24A-052 (2) The Commonwealth of Massachusetts
„�� � Department of Industrial Accidents
t►'=5 7�td Office of Investigations
p ,= a 600 Washington Street
''_ Boston,MA 02111
-, www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organimtion/Individual): J;cAcci File Jy S nu :`'l�tq
Address: Ortp �►oc t-to e 1
City/State/Zip: - . ,-' ol '='_ — Phone#: • - - - "L
Are you an employer?Check the appropriate box: Type of project(required):
1.2jel am a employer with alp 4. ❑ I am a general contractor and I
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
These sub-contractors have 8. Demolition
ship and have no employees ❑
working for me in any capacity. employees and have workers' 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 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.❑Other
employees.[No workers
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 whetter ec 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 In employees. Below is the policy and job site
information. .
Insurance Company Name: LL+.co- kh crr.I...-t-.ss u Milne, CZCCIt t:p —
Policy#or Self-ins.Lie.#: LS'4. 151 y Expiration Date: q` II Zol q
Job Site Address: 1&s4 '.1c tt Ste. City/State/Zip: Noe ae}r+ AA-Oto(eb
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 DL&for insurance coverage verification.
I do hereby c.4. •– ;, der the pains and penalties of perjury that the information provided above is true and correct
Si:4.attire- I _
/ U 'J 'A Date: L7 Z.o i
Phone#: III ill – 4 4a 3 __ ----
Official use 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#:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) y!
"2to �� /s-
5�ev1 1(. as14.4 'v :cAo> >YAny Sbt. License Number Expiratio Date
Name of CSL Holder !!
List CSL Type(see below)
.
No.and Street Type Description
n U Unrestricted(Buildings up to 35,000 Cu.ft.)
5 QnV 4-rt.!!Q ,, .A- of l'Z . R Restricted I&2 Family Dwelling
City/Toovn,Stte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
twAyevrL-toy'C W/fata.}i,rs,cr., I Insulation
Telephone Email addrdss D Demolition
5.2 Registered Home Improvement Contractor(HIC)
r� _ I4 l>r , ��1 r1 et(
J:C burp., HIC Registration Number Expiration Date
HIC Company Name of HIC Registrant Name
One 14-04-441.4 S No.and Street I�l:.tiL Ist o .CarM
�•i -,[fc�iroSZ Email address
111�.u'� lkrr 577-3oG-44s'3
City/Town, State,ZIP Telephone
SECTION 6: 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 l l No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize J:c-O t( &r it 1 C 1�..4.
to act on my behalf, in all matters relative to work authorized by this buildi g permit application.
, 01iN Mo�Cof;cry Se1z7/!S
Print Owner's Name(Electronic Sig ature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Met, (--t or.—L,dd t c>12:3 I
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 173 S (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count 7
Number of fireplaces k Number of bedrooms 3,
Number of bathrooms Number of half/baths
Type of heating system '04. d 6(7} Number of decks/porches 4..
Type of cooling system Alt Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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 DON'T KNOW YES C
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0 ,.
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO g
•
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex ation, 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.
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Department use only
City of Northampton 3 SI— Status of Permit:
I Building Department Curb Cut/Driveway Permit
212 Main Street
Sewer/Septic Availability
20 3 Room 100 Water/Well Availability
U 2 Northampton, MA 0106087-
Two Sets of Structural Plans
lectric.Pi�.�r■i ru tea_ n ' 13-587-1240 Fax 413-51272 Plot/Site Plans
ortrE ii r.
u r rtA c,eeo
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
34 '6aseet - .%'• Map Lot Unit
AJOc'` l(A ,MA 0%0(.0 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S any- 'y L:(14, ,-d )%f veal ell J L3 4 '�o ce±t' .S4. Nork.hanQ+t � c�mo.e
Name(Print) Current Mailing Address:
41 -s•tL— c 1 -g
Telephone
Signature
2.2 Authorized Agent:
Ni; c-t n c.� / Y Sat�;oc 5 Oro c�oe S?• A-gr:44+.,, Cr most-
Name(Print) "'� 3 Current Mailing Address:
✓lr .. " .w..w. r))-D oc--49Y'
Signature """ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS r,ol... 110.4 °"mss IA SI••(+f
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 4 C-00 (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 e
6. Total = (1 +2+3+4+5) & S-'00 Check Number 033 I 53
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0516
APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC
ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN (877)206-4483
PROPERTY LOCATION 134 BARRETT ST
MAP 24A PARCEL 052 001 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 ?� 6-6--Fee Paid 627 S"'
Typeof Construction: INSTALL RIM JOIST INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 93101
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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
D-molitio l ela.
Ar/... ._4, o —2 /
Si: o :urla ng •ffi ial 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.
134 BARRETT ST BP-2014-0516
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-052 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2014-0516
Project# JS-2014-000886
Est.Cost: $500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VICTORY ENERGY SOLUTIONS LLC 93101
Lot Size(sq. ft.): 22128.48 Owner: MOULDING RICHARD T&JANET G
Zoning:URA(100)/ Applicant: VICTORY ENERGY SOLUTIONS LLC
AT: 134 BARRETT ST
Applicant Address: Phone: Insurance:
1 HARTFORD SQ SUITE 206 (877) 206-4483 WC
NEW BRITAINCT06052 ISSUED ON:11/1/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL RIM JOIST INSULATION
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 11/1/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner