17B-015 (4) 1
The Commonwealth of Massachusetts
__ Department of Industrial Accidents
Office of Investigations
=1:f 600 Washington Street •
�����=` Boston,MA 02111 .
°,M _`,.'� www.mass.gov/dia
•Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
/
Name (Business/Organization/IndividuaI):[ e.1 .
Address: i3, 86,, 62•City/State/Zip: /7• ; •, � e 0096 Phone#: /1/3 695'-7759
Are you an employer?Check th• appropriate box: Type of project(required): /l
1.❑ I am a employer with 4.. ❑ I am a general contractor and I
Y 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling.
+ ship and have n_o.employees These subcontractors have. .g. ❑Demolition
working for me in any capacity. employees and have workers'
g Y P t5' $•
9. ❑Building addition
[No workers'comp.insurance comp.insurance.
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.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.®.Roof repairs •
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.].. '
I r
*My applicant that checks box#1 must also fin 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sicnature �„✓ Date: 41 /e°20/3
Phone#: y./,3— 9'5-- 9:
Official use only. Do not write in this area,to be completed by city or town official:
• ! ., ' f , f ! .Y f .f ` A ,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other r
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 9 /5/
License Number
`c.1Bau 6Z W40.01447. MA O'/096 7•/3 -201f
Address / Expiration Date
5'/3-ZI't•7as9
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company?the Registration Number
Aaa•x62 idileama447. O/4% 5$- 3 •201f/filif
Address / Expiration Date
7 Telephone 0.5"OS—746?
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 OWITmExemption
The current exemption for"homeowners as extended to include Owner-occupied Dw• in.s of one(1) or two(2)families
and to allow such homeowner to engage an in ' 'dual for hire who does not possess a 'cense,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Sectio 08.3.5.1.
Defmition of Homeowner:Person(s)who own a parc of land on which he/ -- resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attac -4 or detached . ctures accessory to such use and/or farm
structures.A person who constructs more than one home in ; o- =:r period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form ceptable to the Building Official,that he/she shall be
res i onsible for all such work I erformed under the buildin. ermit.
As acting Construction Supervisor your presence on t h e '.. site will be r-•uired 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 15 ' orkers'Compensation) an' hapter 153 (Liability of Employers to
Employees for injuries not resulting in Death : the Massachusetts General Laws • 1 •tated,you may be liable for person(s)
you hire to perform work for you under th.:permit.
The undersigned"homeowner"certifi-: and assumes responsibility for compliance with the : e Building Code,City of
Northampton Ordinances,State . • ocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signa ure
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors 0
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [0 Siding[D] Other[CI]
Brief Des •o tion of Proposed .•
Work: .47. /___ ,. ' ,__.i/_ I Oar i1_ /.
-`
/
Alteration of existing bedroom 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 1 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
1,� ' GU 440'f' - dor.e r 71 j /ri,,,N�-y e� ,as Owner of the subject
pfoperty
hereby authorize G i/.144.oYr $ C..
to act on behalf,in matters rela' to work authorized by this building permit application.
0._ Qc.Zc /S 2013
Signature of Owner Date
I, c a ,as Owner/Authorized
Agent hereby declare th a 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 of perjury.
f O4iAAD i2/c/c y
Print Name
O l6- 20/.3
Signature of er/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
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 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O r.R YES O �.Ws�,ik ;r
IF YES: enter Book Page ?or #
ua " - sxa Pn�rws, s aou . s �. e
MX=Mall! = t pax
4/k! MOW AMIE NNW MMIUMNIMILO 11161111111MAIIIIRINNINWSIIMMMIRMIIIIRMININfto Salta
` 'IrIFES:TarlYWATEMITrITMOITOMMTMMITeireWiti n ri ss on
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�� Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
L! ;'u, �; LU! 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
lectric. F' -;sections Northampton, MA 01060 Two Sets of Structural Plans
ru lif hne 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
399 751"4"' Map Lot Unit
. L' / Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4
Name(Print) Current Mailing Address:
yl3-SZq• 0885
c, Telephone
Signature
2.2 Authorized Agent:
eiQWr1R P J' RlGICEY Pa. igodY 62. 21� 10/094
Name(Print) Current Mailing Address:
Ws -6 98=705-7
Signature Telephone
SEC ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $Zc pp (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) 4 6� 8 ZS.°v Check Number 02/
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
399 BRIDGE IW BP-2014-0451
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-015 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-0451
Project# JS-2014-000784
Est. Cost: $6825.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): Owner: WILLIAM FACTO PROPERTY MANAGER
Zoning:URB(189)/WP(79)/ Applicant: EDWARD RICKEY
AT: 399 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 62 (413) 695-7059 WC
WILLIAMSBURGMA01096 ISSUED ON:10/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE FRONT MAIN & GARAGE
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 10/16/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner