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31A-279
The Cmmiortwealth of Masdhue tts Department of Industrial Accidents 1 6 Office of I mesh 9ati ors %V... 1 Congress Street Suite 100 -,.. ,ii;' Basta), MA 02114-2017 'S ;, wwwcn assgatirfa Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADD'icant Information Pismo Print Lertibly Name (Business/Organization/Individual): LGa'' cehA0CJ LA P-1/41 COUtiTR`-( 6 tjk-13 25 Address: 82 eC L C S u5 64l i 0 w e----6 . City/State/Zip: N0l -r1'tPtaNl Nt4 , 0(0(6® Phone#: I1I _ 5-e (6-7? 0e Are you an employer?Check the appropriate box: Typed project(required: 1.pI 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 ca capacity. employees and have workers' g P 9. ❑Building addition [No workers' comp. insurance comp.insurance. ra required.] 5. ❑ We are a corporation and its 10.17rElectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.©Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.53 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *My 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: T R.AV cc_e- S _ Policy#err Self ^#. O�—9'7 17 P 3?Li-13 Expiration Date: 0(Z 5 /Z-0 1 I Job Site-Address: e 5 w Pt 5`4'6-k,TO tl., sr.. City/State/Zip: P o i2 1 A-MP'fON tk 0 10 6 6 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 Investigati• DI, for insurance coverage verification. I cb her:• • •- the pains andpansdpe►jur ythattheinformation proviiab�o+eistrueandcorrect Signature: 1 - Date: (�3113 Phone#: &[ (3- 586-7 o & Offidal use only. Do not write in thisarea,to be completed by city or town dfiaar. City or Town: Per mit/License# I seeing Authority(drde one): 1.Board d Health 2.Btlding 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: QO'l G G t J G (-G 0 IZ\ ° O G2_ License Number LE s M�A ba w 6, 1'� --IM AM fO(kit M)9/ C�[o 6 o l\ (7 5A 3 , Address Expiration Date 14- Signature Telephone 9.Realstered Horne Imorovement Contractor Not Applicable ❑ RO`-( (.0(f)4,49 t11EGo Ps(' (0,9,30 Company Name Registration Number 82 c-0CeS ttEtgoYw 1�D, fP- 1-14MIi I`D`v &IA WI`/ Address < Expiration Date Telephone 'i'.3 S 6 7 20 c 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 Exempti©n 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 ❑ Replacerneniindows Atteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [Di Decks [[J Siding[titj Other CO Brief Description of Proposed 2 E v� C`(`ST� NCB �t 41 M F. f paw t ► �f E c E ol.r Z`l2 t 1- l-i-cars, /v Ey�J Work:hM SqS M NEvv Ec.CC— �Rt"EL New �t?_uc4�. fCr✓�(O iwjki! c (N14( o I cm!A 60,v, t'STA« 4141-A�v.,cx.,>a =ccc�2S t r Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet NO Nr✓ 6a.if New house and or addition to existing housing. c onsolete the foiiowind: 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 -/ o 12'i a✓HOC"1 , as Owner of the subject property hereby authorize kc`f Col il..C7 0.E(, 01210 6/6j4 c01-/T MP0 -ie 6w(--0e12S to act on my behalf, in all atters ative to work authorized by this building permit application. P/2-3113 Signature of Owner Date Q04 G t -NG 0--G 0 Y2 t0 , as 9wnerIAuthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the •.ins and penalties of perjury. 110 , Gl NC, (LOG()kc() P• tName • e1z1jts • Signature of a• _/Aeent 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 °Io 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 DONT KNOW ® YES C IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO 10®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 IF YES, describe size, type and location: E. 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. Department use only City of Northampton Status of Permit (,..____._._____ _._i Building Department AUG \ 212 Main Street Curb Cut/Dmreuvay Permit, 262013 Sewer/Septic Availability Room 100 WaterMiell Availability Northam ton, MA 01060 0. Two Sets of Structural Plans P ectric,Plumbing&Gas Ins 13-587-1240 Fax 413-587-1272 Plot/Site Plans Northampton, MAN 01 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 �f i 8 vs, o s i-t j U't o N, i � Map Lot Unit IV Co li--i(-4 A lu1'P -r2)V-' N /4 U [G 60 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,� `/OP's /�G �l,a.rj CS C-01.14119 l'eV2✓ - ' mil Name(Print) Current Mailing Address: 0/o.11 4--/i3 5 y9 02_7_5 / Telephone Signature 2.2 Authorized •ent: 0/0 (0 ' licr►i() 2C6 0ktO 82 ODc-E:s KE(IpQ ie-Q. N'(-1TQf , ILIA ame(Prit _ Current Mailing Address: _.11 e{13_-66-7 -108 Signature Telephone SECTION 3-ESTIM•TED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 30 k (a)Building Permit Fee 2. Electrical / K (b)Estimated Total Cost of -,7 l� Construction from (6) 3. Plumbing K Building Permit Fee 4. Mechanical(HVAC) 30 K 5. Fire Protection S 1� 6. Total =(1 +2+ 3+4+ 5) 77 K Check Number 7/ 4ol-ittol This Section For Official Use Only Building Permit Number: Date r: Issued:. Signature: Budding Commissioner/Inspector of Buildings Date File#BP-2014-0222 APPLICANT/CONTACT PERSON ROY GIANGREGORIO ADDRESS/PHONE 82 COLES MEADOW RD NORTHAMPTON (413)586-7708 PROPERTY LOCATION 88 WASHINGTON AVE MAP 31A PARCEL 279 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out � �j,/' Fee Paid 0171 J� Typeof Construction: REMOVE CHIMNEY,NEW HVAC SYS,ELEC,KITCHEN,ROOF&REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 062571 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF(�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 De olition I elay Si 711P-r-e of Buil,ing 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. 4111jr-j-, *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 88 WASHINGTON AVE BP-2014-0222 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A-279 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-2014-0222 Project# JS-2014-000370 Est.Cost: $77000.00 Fee: $462.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROY GIANGREGORIO 062571 Lot Size(sq. ft.): 9801.00 Owner: FRIEDMAN THOMAS H& Zoning:URA(100)/ Applicant: ROY GIANGREGORIO AT: 88 WASHINGTON AVE Applicant Address: Phone: Insurance: 82 COLES MEADOW RD (413) 586-7708 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:8/29/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE CHIMNEY,NEW HVAC SYS,ELEC,KITCHEN, ROOF & 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 8/29/2013 0:00:00 $462.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner