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The Commonwealth of31assachusetts
Department of Industrial Accidents .
Office of Investigations
_ a 600 Washington Street
Boston,MA 02111
,',N s•' www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb.ers
An ticant Information Please Print Le ibI
Name (Business/Organization/Individual): .
Address:
City/State/Zip: / % Sl�� Olda Phone.#: %�3 ZJ�3 3��
Are u an employer?.Check the appropriate box: Type of project(required):
1. I am a employer with 4., [] I am a general contractor and I
. l 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. E]Remodeling.
ship and have.no.employees These subcontractors have _ g, F-1 Demolition
workers'h
employees and working for me in any capacity. 9. []Building addition
[No workers'comp.insurance comp.insurance.$
required.] 5. F_� We are a corporation and its 10:0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions
myself. [No workers'comp. right of exemption'per MGL 12.Q Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑Other
employees. [No workers'
comp.insurance requited.] '
*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.
xContractors 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.
Aram 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: l ��O� ST 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 lip 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 nder the pains and Ides of ury that the information provided above is true and correct.
3 Signature: �( 1-�, -_-'�l__- Date: 2 �� /
Phone#• 73 �OG
Official use only. Do not write in this area,to be completed by chy' or town o fcia!
"
+
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 ❑ r/
Name of License Holder
License Number
Address Expiration Date
/ Z
Signat re Telephone
9.Registered Home Im rovement Contractor: Not Applicable ❑
Company Name Registration Number
-75 " ►mil�'�>D�iL� i � 1/1 2-2—
Address Cl- Expiration Date
Telephone?��i� O
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 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 _
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ��_ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[O]
Brief Description of Proposed ,s�j-�!�
Work: Bathroom Renovation
Alteration of existing bedroom Yes t�,_No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x 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 Com nce. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction in 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of ba0ement 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, r—_M-6" :f2 i4 4 as Owner of the subject
vproperty
Ai hereby authorize AA 6WNR_V? R
`Y act n my behalf, in all mattersrel work authorized by this building permit application.
Signature of Owner Date
1 (�< 6, as Owner/Authorized
Agent hereby decl re that the s tements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed und"th ain s and penalties of7err.
Print Name
1`z � � q, z
Signature of Owner/Agent Date
Department use only
`/- -- City of Northampton Status of Permit:
Building Department Curb Cut/Drj Permit
<,1 212 Main Street f Sewer/Septic Av4i ability
c ak
� DEC Q 20!3 Room 100 / t+ A4aj1 bilitNorthampton, MA 010 @lect�, t�Tgtvell
s of, tural Plans
l - -- -pho a 413-587-1240 Fax 41t " " C t/Siteans
Elect ,ions
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLIS NE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1'Property Address:
This section to be completed by office
19 Allison Street Map Lot Unit
Z
Northampton,MA 01060 one Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Emily & Philippe Baillargeon 19 Allison Street, Northampton, MA 01060
Name(Print) Current Mailing Address:
Telephone 413-320-6199
Signature
YYf G G
2.2 Authorized Agent:
2 �t.3 /V/�o� sr *A1
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building d D (a)Building Permit Fee
2. Electrical C (b)Estimated Total Cost of
J C7 Construction from 6
3. Plumbing / Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissi r/inspector of Buildings Date
19 ALLISON ST BP-2014-0742
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 123 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-2014-0742
Project# JS-2014-001120
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOWARD R PAUL 059242
Lot Size(sq. ft.): 7710.12 Owner: EBEL ELIZABETH L&GREENFIELD SAVINGS BANK
Zoning:URB(100)/ Applicant. HOWARD R PAUL
AT. 19 ALLISON ST
Applicant Address: Phone: Insurance:
355 MIDDLE ST (413)253-3698
AMHERSTMA01002 ISSUED ON.1212012013 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATHROOM
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 12/20/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner