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32C-319 (17) 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 foregoin 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 dw-ellina 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 Iocal 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),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)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. 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. 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 Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has prodded 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 .(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 year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i_e.a doh license or permit to burn leaves etc.)said person is NOT required to complete this affidavit ... ' The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number: The Commonwealth of Massachusetts flidus al--Acciden&= Office of Investigations 600 Washin©ton Street Boston,MA Q2111 Tel. -14-11617-727-41900 ext 406 or I-877-MASSAFE Revised 11-22-06 Fax n 617-727-7749 'Alw-yv.mass-aovEdla The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,M4 02111 www.mass.gov/dia -Workers' Compensation Insurance Affida`-it: Builders/Contractors/ElectricianslPlumbers Anaiicant Information Please Print Leoibly NaMe(Business/Or;anizarion/Individual): Jon( �G(o►^4�PSa*-( Address: 266 I w )` City/State/Zip: 66� A- 0(o?2- Phones: 6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I have hired the sub-contractors 6. ❑New construction employees(full and/or part-time).* 7• Remodeling, 2.[X I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have g. ❑Demolition �, employees and have workers' 9 ❑Building working for me in any capacity. addition [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑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 MGL 12.❑Roof repairs insurance required-]t c. 152,§1(4),and we have no employees. [No workers' 13•7 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 subtrdt this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicators 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 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: — Policv#or Self-ins.Lic.m: Expiration Date: Job Site Address: City/State/Zip Attach a copy of the workers' compensation policy declaration pane(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 DLA 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:40- L G- Date: 3 /3 200 —-- Phone 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): \` I Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person- Phone SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ,JOI-1 X10 tnti PSO i•l 4214-++- License Number 266 1��H�4w. L+rw �er+� �jhJf�Sl3J 1 MA 01072 11,5 Address Expiration Date fIg -2 SS9- 1(,2-0 Sig ature Telephone 9,,Retr stied tiome groyeMent Cont=W: Not Applicable ❑ _.7G�►-lo rM P5ow1 (244?&,J•c-Z --eJ 1 LD6-W— //1f72- Company Name Registration Number 26b? SI�1)1r*9J Y)A4 olo?z 11612W9 Address Expiration Date Telephone 4/3 25r-1620 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....... 9Y' No...... ❑ I1 - Home Q*vner 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 S-DESCRIPTION OF PROPOSED WORK(check altapplicable) New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing [� Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding[O] Other[0] Brief Description of Proposed Work: �Q, �,FavN 04T1,ol+�I. Ste- ,Sd 14,P 'J Alteration of existing bedroom Yes�_No Adding new bedroom Yes >_No 1-)014 N � Attached Narrative Renovating unfinished basement Yes _ZNo Plans Attached Roll -Sheet sa. if New house and or addition toexisti6a,housing,cam late the(olfawin ': a. Use of building: One Family Two Family X_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. 51 Dimensions e. Number of stories? I- f, Method of heating? U/O nQ t7IL— Fireplaces or oodstove Number of each g. Energy Conservation Compliance. Ye5 Masscheck Energy Compliance form attached? N 57 h. Type of construction WOOD F,eawt& 6/19) i. Is construction within 100 ft.of wetlands? Yes __X1_No. Is construction within 100 yr. floodplain Yes 4—No j. Depth of basement or cellar floor below finished grade *r 6A-+4-c>6- 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 )r2nl C- tueso.1-J to act on my behal in all matters relative to work authorized by this building permit application. Signa a of Owner Date 1, )orb G 'Ho M IN,0rJ asQwrter/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. Job C �rt0IAAp5014 Print Name Signatu of4AwrodAgent 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 Zgs Side L: 3d R: ��' L:,-,-, R:. Rear SO Building Height f Bldg. Square Footageap Open Space Footage (Lot area minus bldg&paved parking) #t of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued forlon the site? NO DONT KNOW 0 YES Q IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO K7% DON-r KNOW Q YES i IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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. Q � R, �I�,;3Q� ilk 178j�a�tClettt ltSe t�C31�;, ,•" - _ `� Cit y;of Northampton Status pf PermiL. ., 80f1Z �UringDepartment #emit bv� Main Street Sewed ptjcAoaillabilityr . ` � Room 100 Na'>;erAAfelt,4w�aitai�lity -�-tr — o aTpton, MA 01060 Ewa s #sof Strcictttr i i?lans i�0 - ". 240 Fax 413-587-1272 PtfltlStte Piz�tt 1 others ecI 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 completed by office Map L2 01 Lot 3 1 Unites Zone Overlay District Elm St.District Ce District�,� SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: hof—n4 4v-��^ri Name(Print) Current Mailing Ad less: -0,6; 76-86 Telephone Signature 2.2 Authorized Agent: ) )o.J C_ lao wt PSOn1 66 PEA*" 4Lt— !-P&6,gLj � Name(Print) Current Mailing Address: s.t_. 2sg - /620 Si at re Telephone SECTION 3;ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by rmit applicant 1. Building $ 'G�C��G ,00 (a)Building Permit Fee � 2. Electrical IJA" (b)Estimated Total Cost of Construction from 6 3. Plumbing Alk Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number d i` This Section For Official Use Only Buildin Permit Number: Date g Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2008-0782 APPLICANT/CONTACT PERSON J C THOMPSON CARPENTER BUILDER ADDRESS/PHONE 266 PELHAM HILL RD SHUTESBURY (413)259-1620 PROPERTY LOCATION 1 VENTURES FIELD RD MAP 32C PARCEL 319 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction: JACK UP BLDG&REPAIR FOUNDATION New Construction Non Structural interior renovations _ Addition to Existing Accessory Stricture Building Plans Included• Owner/Statement or License 042444 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Z X04 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. �� ,�, i � S � ►,ice E�ii1d �J �J'� City of Northampton BUILDING INSPECTION LABEL APPRO E [3 Inspector Date RD COMM NWEALTH OF MA.SSA.CTWSE TTS : :; CITY OF NORTHAMPTON PF. SONS CONTRACTING WITH UNREGISTERED CONTRACTORS extnit: Buildlna. DO NOT HAVE ACCESS TO THE GUARANTY FUND (AJMGL 042A) t gory: N� P Perrnit`# BP-2t?t}8M782 Proiect# JS- 008.001103, Est.Cost: $90000.00 Fee: $450.00 PERMISSION IS REREI4'Y GRANTED TO: Const.Class: Contractor: License: Use Group: J C THOMPSON CARPENTER BUILDER 042444 Lot Size(sa.ft.1: 71002.80 Owner: JAMES BEN ni ini URC Applicant: J C THOMPSON CARPENTER BUILDER AT: i`VEiN J i RES FiEL Applicant Address: Phone nsurance 266 PELH.AM H LL 413 259-1620 SHUTESBURYMA01072 l SS UED ON.-1124 12008 0:00:011 TO PERFORM THE FOLLOWING WORK.-JACK UP BLDG &.REPAIR FOUNDATION il 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. IWO Certificate of Signature• FeeTYpe: Date Pala:_ Amount: Building 3/24/2008 0:00:00 $450001300 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo \YY A�