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32C-259 (4) q f Information ana lnstrucuous Massachusetts General Laws chapter I52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, expfess or implied, oral or written." An employer is defined as"an.individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who.has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152; §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this.chapter have been presented to the contracting authority." Applic ants. Please fillout tine woik6r.i compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s),name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LL wi n an 2r7he members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial,Accidents: Shauld yoii-hav e•any questions,regarding-the law-or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured.companies.should enter their self-insurance license,number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom _ of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be.sure to fill in the permit/license number:which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current .policy information-.(if necessary)and-under'"Job Site Address"the applicant should write"all locations in (cit'-or town)."A=copy oftYie affdavit that has-been officially stamped or marked by the city or town may be providedto the applicant �s mo al d affidavit_-is-on i foz• uturE.per-nits or-licenses:-A new-a mt musf be=filed out each _ . year. ere-a home owner? citizen is'ob'taimzzg a license or permit not related to anybusiness or,comrnercial venture. i.e. a d6g,license or' eunit 6 bum.leaves etc: said erson is NOT required to completer this affidavit. Th.&Office'of hvestigatrons would like fo thank you in_ad'vance for your cooperation and should you have any questions; please do not 22esitate 6-give'...us a catl.. - Tlie Department's address,telephone and fax number. The Commonwealth of Massachusetts 1 art�xr nt 6fladustr of Acc dents Qffice of Investigations 600 Washington Street Boston,MA 0'2111 Tel. # 617-727-4900 ext 406 or 1-877 ASSAFE Revised-4-24-a7 vv-ww,mass.,.1 aa The Commonwealth of111assachusetts r_ Department oflndustrial Accidents pn Office of Investigations 600 Washington Street ` Boston, MA 02111 t www.massgov/dia Workers' Compensation Insurance Affidavit: Build ers/C ontractors/Elecfricians/Plumb ers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /ti</I Address: S_0 S4 h 4p.w Ln k City/State/Zip' 1,ul/ti lz f )WJ K s ° Phone#: *3_ J_/Y _ S_ef GT Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a ezri to er with 4. ❑ I am a general contractor and I P .Y hired _„ 6. New consfittctiori employees (full and/or part-time).* have hired the sub-contractor S, 2. I am a sole propri etor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees 'These sub-contractors have g. ❑'Demolition working for me in an capacity. employees and have workers' Building Y P 'Y S. ❑ Building addition comp. 1 [No-workers' comp,,insurance. co__^tnsuraucea_ _ 10. Electrical re required.] 5. [] We are a corporation and its ❑ pans or addrtions 3.❑ I am a homeowner doing all work officers have exercised their 11:❑ Plumbing repairs or additions right of exemption per M61 myself. [No workers comp. 12.❑Roof repairs insurance required.]t c. 152;§1(4),and we.have no employees.[ No workers' 13.❑ Other . comp.insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensationpolicy information. Ho meowners who submit this'affidavit ind ca�g"they are doing atl wo&2nd-then-hire-outside contractors must-submit anew 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 enV loyees. If the sub-contractors have employees,they must provide their workers'comp_policy number. I am an employer that is providing.workers'compensa6n insurance for my employees. Below is the policy dwd job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job.Site Address: City/State/zip. .�'102MkX»s A P yl Attach a copy of the workers'compensation policy declaration page(sowing the policy number and expiration dafe). Failure to secure coverage,.as regiured°under Se-M-6n 252Co_MGL c i32 can Ieadto the 3mposi o cmm�iral enal#�es 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 an fine of"up to$250.00 a day against the viola.#or. Be.advised that-a copy of this statement maybe forwarded to the Office of, . Investigations of the DL4 for insurance coverage verification Tdo hereby certify under the aims and penalties ofperjury that the hiforrnatiori provided above is mud and correct, .;Siertature: UY Date: _ Phone# / 413- s'/9 Offcial 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. ether Contact Person• Phone#: - . , . SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: l r K ") 7, kL4 t�t (i s ?r / License Number C� suv� �lr'r`/f��' l r� . LNCI��L� , /�111SS T'IC`S" ��%�l� %40JO Address Expiration Date Signature Telephone 9.Realstered Home Improvement Contractor. Not Applicable ❑ G'Al,ly J_- X140 / 5-6 7.�,() Company Name / Registtlrati n Number O/6 � /, - ., Address Expiration Date Telephone II/3� � `��/C 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...... EF- 11. - Home Owner Exemution 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$-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors I] Accessory Bldg. ❑ Demolition ❑ New Signs [a Decks [jam] Siding[0] Other[I7J Brief Description of Proposed V oil ���` \ Work: i), �4Dtl SU7�c.�4�sSLlhc,, f/t��',�,y� �i�:•,t1 ��c,cl�, ��Qiw,��J LAM( Fa©1 P�l4 Alteration of existing bedroom Yes No Adding new bedroom Yes �No Attached Narrative Renovating unfinished basement Yes _ i-/No Plans Attached Roll -Sheet ea.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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, c—l.ZA L��4 b as Owner of the subject property hereby authorize to act on my beha in all rs re rk authorized by this building permit application. �fY _ *nature of Owner Date I, CA);,) j 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. (�fH ,,l T- JL EL Print Name Signature of Owner Agent Date T� 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 i 30 Frontage Setbacks Front 127 Side L: 1-1 R: 3 L: R: Rear �� ► Building Height Bldg. Square Footage j�W % Open Space Footage % (Lot area minus bldg&paved SYSv #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW g4gh YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on 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 or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permfi Building Department Curb CutlDrivewsy Permit - 212 Main Street Sewer/Septic availability Room 100 WaterMfell Availability APR 2 2 09 Nbtthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PkWSite Plans Other specify L APPLICATION TO-CONeTRIJdT,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 CL , ���, S St Map Lot Unit ( Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 6 d-q 6 uv--�5 P t e4i6p,M,4 Name(Pri Current Mailing Address: C Telephone ignature 2.2 Authorized Aoent: Name(Print) > Current Mailing Address: 'em 3 S% Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 7-7 6. Total=0 +2+3+4+5) j ,;� c C c' Check Number This Section For OMcial Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0879 APPLICANT/CONTACT PERSON GARY J RUEL ADDRESS/PHONE 50 SUNBRIAR LANE LUDLOW (413)519-5465 PROPERTY LOCATION 25 WILLIAMS ST MAP 32C PARCEL 259 001 ZONE URC(100)/ 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 SONOTUBES/DECKING ON 2 PORCHES FRONT PORCH ROOFING (SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 97190 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO)ZMATION 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 c; / 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. BP-2009-0879 GIS#: COMMONWEALTH OF MASSACHUSETTS k='1VMgp:Block:32C 259 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: BUILDING PERMIT Permit# BP-2009-0879 Project# JS-2009-001287 Est. Cost: $12000.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GARY J RUEL 97190 Lot Size(sq. ft.): 4399.56 Owner: KATZ ELIZABETH D&LETICIA S MUNOZ Zoning:URC(100)/ Applicant: GARY J RUEL AT. 25 WILLIAMS ST Applicant Address: Phone: Insurance: 50 SUNBRIAR LANE (413) 519-5465 WC LUDLOWMA01056 ISSUED ON:412812009 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE SONOTUBES/DECKING ON 2 PORCHES, FRONT PORCH ROOFING (SAME FOOTPRINT) 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 4/28/2009 0:00:00 $72.003084 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo