24C-143 (3) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
-t y.
600 Washington Street
l `; ' Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): l v �`/ c S ir, pj,: fd`
Address: /G c' t—/L 4resF T`
City/State/Zip: ptyr- ,¢ 0/000 Phone#: `f/3 -5s7-3c.
Are u an employer?Check the a propriate box: Type of project(required):
1.2 II am a employer with 4. 0 I am a general contractor and I 6. ❑Ne construction
1 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. emodeling-
These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for in any capacity. employees and have workers'
g Y p ty 9. 0 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 11.0 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
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any 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.
+Contractors 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: /h r-t°r C� cD( L-'to( •
Policy#or Self-ins.I,ic.#: DO( 56/yQ Expiration Date: o/0//pei/y
Job Site Address: 11 :- //A t City/State/Zip: /' l ir�k1 J/A O(e6/0
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.
Zdo hereby certify and the p • s and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: &13 5 v 7 3 S&.
I fici2'.iuse 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#:
SECTION`S CONST.Rl ,0 SE 0
e
8.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder: II 0*iv K • kw P R I CS F3N
V. License Number
Y.
0 ' L • Expiration 3/c / /
Address
W1ii(4-14 *N MA' ()lobo
Signature Telephone
(le). c 11 • 3 050
Not Applicable
ot
Campdnv Name / Registration Number
_Address _--- Expiration ate
04 4r, � i '4 a(go Telephone yi?- 7-15
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 buildi permit
Signed Affidavit Attached Yes No ❑
The current exemption for"9,99 eowners"was extended to include Owner-occupied Dwellines of one(1) or two(2)families
and to allow such homeowner to -.9 gage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth ' .'tion Section 108.3.5.1.
Definition of Homeowner:Person(s ho own aparcel of land on which he/she resides or intends to reside;on which there
is,or is intended to be,a one or two farm' dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more an one home in a two-year period shall not be considered a homeowner.
Such"homeowner"-shall submit to the Buil. •; Official,on a form ac eptable to the Building Official,that he/she shall be
res.onsible for all such work .erformed unde. the building •ertn.p.
As acting Construction Supervisor yo presen = • the job site • -quired from time to time,during and upon
completion of the work for which this p ••'t is e•
Also be advised that with reference to � ter' 52° o ers'Coin , and Chap ter 153(Liability of Employers to
P Cw P�� :.° ) P tY
Employees for injuries not resulting in a ea )• the Mass. .userts eral Laws Annotated,you may be liable for person(s)
you hire to perform work for you under s p- •'t.
The undersigned"homeowner"certifies : d assumes responsibi 'a for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State . Massachusetts General Laws Annotated.
Homeowner Signature
•i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition [] Replacement Windows Alteration(s) [❑ Roofing ❑
Or Doors ❑ _
Accessory Bldg. ❑ Demolition ❑ New Signs [CO] Decks [E] Siding[DI Other[DI
Work:Description of Proposed �/oco- 4I�L�` re _ n� /
Work: H C�J' 1
Alteration of existing bedroom Yes x No Adding new bedroom Yes K. No
Attached Narrative / Renovating unfinished basement _Yes X No
Plans Attached Roll -Sheet
tl'z4te- + ,g*. 4 .a «v& d '�"'; v; %3 a4., :u r '.1 ,:yam, '`m'Y,�
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. Dime ions
e. Number of stories?
f. Method of heating? Fireplace- or Woo toves Number of each
g. Energy Conservation Compliance. Mas- heck E rg 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 r_•ulations? 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 1 )/ ppc
t (‘A ci1�, ,,..5 ,as Owner of the subject
property
hereby authorize �Q tk L
to act on my behalf, in all m tters relative to work authofized by this building permit application.
Signatur�'of t ner Date
I, SL LlL_d ,as Owner/Authorized
Agent hereby declare that the state ents 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.
ate(
Print Name
Gil 1 e? `l
Signature of Owner/Agent f / 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 )_ Ii___ = 1 . _ __ -__° .
Frontage (I, • 1 i
Setbacks Front = s _
Side L;? —.--s R:1---J L _ R:�€ 1 ._
Rear
Building Height ( i
1
Bldg.Square Footage I-1 1 --1 % = i i
Open Space Footage %
(Lot area minus bldg&paved r j I 1 f f
parking)
#of Parking Spaces -- _ i" "' i
Fill: .o-,�.,-._.,kf..�.�..._-- ..,. -
(volume&Location) i,.
A. Has a Special Pe it _dance/Finding ever been • sued for/on e site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Regis of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book 1
L
i Pagel and/or Document#L_,.
B. Does the site contain a brook, body o water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or ne;• to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the p'•perty? YES 0 NO 0
IF YES, describe size, ype and location: ?
i. ___ _..
D. Are there any propo.ed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describ- 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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
., /icy,ke,trIA,C-4# i{��of Northampton e ' ,a ' l� ^
Building Department � `�:: �u �:Q ,;
,33' `2! ,,,, ...` a �f 7,,,,b #4 `
�- / � 212 Main Street �� - fr
�� _ ii Room 100
Oe
�', I orthampton, MA 01060 U �a � ' ���
OCT 2 5 20�3phoitt 3-587-1240 Fax 413-587-1272 '
� �,.„` t ?�«-..�: c .f�.
lectriNo irk &u,s rspec i•
,t;v,ATilik:Tm CON•TRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
� �Tt • completed ffice
FA
1.1 Property Address:
�t,�s 4.,-,, °a''�-` � � �4�, f ors ��� °�,�
,� q a E >~w t'4 ``6e'], x k 3
. ... itte. cAr
�� � a �` �� a��e
SECTION 2-PROPERTY OWNERSHIPIAUTH,ORIZED AGENT
2.1 Owner of Record:
Name((Pri�t� d ess: 3 3/ n
Telephone
A
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS°
Item Estimated Cost(Dollars)to be Official Use Only
_ completed by permit applicant
1. Building i27,70e
(a)Building Permit Fee
2. Electrical 0� (b)Estimated Total Cost of
Construction.from 6
3. Plumbing a '696'
Building
Fee
4. Mechanical(HVAC)
5. Fire Protection "'��
6. Total:e(rim+it2N+um3+4+5) /d Cheok Number ♦ / e This Section For Official Use Only Building ber: Date
Issued:
%' f/ . �1
Signature: -�' •�
g,,,
�:ui•mg •mm�ssioner/Inspector of Buildings _ Date
11 ARLINGTON ST BP-2014-0517
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 143 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-2014-0517
Project# JS-2014-000888
Est.Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN LANDRY 093450
Lot Size(sq.ft.): 10410.84 Owner: ELKINS NIRA
Zoning:URB(100)/ Applicant: JOHN LANDRY
AT: 11 ARLINGTON ST
Applicant Address: Phone: Insurance:
104 NORTH ELM ST (413) 204-9880 WC
NORTHAMPTONMA01060 ISSUED ON:10/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL 2ND FLR BATH
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 10/28/2013 0:00:00 $72.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner