31B-257 ` `a The Commonwealth of Massachusetts
k Department of Industrial Accidents
r. rr!.� r
Office of Investigations
� Y
1 Congress Street, Suite 100
r -'
X Boston, MA 02114-2017
"✓ www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `` Please Print Legibly
Name (Btlsincsr.Organization'Individual) _... m ieI, 43-7-0/Cht--74))11,.....Wit ilIHJ C
Address: ,3v ge/n.es (//Ye
City/State/Zi : 0 t?0- " ' /7 'Ai?? Phone#: ii1/? "53' .)-- -02 72)-
Are you an employer? Check t to appropriate box: Type of project(required):
1.7[ I am a employer with_ _- 4. ❑ I am a general contractor and I
employees(fitll and/or part-time).*
have hired the sub-contractors 6. 1:: Nei; construction
2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ig Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insuuance.=
❑ We are a corporation required.] 5. oration and its 10.0 Electrical repairs or additions
❑ 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 [] Roof repairs
insurance required.] ` c. 152, §1(4).and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
`Any applicant that checks box 01.must also fill out the section below showing their workers compensation policy infoiination.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Coutractors 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. f /
Insurance Company Name: /� r-/y i iq Jot i
Policy #or Self-ins.Lic. #: 'c ,3/S -3?1/70 Y -p Expiration Date: WC/
Job Site Address: T '/ S4Ac- Sf City/State/Zip: 07-7k5rry,7`4// /-1/,5z 0/000
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
tine up to S 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 5250.00 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 t :p ins and penalties o perjury that the information provided above is tru.and correct.
Signature: Date: /0/ /3
Phone#: --- r .1-7/3 -59,7)-,2 7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Perntit/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,gervisor: Not Applicable o
1 , /
Name of License Holder. Li o...5-c-f)4 ig- C.,,'1 6 lr.' es'-/036/v
License Number
„
/ r-
' ( , , at Ji 1-ns,Cee.-- (-t ' g(.30A0/.5-
6 LS ii i , _......_
Addres:Wil
PPP— Expiration ate
" 3 -icd- 72 a_
Signal L 9111 Telephone
9.Reg istered Home Improvement Contractor:
i-e Ashy---7-1-?ew. 0/t oi-7?-?-7s ,1-"ne- Not Applicable E-2
Comp k s
/&g 9°27
Company Name Registration Number
)4(1,, ti-e--5 fke e_
2-S, (I / /-&?- / 3
Address Expiration D te
al/e6p-ee y
eze 2- ) Telephone 'If 3-55,2-?)7,-
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 Is No 2
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.CNLR 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,von may be liable for person(s)
you hire to peiform 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 Ammtated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) L Roofing ❑
Or Doors 0
Accessory Bldg. El Demolition El New Signs [Ip] Decks [Q Siding[I;Ij Other[0]
Brief Description of Proposed
Work: C-/i2QR, /�,e�cieeor,frit, -JSt'/( -ne&J K-f7Gh .ct (�/1,6/h./' . -
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes A 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 s
/ t-11- ke,m. A (fl0 - ,as Owner of the subject
property
hereby authorize littl� ��S7G72gi(7 ,`,l d
4 14>n S
to act on my behalf, in all m ers relative tona..1 �work auti�orized by this building permit application.
ve
K 11l .y Signature of Owner Date
I. �czSt�h �jr��`►�'i C O' 'r/ ' 4mzø47 Stitd 1„S ,as Owner/Authorized
Agent heresy declare that the statements and inforfhation on the foregoing application are true and accurate,to the best of my knowledge
knowled 9
and belief.
Signed`under the/paiin- • • •-nalties of perjury.
Print Name 1 r if 7 d/41/3
Signature of Own- ent :I. Dale ■
Section 4. ZONING All Information Must Be Completed Permit.Can Be Denied Dee To Incomplete Information
Existing Proposed Required by Zoning
Thts column to be filled in by
Building Department
Lot Size 47q 2 st
Frontage Sitt
Setbacks Front
Side 1., R:' l.: R:
Rear
Building Height ShT
Y
Bldg. Square Footage
Open Space Footage °%o
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a aiecial Permit!Variance!Finding ever been issued for!on the site?
NO 0 DON'T KNOW IV YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 0 YES 0
IF YES enter Book Page and!or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES i NO
IF YES describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 9 acre or is it part of a common plan
that will disturb over't acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1 l i C , i Department use only
i`
' ,City of Northampton Status of Permit:
2013 .:J
uiiding Department Curb Cut/Driveway Permit
\\ OG1 -' Q
212 Main Street Sewer/Septic Availability
,r ,,c,t ons Room 100 Water/Well Availability
ptumt Ino 6(3. ,',-
ot. , r:.) ■ - hampton, MA 01060 Two Sets of Structural Plans
EtectrIc, ,_errP
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
q--fItkS '
Map Lot
Unit
Zone Overlay District
l o"Hf (p1 I D " V Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: LS I }-t (-Q
V14 6--jeti.x4,Li rcdro-pt,rtt'es L-Le- l _,6 ,w IARci..'' V-L Att-t jor),(R4 .
Name(Print) Current Mailing Address
A. C (90..t.4...A.-1 Telephone
Signature
2.2 uthorized :.__:;nt:
6in 'L. `� . d2 J 36 ✓7°/,'-cf/-i-'s e°Y-ev/-e( ((i..Co,-Perig/?
Name(Print) - /Ay, Current.Mailing Ad ress.�� , 2 . ?- 7
Signature or , Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /67 Ste' (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Ii GrZre Construction from(6)
3. Plumbing / C Zf71 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �
6. Total=(1 +2+3+4+5) �" IR / S Check Number �f 7 F T/6
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
,
File#BP-2014-0417
APPLICANT/CONTACT PERSON JOSEPH M GILLETTE
ADDRESS/PHONE 30 HAYES CIRC CHICOPEE (413) 592-2772
PROPERTY LOCATION 44 STATE ST
MAP 31B PARCEL 257 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �I a
Fee Paid
Typeof Construction: FIRE DAMAGE REPAIR KITCHEN CAB/CTRTOPS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103014
3 sets of Plans/ ' .t Plan
THE FOL I WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
•pproved 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
Demolif•• De ..y
Signa e of Building 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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
44 STATE ST BP-2014-0417
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-257 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: FIRE DAMAGE BUILDING PERMIT
Permit# BP-2014-0417
Project# JS-2014-000710
Est. Cost: $12500.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH M GILLETTE 103014
Lot Size(sq. ft.): 4878.72 Owner: MAIEWSKI PROPERTIES LLC
Zoning: CB(100)/ Applicant: JOSEPH M GILLETTE
AT: 44 STATE ST
Applicant Address: Phone: Insurance:
30 HAYES CIRC (413) 592-2772 WC
CHICOPEEMA01020 ISSUED ON:10/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:FIRE DAMAGE REPAIR KITCHEN
CAB/CTRTOPS
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 10/7/2013 0:00:00 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner