29-462 (2) 1
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CC
The Commonwealth of Massachusetts
Department of Industrial Accidents
--�-` Office of Investigations
600 Rashinaa ton Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
A imlicant Information PIease Print Leaibiv
Name(Business/Organization/Individual): �b� J 141A..*
Address: ;)69 4skf✓otr '�
City/State/Zip: UAAk ,per t M11 00 Phone#: 413- 457a-3130
Are you an employer?Check the appropriate box: Tvpe of project(required):
1.R9 I am a employer with 1 4. [] I am a general contractor and I
* have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. M 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.❑Electrical repairs or additions
�.❑ 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 I2.❑Roof repairs
insurance required.]t c. lit, §1(4},and we have no
employees.[No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box n1 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-oontractors 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: M �,1Slarn i
Policy#or Self-ins.Lic.#: ljL 1 _ 3 5 _.Y'"o75 Expiration Date:
Job Site Address: 't 7 UfS r WLAJ Av<. City/State/Zip: A)Ah-f4^�''�A a io 10
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
Signature:
Date: io1��11
Phone#: y13- I5"1' 3y36
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#•
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction'S'upervisor: Not Applicable ❑
Name of License Holder: I upa 8J A4wRA4�� 191300
License Number
26A, /Lcse.,rveif ,v-\A otoVT 117 lo-U0
Address Expiration Date
f 6�1 . Lip- csa -313 d
Signature Telephone
9 :Re 'istered'Hirie tin r""ovemeriteGontractor 4 TM a Not Applicable ❑
T�d d 4 n caa,.4y-. I`I 1o4f I
Company Name Registration Number
bra hk*Lrs,�- �,J InS��� , ,►ntj oloZ7 g1517/Vi
Address Expiration Date
Telephone '5113 65�—3�13�
SECTION 10 WORKERS'COMPENSATION INSURANCEAFFIDAVIT(M.GL.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...... ❑
Uwneri"Y" "t'l n
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
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition [] Replacement Windows Alteration(s) Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[lam] Other[fit)
Brief Description of Proposed �i5f !►��x �� t 1 5 C^ ( 4r 1,
Work: Q�er,ir,G � ceol4te, t1^S T '�� GSTS qn gnGwr�' 'T
Alteration of existing bedroom Yes X_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
sa If.New hoase.and brad-d tto>r1 A exist n"a iio rsrrid''complef AhW,M,166.1nQ_:
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
as Owner of the subject
property
hereby authorize —rodd MW-A
to act my behal 1 in I nvtters lative to work authorized by this building permit application.
10 1 I or
Signatuk of Owner Date
I, 1—'D A rt t'c gn dV as Owner/Authorized
Agent hereby declare that the 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.
TQid �c}�
Print Name
Signature of Owner/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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varianoe/F ever been issued for/on the site?
NO 0 DON7KNOVV VIV YES K J
(F YES, date <ssuedJ
IF YES: Was the permit recorded at the Registry ufDeeds?
NO 0 DONT KNOW
IF YES: enter Book Page, and/or Document#� �
��
B. Does the site contain a brook, bod y ofwm�eror�e��onds? 0O �_/ DON7KNOVV YES
IF YES' has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �_� Obtained�~� a � �~\.�� Date' � `
?,-A C. Do any signs exist un the property ��� YES �~� NO
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,excavation,or filling)over 1 acre nris it part ofa common plan
that will disturb over 1acre? YES [��l NO ���
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• %OW
Department nse onC "
City of Northampton Status of fe iTlit
Building Department CurtiteNraye �
a ,-� ,`
212 Main Street S�we e at abil �>
k
Room 100 WrA6feAle tl� . � gp
Northampton, MA 01060 woefsa Luc uraans ` � "
5 p' le 4�°3°'�8T=1240 Fax 413-587-1272 Plot{ Ptans" P=k
APPLICiQ Cf�TION TO TRU ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
p ;sa
S�CTIAN-f SITE INFORMATION'
Tfiis section to be completed by}office
1.1 Property Address:
4SCKI �� Map 'Lot Unit
(crt r1(R I'"7 o I o O Zone Overlay District
EIm St.Distract CB D%stnct
SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Re F ord.
y? CA-tgW'i._v' Avt,,,Flvrthce- 0 Z
Nam Print) Current Mailing Address:
cjq
Telephone
Signat re
2.2 Authorized AggeentJ ^f /� 1 >
�Qdi r� `s'l`anOV 2®o� kk'�(yc'lr P-J. W`S n rr1 tr1� �IGZ
Name(Print) Current Mailing Address:
x{13-- (6 5.1- 3`130
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building j 5" (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) S� Check-Number °S
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
. 40
*Iftle#BP-2009-0417
APPLICANT/CONTACT PERSON TODD ALEXANDER
ADDRESS/PHONE 202 RESERVOIR RD WESTHAMPTON (413)529-2465 Q
PROPERTY LOCATION 47 CRESTVIEW DR
MAP 29 PARCEL 462 001 ZONE URA(100)//WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE CARPORT POSTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 084300
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
THE
PRESENTED:
Approved 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
Demolition Delay
f-d
to// 40
-I.- �., �Aj
T
Signature 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.
"SMEW DR BP-2009-0417
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:29-462 '° CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0417
Project# JS-2009-000564
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TODD ALEXANDER 084300
Lot Size(sq. ft.): 10018.80 Owner: SLOAT REXFORD K JR&NANCY R
Zoning:URA(100)//WSP Applicant: TODD ALEXANDER
AT: 47 CRESTVIEW DR
Applicant Address: Phone: Insurance:
202 RESERVOIR RD (413) 529-2465 O
WESTHAMPTONMA01027 ISSUED ON.1011512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE CARPORT POSTS
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 si nature:
FeeTylie: Date Paid: Amount:
Building 10/15/2008 0:00:00 $55.001698
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo