09-009 The Co nu. onwealth of Massachusetts
Department of Industrial Accidents
�
—: Office of investigations
=i; ' ,of Ness Street, Suite 100
VERLW 47-
"nston, MA 02114-2017
;
.s� www ntass.gov/dia
Workers' Corr. ':is: 'ion Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Inform!' on Please Print Legibly
Name BusinessiOrganir.) ' ., ' dividual : a /
( ) � Y ' � - h �d 4 S ly
Address:-4 s0vf--- 4;,,,, fvu SfL,- / l'4r
City/State/Zip: FL _I _ Phone 4: =_j` 7.7�-- 4 e °J
Are you an employer? C'. 1. ., U appropriate box: Type of project(required):
1. I am a employer +. ni! T -._., a general contractor and I
employees (full ar. time).* have hired the sub-contractors G. New construction
2.111 I am a sole propric �; a tner_ li:,�.: l on the attached sheet. 7. n Remodeling
ship and have no e[ '' tese sub-contractors have 8. n Demolition
working for me in ach , :tployees and have workers'
g y 9. I I Building addition
[No workers' comp . ' :e r,,mp. insurance.
required.] 1-] 'y are a corporation and its 10.17 Electrical repairs or additions
3.❑ I am a homeowner d, ��rork �ccrs have exercised their 11._ Plumbing repairs or additions
myself. [No ssorl<u� t 'it of exemption per MGl.
Y [ 1 2;g1 Roof repairs
insurance require' r. 1 i2. §1(4), and we have no
or ,'rloyees. No workers' 13._ Other
- ,[„p. insurance required.]
*Any applicant that checks box „till out the section,H, showing;their workers'compensation policy information.
t Homeowners who submit this.. .1icating they:II c i' .‘ork and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box i Ad an additional shcct xvv ire the name of the sub-contractors and state whether or not those entities have
employees. If the sub-con(melt): 'twees,they must pro '[heir workers'comp policy number.
I am an employer that is p workers' . ,•. 'fiat!insurance for nip employees. Below is the policy and job site
information.
Insurance Company Nart,'• Cveli �691-,�&0
Policy#or Self-ins. Lie. WC 3()=,-:- J 1/‘ V Expiration Date: ' 6 2 C/
_�0 1
Job Site Address: .SCE a._ /1„„ L� /2,2 City/State//ip: c^r.�”_. V _1<///-
Attach a copy of the wot .rtensatiou pn 1!uration page (showing the policy number and lxpirat�io date).
Failure to secure cox Brag, I under `''H • of MG!. c. 152 can lead to the imposition of criminal penalties of a .
fine up to $1,500.00 .Ind.. impriso . 11 a.; civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day app': _jlator. F . 'Hit a copy of this statement may he forwarded to the Office of
Investigations of the 1)1,A. 1 ice coveralic r . Lion.
I do hereby certify uncle and penalti'/Of '. fury that the information provided abov is true a d correct.
/
Signature: ./ -- Date_ , 70// J
Phone#: y/ ,- 7? - ‘40 k
Official use only. Do ' this art . , - '•'olererl ity city or town official.
City or Town:_ Permit/License #
Issuing Authority (cir
1.Board of Health 2 `cpartt►n.c.t; ; t'own 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: ( L2 V 67, Ce //Jv G — / /-7 b/
License Number
( ---Cav'tt/LAYM P-oe° tAdia.5-1-knA4y4bA Al4 0. (017 ih,b0/9"--
Address Expiration Date
> O-
Signature Telepho-e
9.Registered Home Improvem, Cr;ntracto : Not Applicable ❑
Company Name / Registration Number
l35 f y Rcit --- _ 12/z7/2 0,/i
Address
r l
4,1 Expiration Date
ah?7 Telephone y/,' 7?—‘6 gcl
SECTION 10-WORKERS'COMPr'dFATION 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 g No...... ❑
11. - Home Owner Exemption
The current cscnil,tit, „ -le nicowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such hoe' •cry r to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CM k .dvth Edition Section 108.3.5.1.
Definition of Ilomeowner: Person(s)who own a parcel of land en which he/she resides or intends to reside,on which there •
is, or is intended to he, a are or two family dwelling, attached or detached structures accessory to such use and/or farm
structures.A person w-',n constructs more than one home in a twin-year period shall not be considered a homeowner.
Such"homeowner"shad submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all slip's work performed under the building permit.
As acting Constructs ('unervisor your presence on the job site will be required from time to time,during and upon
completion or the we which this p:e, uit is issued.
Also be advised that' ':H wrfcrence to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees fur iujur■ .uliing iii Death)of the Massachusetts !ienc•al Laws Annotated,you may be liable for person(s)
you hire to pc roorm r you under this permit.
The undersig,:ed"ht,,, certifies and :is,utncs :espunsibiiity for compliance with the State Building Code,City of
Northampton Ordinan. State and local Zoning Laws and State ui Massachusetts General Laws Annotated.
Homeowner Signal t:
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) I I Roofing ril ,
Or Doors D
El�
Accessory Bldg. i I Demolition ❑ New Signs [0] Decks [C] Siding [O] Other[[CC
Brief Description of Proposed
Work: Sttri p a,rct�-`� ., ](c.s & 1& (C ---,(0,,-..P.
Alteration of existing bedroom J Yes ✓,/ 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, Aci f e• t-s-& Vi , as Owner of the subject
property t
hereby authorize ( 0 C C' I V ye,
to ac n my behalf, in all matters relative to work authorized oy Ibis building permit application.
Signature of Owner Dat,: 9-67'4171/ 3
nW�"
I, ) 6 (-Ice C,d (LvA , as Owner/Authorized
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 pains and penalties . perjury.
I-0de( Ca 11
■ _./-' / _t/ i
Print Name `
Sign- .re of —
g f O /or gent i Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing T Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage % --
(Lot area mina,bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW O YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i Department use only
M
f. v, o City of Northampton Status of Permit:
.,, cv
I.--, ? Building Department Curb Cut/Driveway Permit
I, m 212 Main Street Sewer/Septic Availability
■ ,.) r2, Room 100 Water/Well Availability
j Northampton, MA 01060 Two Sets of Structural Plans
ri'L (I' -' 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 _J
1.1 Property Address: This section to be completed by office
j.-.30'6 V_tolc17 P.--,3Q, f\j t ,, 1isNiMap Lot Unit
f Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r`
Name(Pri / Current Mailing Address.
LL- y Telephone
Signature
2.2 Authorized Agent: .
Name(Print) _ Current Mailing Address:
-4(: 141 3 5a-7 X00/
Sig oture �� 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
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 99-3 Cf
6. Total=(1 +2+3 +4+5) Check Number V
This Section For Official Use Only
Building Permit Number: _ Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
508 KENNEDY RD BP-2014-0392
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 09-009 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-0392
Project# JS-2014-000679
Est.Cost:
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SOVEREIGN BUILDERS INC060176
Lot Size(sq. ft.): 68824.80 Owner: VERSON ALAN&PAULA
Zoning:RR(100)/WSP(100)/ Applicant: SOVEREIGN BUILDERS INC
AT: 508 KENNEDY RD
Applicant Address: Phone: Insurance:
135 SOUTHAMPTON RD (413) 527-8001 Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:10/2/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 10/2/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner