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The Commonwealth of Massac zu.ve is
Department t f lrtdavir ial Accidents
Office ofInvestigations
1 Congress Street, Srrlte 100
UV Heston,a►'fA 02114.2017
wrtr.Mass.govIdia
"4 orkers" Compensation Insurance Affidavit: Builelers/Contracctorw/E l ctricians/P'lumbers
Applicant,Information Please Print Lc Xilrl
a2rt {I3t.�irsc slC}r attixattiaztJttadi�idual :�_ Lm r-J
Address:-- 109 Val�S T
.1tV. s-r
C /s w/zip, ANIM-t ' tatae .
AA WijSr % � 413 Sti6 1633
Are you an employer?Check the appropriate boxy� Type or project(required):
I.El T at a employer xvitlt 4. F1 I am a general contractor and T . �]N ww cotrstruction.
nplo ees(full and'tar part tune).* have hired the sub-con ctors
? 1 am a sole}.proprietor or partner- listed on the attached sheet. 7. 1'�emode:ling
strip and have no employees These sub-contractors have 8. F1 Demolition
working; for me in any capacity. employees and have workers' e3, []Building addition
[No workers'comp, insurmice comp. insurance,.*
required..] 5. [3 We are a corporation and its 1 Q,C] Electrical repairs or additions
3.0 l am.a homeowner doing all work officers have exercised their ►1,(] Plumbing repairs or additions
myself [No workers'comp, right of exemption per h4GD 11Q Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13,Q Other .
l comp, insurance required.)
*An} applicant that checks box#1 must also lilt out the section below shmving their worLers'compens€ttiort policy information.
#I to meownert;who s burnt this affidavit indicating they are doing all work and then hire outside contractors must submit a new altidavit indicating suds
wCSntrators th;tt check this bast must attached no additional sheet showing the»ante of the sub-contractors oast state wheclicr or not those untitics have
emptoyecs, If the sub-contractors have employ s,they must provi de their wieners'ct,tnt>.Itulicy numtscr.
I arrr air entpltc yer that Is providing workers'compensation insurance for"ty ernplgi ees. Below is Ilse policy and job site
information.
Insurance Company Dame: ._..._. _ ...
Policy#or Solt"-ins.Lic.#: Expiration Date:
Job Site Address; �. T CitV/State/zip: ___..
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration(late).
Failure to secure coverage its required under Section 25A oflvlGlw c. 152 can lead to the imposition of criminal penalties of
litre up to$1,500,00 and/or nine-year imprisortment,as well as civil penalties in the forrii of a STOP WORK ORDER,and a fin
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 ILIA for insurance coverage verification.
I do herebtr certi�r+u z/re asst qndanaliies e er'rtrY that the in rartrratitttr Irrravidr"ri above Is true and correct,
F'honc#:
(Yfrcial use earls*. Do not write In this area, to he comptet d by eity or town officiol.
City or Town, Permit/License#
Issuing Authority(circle one);
1.Board of Health 2. Building Department 3, CityA*own Clerk d. Electrical Inspecto• 5.Plutttbing inspector
t.(]titer
Contact Person: Phone
SECTION 8-CONSTRUCTION SERVICES-=
3.1 Licensed Construction Supervisor: Not Applicable ❑ ^
Name of License Holder: RL��dJ J'` I�A�''� CS - o42S-74
License Number
_109 4A9L-,=Y A, 013 �� 6 f 2.e I Z01
Andress Expiratioii Gnat.
I3 SYG 9� 3�
signatur Telephone
9. Registered Home I nprovement Contractor: Not Applicable ❑
At-,jO- Jet • l4,�-LA X764 G _
Company Name Registration Number
107 W(�5f- to i3 ?,U� -
Address d
Expiration D te
^
Telephone `f11 sib-1 G33
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§ 25C{6})
tiNlorkers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
n the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
11 - Home Owner Exemption
Tlie ciuieiit e-:ent?tiorifir"luuiieoaliel s,was e-,deruded to iiichide Clwiier-occupied Dwrllfn_s ofone (1) or hvo(2) Eimilies
.uul to allow siiclilioilieoiiiier to ei>vsage aiiiiulividim1for live whir does iiot possess a liceirse,provided that the owner acts
as supevtiisoi% C'NIR 780, Siartli Edition Section 1113.3.5.1.
D efiiution of Homeowner:Perscm(s)wiuo ow71 a parcel oftand on which}ie/she i esides or intencls to reside,on Nvhicli there
is. or is hilciuled to be, a one or tivo Jill IUh-(INve ffing,attached or detaclied striictiue: acces�oryto sucliuse aii& or fu-ni
straichures.A person mlio coiiOivcts inor•e tliall one home ill,i tivo-vearpeiiod shall not be consiclerecl a homeowner.
Siuh'hon>eoi471er""slLall saibni t to the Buildiit;Officbl ono fojiii acceptable to the Builcli lL,O fici<il tli:it lit,'sli►e shrill 17e
responsible for:ill sucli iiaik pei•foiinetl under the ixuldiiia permit.
As actn> C'onstriction Supe.i-visor yams-presence on the Job site will be requi-ed fi-oiii tiler to tniie, chum uid anion
coiilAtAion oftlie�,vork for xvhidi this perri>it is issaiecl.
Al o be ad%-i�ecl thit`vitlirefereiice to CImpter 152 r�V cu•kers" aiul('.hipter 153 (Liabilit s to
Fii>j)kyees for iiyiir s not resukilg iril)eath)ofthe Nl i:sachii.etts GeilenalLaw•5: uiotated,you m:ay be liable tier pea soiif s)
�ro111>v e to peifirniivork liar yoiiiuuler dais peiritit_
The iuiclei sipied-honieois7>er"certifies wid assiunes respoiisibiuy fi)r coiij)h-uice with the State Biliklni Code. Cite of
Nortivaij)tonOrduLdices.State aiul Loca1ZoiLui;:LmNN quid State ofltlassadnvett,?C7e11era1Laivs. iuu7tated.
Homeoiiitei•Si,iisitiu•e
SECTION 5'-'DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [Cl] Decks [M Siding [Ell Other[0j.
Brief Description of Proposed
` ���W �l`,1V or s: T�-�tt I`� a AT ti Y'L.JDk
Alteration of existing bedroom Yes V//No Adding new bedroom Yes V_No �
Attached ,Narrative Renovating unfinished basement _ Yes _—No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing hous`ing :Complete the fallowing:
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?
I
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I
f. Method of heating? Fireplaces or vvoodstoves Number of each_
g. Energy Conservation Compliance. P:asscheck Energy Compliance form attached?_
h. Type of construction
Is construction reithin 104 ft. of wetlands?__Yes No. Is construction within 100 yr. floodplain Yes--No
Depth of basement or celar floor below finished grade
i
'�. 'Alill 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
J560 • PAQL Mk tTt-JS t<r as Owner of the subject
property p
hereby authorize Al^� �J M. L�_
to act an nr behalf, in all matters relative to work authorized by this building permit application.
Si ature of ,ner Cate
� ) AL-4-
a s te�`A utho,ized
Agent hereby declare that the statements and information on the foregoing application are true and accurate.to the best of my knowledge
belief.
Signed under the pains and penalties of perjury.
A t y I r-J
='tint Narne
91 -/#. 2J -wig
Sign i,uie otvii*r►i+�r Agent Date
Thr cohnni to be filled mi by
Lot Size
Ft oilta-e
Rear
Opeii'>pace Footage 00
(Lit Effea timus bldg_1'paved
A. Has o Special Pennit/Jaranoe/Fimdiny ever been insued for/on the cite'
rA& ���� ��
N0 n�y DONTKNOVV YES \_�
|F YES, date issued: |
IF YES: VVas the pennit recorded at the Registry ofDeeds?
NO `_�/-� DONT KNOW ��
~�� .E0
IF YES: enter BunkF------ l PaUe -- -` and/or Dooument#|
E. Does the site contain o brook, body of water urwetlands? NO 0 DONTKN[W 0 YES 0
IF YES, has a pennit been or need to be obtained from the Conservation Commission?
Needs tobeobtained \_�/�� Obtained �-\�.� Dut* |ooued' � ---- �
' ' �____-__ _J
C. Do any signs eAeton the pmpe�� Y ��ES \_� NO
- - - -- - - - - l
IF YES, describe size,type and location: | �
D. Are there any proposed changes to or additions of signs intended foi-the property YES 0 NO
|F YES,describe size,type and location: [ -- - - - -- ----- ----------
E. VYiU the construction activity disturb(clearing, grading avaton. or filling)over 1 acre orish part ofacommonplan
that vxUdkstu,b over acre? YES ��� � NO (�)m�
!F YES,then a Northampton Storm Water Management Permit from the DPW!srequired.
]Department use only
J City of Northampton Status of Permit:
�.
JAN 1 2014 Building Department Curb CuVDri 6way Permit
M
212 Main Street ewerleptic Ayatiabtlrty
t — _ __ r_4_..__1 Room] 100 1Na`te'r/NegAVailability
Eed �;
�r�octions Northampton, MA 01060 Two'Sets ofStiructural darts'
`prone! 13-587-1240 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 compieted by office
Unit
4g i.t�3 t� s-r Map Lot- —Unit
il r-J CE' MC Zone Overlay District _
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
R�► •V MrJL LA acY" t ST �c.vritrrcE M/�
;dame(Prin Current Mailing Address: 646 �2�- 2,Q 4
Telephone
Sign K uIe
2.2 Authorized A(lent:
Pi"Ir► M ,
N ame i.Pn Current Mailing Address:
_413 S16 4 632
3ignati.ire ,
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
con leted by ermit applicant
1. Building 2,E- 0 a) Building Permit Fee
i
2. Electrical il (b) Estimated Total Cost of
Construction from 6)
3. Plumbing l 0 v Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+ 3 +4+ 5) 3'' c1 UV (.IV Check Number
This Section For Official Use Only
Building Permit Number: D ate— — Issued:
Signature:
Building Cornmissioneiiinspector of Buildings pate
File#BP-2014-0799
APPLICANT/CONTACT PERSON ALVIN HALL
ADDRESS/PHONE 109 WEST ST HADLEY (413)586-4633 O
PROPERTY LOCATION 44 LIBERTY ST
MAP 30A PARCEL 054 001 ZONE URB(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: RENOVATE KITCHEN&BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 042574
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO IMATION 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
emolition Delay
Signature of Building`Ofricial 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.
44 LIBERTY ST BP-2014-0799
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-054 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-2014-0799
Project# JS-2014-001378
Est. Cost: $34900.00
Fee: $209.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin ALVIN HALL 042574
Lot Size(sq.ft.): 15855.84 Owner: MAITNSKY JEAN PAUL
Zoning: URB(100)/ Applicant: ALVIN HALL
AT: 44 LIBERTY ST
Applicant Address: Phone: Insurance:
109 WEST ST (413) 586-4633 ()
HADLEYMA01035 ISSUED ON:112112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN & BATH
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 1/21/2014 0:00:00 $209.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner