 6 to act on my behalf, in all matters relative to work - - - ed by this building pe it application. . r ./.e A . . i • .. Signature of Owner Date 41121 _Q116. 1 ,• '1 dr ■ `e•✓ > , as Owne u thorize • Agent r-reby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge - • •elief. Signed under e pains and ✓�'l nalt��of perjury. ---- Print Name ,/...i __ _ . _ 7- 17 - / 3 Signature o f,•: 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.. _.. ----: Rear ___ _ _ __.__-, Building Height Bldg.Square Footage t ----; % t_---, ;.— _ _ — Open Space Footage , % --- (Lot area minus bldg&paved i, i , ..,_..aJ 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 0 '..P\------- 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 it. B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 0 NO 0 IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended-for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activi ty disturb(clearing,grading,excavation,or fillina)over 1 acre or is it part of a common plan . that will disturb over 1 acre? YES 0 NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. CC /1/ of Northampton Stat s 'eut-CC /1/ .'ig Department • 21. Main Street ServerFsep`tia aitabirty �� 'oom 100 Water tlelfAvailabiltty r. dEPT N•rth. mpton, MA 01060 Two Sets offStructural Plans koerHA ToN • •�ec41.4-5: -1240 Fax 413-587-1272 Pro S f?ians' 0,060 �1'S Other Specx € APPLICATION TO CONY mUCT,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: ij r tree ,, • Map Lot Unit A v T 11 Zone . Overlay District h e / EimfSt.District Ca District SECTION 2 PROPERTY-.OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: pc:• tr-d aq '— Name(Print) Current Mailing Address: 6/13 SSE 617 y rO 4 ,.Q i. Telephone Signature Aut in.A u �- 52-1 r 1.1, 14 al f d Name(Print) Current Mailing Ad ress: !t 035 Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar )-to be Official Use Only completed by permit applicant 1. Building I © Dc (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) I V I I✓~• Check Number ?06 - _ - 'This Section"F`o:F Offrcia[ttse Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 48 EVERGREEN RD-UNIT 216 BP-2014-0036 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 06-022 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2014-0036 Project# JS-2014-000104 Est.Cost: $1500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RANDAL ROBERTS 042573 Lot Size(sq. ft.): Owner: WOODWARD EMILIE S Zoning:URA(99)/ Applicant: RANDAL ROBERTS AT: 48 EVERGREEN RD - UNIT 216 Applicant Address: Phone: Insurance: 321 RUSSELL ST (413) 530-2703 () Workers Compensation HADLEYMA01035 ISSUED ON:7/17/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS 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 7/17/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner