24A-005 Information and Instructions
Massachusetts General Laws chapter 152 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,
express 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."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone numbers)-along with their certificate(s)of
insurance. Limited Liability Companies(UQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Ee 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. Should you have 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 Towp 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 permitnicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and tinder"lob Site AddrW the applicant should write%II-locations in {city or
town).-A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
Applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit must be filled out each
yin.Where a home owner Orvitizen is obtaining a license or permit not related to any business or commercial venture
(Le-a dog license or permit to burn leaves etc.)said person is NOT requiredto.complete this affidavit.
The Office of Investigations would like to dunk you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a ball
The Department's address,telephone-and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidea
4lfice`of Investigations
604 Washington SUvet
Boston,MA 02111
Tel.#617-727-4940 ext 406 or 1-877 MASSAFE
Revised 11-22-06 Fax#617-727-7749
www.mm.gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
IA
Name(Business/Organizat' ndividu \ \ �-.A
Address:_[`?- L 6,L . QX
City/State/Zip:L�J MA 016 S--"j Phone.#: I/!3 9'F64J
Are you an employer?Check the appropriate box: Type of project(required):
1.El am a employer with 4. ❑ I am a general contractor and I
Sr gees(full and/or part-time).*
have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.x 9. E]Building addition
required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL
insurance required.]t c. 152,§1(4),and we have no 12. oof repairs
employees.[No workers' 13.❑ 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 thin hire outside contractors must submit a new affidavit indicating such.
=Conductors that check this box must attached an additional sheet showing the name of the subcontractors 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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 up to S 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 DU for insurance coverage verification.
I do hereby ce er the pains a of perjury that the information provided above is true and correct
tore• � �
i '"�—`
ate:
hone#:
Official use only. Do not write In this area,to be completed y city or town q ffwkL
CIty or Town: Permlt/Ucense#
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 4-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.Q 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....... tY'' No...... ❑
SECTION 5 DESCRIPTION OF PROPOSED WORK(chack all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alteration(s) ❑ FAddition ❑
Accessory Bldg. ❑ Pool ❑ Other ❑ Specify:
Shed t] Fence f1
Brief Description of Proposed Work: Building Height: i - Num of Stories: Building Area:
�Y-� �2-Y'�L�- �l r►.� ESL._ �`+'��+ , .
SECTION 6-ESTDUTED:CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Offieia .U se Only
completed by permit applicant
1. Building (a)Building Permit Fee
�UV Mttip)fer
2. Electrical ;tb)Building Area
from Section s above
3. Plumbing
4. Mechanical(HVAC) Buildiing Persait Fee „O
5.Fire Protection p
-s
6. Total=(1 +2+3+4+5) VCheck Number:,:,:::: .0
SECTION 7a. OWNER:AIITSORIZATIniY TO-BE.COMPIrETED:>WHEN d
.OWNERSAGEP[T.OR CONTRACTOR.APPIdES<FOR B mmngG:PERMTF.
in as Owner of the subject property
hereby authorize _ 4��. ✓LG,_ .- to act on
my behalf.in all tters relaUvWW 151orfeauthorized by this building permit application.
Signatuiew Date
SECTION::7b-OWNERMIJTHORIZED AGENT DECI:ARATION.
I• �""`� !�"� as Owner/Authorized Agent
hereby declare that the s tements and information on the foregoing application are tFtre and accurate,to the best of my
knowledge and belief.
Signed under the pains d penalties of perjury.
<-F"'o -
Prin
Signature of Owner/ nt Date
Tax Collector Affidavit
This is to certify that,in accordance with Chapter 74 of the Acts of 1996,the persons and properties named
herein have no uncollected taxes,fines,fees or other charges owing to the City of Holyoke that would prevent the
issuance of permits.
Holyoke Tax Collector or his designee Date
Rev.11.9 7jt
n (XW,of Na"mpton
The Commonwealth of Massachuseitsll,n _ Zwoling-
State Board of Building Regulations and 212 Main Street
Standards
RoOrn 100
Massachusetts State Building Code'-
780 CMR NOmpton:MA 01060
_phone 413-587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR.RENOVATE ONE''OR TWO FAMILY DWELLING
This.Section For Official Use Only
Building Permit Number. Date Issued:
Sigriaturc
Building Commisatomr/Inspector Date
SECTION 1 SLTE INFORMATION.:
1.1 Property Address: 1.2 Assessors'Map,Block,and Lot Number:
li ', 1:^.fill � t
Map Block Lot
1.3 Zoning Information: 1.4 Property Dimensions: Comet Lot Q
Zoning District Proposed Use Lot Area(sf) Frontage(ft)
1.6 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/ I �
1.7 Water Supply(M.G.L.c.40,§54) 1.5 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone ❑ 'Municipal ❑ On site disposal system❑ C
-s
3ECTIOPI Z PROPERTY OWNERSHIP[A=ORIZED AGENT "
2.1 Owner of Record:
�,�,,,r � S'h��•a,;�� � I l 11.E a !� rat � (".. v
Address for Service:
Signature Telephone
orized Agent;
1 (� - L- Vuy
N t) Address for Service:
j 3 53Y XX
S gnatuue Telephone
SECTION 3='CONSTRUCTION SERVICES.:..'..
3.1 Licensed Construction Supervisor. Not Applicable ❑
licensed Construction Supervisor: LAcense Number
Address Expiration Date
Signature Telephone
3.2 Registered Home rovement Contractor. Not Applicable ❑
�. 1--✓cam--_ �;��2E��'
Company Name Registration Humber
t22 (2 /!� y-
Ad Expiration ate
Signature Telephone
L
BP-2008-0468
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2008-0468
Project# JS-2008-000695
Est.Cost: $8400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 149288
Lot Size(sQ. ft.): 36503.28 Owner: ST MARTIN THOMAS P&ANN M
Zoning URB Applicant: TIMOTHY J LUCE
AT: 211 NORTH ELM ST
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON.1013112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/31/2007 0:00:00 $25.00537
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo