44-108 (2) 4'1/4 The Commonwealth of Massachusetts
Department of Industrial Accidents
.., ' a mid
V__ 6--- Office of Investigations
ill
i- ;. 600 Washington Street
°, .,;-, Boston, MA 02111
� -r ` Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Kelly M Kapinos dba Ace Chimney Sweeps
Address: 115 Main Blvd
City/State/Zip: Ludlow, MA 01 056 phone #: 413-547-8500
Are you an employer?Check the appropriate box: Type of project(required):
1.C; I am a employer with 3 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
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. 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: A.I.M. Mutual Insurance Company _
Policy#or Self-ins. Lic. #: AWC-4 0 0-7 0 2 7 8 0 6-2 01 3A Expiration Date: 10/08/2014
Job Site Address: i i (4-k.. Nil g_cti City/State/Zip: f(/AI4 L1 &NO /d c
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 a allies of perjury that the information provided above is true and correct~
JJ'' Cr" Date: ii 0 '(3
Signature: ��G�
Phone#: 413-547-8500
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#:
PROPOSAL Page No. / of Pages
ACE. CHIMNEY SWEEPS
MA Lie, #118355 3433
115 MAIN BLVD.
LUDLOW, MA 01056
(413) 547-8500
PROPOSAL SUBMITTED TO PHONE DATE
Nelson Read 584-2287 10-28-13
STREET JOB NAME
19 Park Hill Road Same
CITY,STATE and ZIP CODE JOB LOCATION
Florence, MA E 0 A NS 0 ?t_ Same
ARCHITECT A , JOB PHONE
John J. kapinos 10-28-13 Same
We hereby submit specifications and estimates for:
6" UL Listed Class A Chimney.
-48"Sections 023.55
-1 -ao Degree Elbow Kit 385.76
1 -24" Length 122.21
2- 18"Length 176.20
1 -Wall Pass Through it 96.16
2-6" Elbows 30.00
1 Tee Support 189.11
2-6" Straight 30.00
1 -Universal Adapter 38.37
1 -Insulated Tee - 72.72
1 -Class A Diamond Cap 120 23
1 -Telescoping Roof Brace 221 45
1 -Cover Plate 30-.30
1 -Standard Wall Support 77 10
1 -- 36" Length 162.87
1 Misc. Materials 95 00
2.471 03 Subtotal
•
55 00 Permit
1,4 70 00 insp. Fee
• 4- 850 00 Labor
• " $ 3,306.03 TOTAL
y ,
/
We Propose hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
Three Thousand Three Hundred Six and 03/100 3,306.03
dollars($ ).
Payment to be made as follows:
Deposit of$ 1,090.00 required prior to ordering materials with balance of $2,216.03 due on
completion. Deposit is non-refundable once materials have been orderea, •
All material is guaranteed to be as specified. All work to be completed in a workmanlike
Authorized j 7
manner according to standard practices. Any alteration or deviation from above specifications
Signature i
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our ote:Thi ro. at may be
workers are fully covered by Workman's Compensation Insurance. withdrain .y us if n#•ac epted within 60 . days.
Acceptance of Proposal _The above prices,specifications
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature
work as specified.Payment will be made as outlined above.
4„7,4-v-3
Date of Acceptance: / Signature
#
SECTION 8-CONSTRUCTION SERVICES /
8.1 Licensed Construction Supervisor: Not Applicable l>d'
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Su)-al-.5 //:-•3 55
Company Name Registration Number
//5 l')2n-► lO 73 V� o 31oa-/ao/6'
Address Expirati Date
/ )
Telephone
S CTI• 0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
orkers 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 I!t No ❑
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.CMR 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,you may be liable for person(s)
you hire to perform 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 Annotated.
Homeowner Signature
C ()im/lidli Dh/i
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 0 DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (3 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO (3
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES (3 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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Mr. Roofing I I
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks (D Siding(D] Other[1321/°.
Brief Description of Proposed / /� e / / may /'I��dj
Work: I/'1 S -a,/I �iCL 41'6 feet Va c S — A fuel C%fili/�/IX.y / -41� 4
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes t/ 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
(1
I, V t./Ss h b- ,as Owner of the subject
property
hereby authorize J b4t7 -� %I?D 5 CL�� Cie. 4`/m 0
to act on my behalf, in all matters relative to w rk authorized by this building permit application.
77 , <<-4 If- GL-/2
Signature of Owner Date
I ,J a h - C d— ipd 5 ciAa.- ,1 e..A//rye -54)14,5 ,as Owner/Authorized
Agent hereby declare that the state Cents and information on the foregoing application are t e and accurtte,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
i
.1)r/ S to mb 5
Pri t a
_..
„I
i.natur o •/. er/Agent Date
k
7)
ir < < Department use only
ifi ity of Northampton Status of Permit:
Li i i�°v ,�' if:uilding Department Curb Cut/Driveway Permit
7 23 ;Li/ 212 Main Street Sewer/Septic Availability
Electric, Plum Room 100 Water/Well Availability
Nc ,r r�;. ` ortham ton MA 01060 Two Sets of Structural Plans
pig r section p
•- 4 3-587-1240 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
(9 ioai-A- Mr// cd Map Lot Unit
fl P ren Ce//'r n/I Aj/0�. Zone Overlay District
A Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT /
2.1 Owner of Record: I Pc4. / ,I 044•Z Cu erlt Mailin r ss / 11'1' gel • Fll i� no
Name(Print) (��?��-Mailing a1�a
)/ r
e dL/ Te e hone
Signature'
2.2 Authorized Agent: *WO C�4'
''∎11aJ- 11110/hi 5 11 '6 tr0-1'/1 72)2-lib zcbsLoW, and
Name(Prjht) r� Current Mailing Address:
,. ‘ q13- 51/T 7_ ;O0
Si. ature` Telephone
CTI , 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
3ii4'6.b 3
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection /PP�-3 05-C 6. Total=(1 +2+3+4+5) •39 .0 3 Check Number
This Section For Official Use Only
Date \ 'b
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
19 PARK HILL RD BP-2014-0599
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44- 108 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2014-0599
Project# JS-2014-001005
Est. Cost: $3306.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ACE CHIMNEY SWEEPS 118355
Lot Size(sq. ft.): 31276.08 Owner: READ NELSON G&BRENDA E READ
Zoning: Applicant: READ NELSON G & BRENDA E READ
AT: 19 PARK HILL RD
Applicant Address: Phone: Insurance:
19 PARK HILL RD (413) 584-2287() Workers Compensation
FLORENCEMA01062 ISSUED ON:11/12/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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 11/12/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner