35-151 (3) The Commonwealth ofMassachitsetts
E i Department oflndustrial Accidents
Office of Investigations
s; u r : 600 Washington Street
i f Boston,MA 02111
r =y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: ' F,fri
City/State/Zip: r C �� ?� Phone#: '3 CY) 4n5i 15 -
A,r�e,y�o n employer?Check the appropriate box: Type of project(required):
1.IJ+�I am a employer with 0 4. ❑ I am a general contractor and I 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.$ ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.E]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Ropfrepairs
insurance required.]t employees.[No workers' 13. they
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 then hire outside contractors must submit a new affidavit indicating such. .
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 1 �,
Insurance Company Name: h
Policy#or Self-ins.Lic.#: �C�' -,�-�`� Expiration Date:
Job Site Address: City/State/Zip: 1 1 'i `r.e- ,
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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and e p 'ns d penalties ofperjury that the information provided ab is rue and correct.
Signature: Date: �r
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Branch Nacre: , Date: Tfi DHotniq arv`rori<s Y -r.
dAlla The Rome Depot At-Homo Services
345A GraclOrood Street,Worcester,MA 01607
Brunch Number, r Job ik 1 jd Toil Free(W)657-5182; Fax:506-756-2859
.. Fadaal to a 75.2""O Ads Ua s C 0439 Rf Cmt U40 16a27
CT L o a 565522; MA Home Imlawemmi Coatnetor Rag.M12W9.3
Imtalladon Addrees: :
Lost 4 DWb 0*00wo
Ptaahaaer{s):
Lie.M& Mawr. W ! P
Rosa$Adglrea:
(Ifdtffat*ftm Lasts Won Addy=%)_ City State Zip
E-miit Address(to receive update's and promotions 8om 7be HtxnoD poi):
t
Project Wormatlea: I/Wallou t`Parchava"j,the owsars of the pMperty located at the abo%c installation ad:bess,offer to
contltsot with TtiD At-Romc#ian!foas,Jr DapoO to&umslrt deliver and for the installation of all material
as described on the attadved spec Sleet 0„� incorporated hommft rbfatlm and matte a part hereof
ttJ K �
Home Depot reserves the mutt a cancel this amuse V,apaa-004axpeetten of the BonsrDOW deferminea that it
cannot pa Fa Its obtipti#*die to a stmetnral problom with the beate,pricing eivoft or beasuee work required to
complete the Job was not tat furled in the.Spec Sheet or Courser.
DRPOSIT Y*Tmxw OPTiOT&�
'�.. (skd*cttoaatdverftta+alm SNOW croditoppove.)
CONTRACT AMOt7NTX' 3' t. CIO**,Cashion tamer or U8 PMW swvtos Looney oedor
poyiale w-no do us DoPOt). .
tLESSDTPOSIT f/ 2. craft CaRro nod/areahorPOW!atWdow-Onto0"selim
BALANCE DIME-' bdYluaCa Dluver A �.
ON COMPLETION;_ S f7�e Noma l7gwt Flans tatprove t.l�oraa Tbm Homy DoW 4aalt Cud
tMiatmem 2594 of Contr"A@W401 due upon �+r AlcouN El Exl i� Aabeaaet [!]tom a tdbCC t�laLY)
a:ecwdm of d h contract. Moy"cram:7 �D rim.a HDCC(MLY)
..`.ni:
IauUaate layaaes(mneiied For Aocak FLy 7itil:
BALANCE DUE QNQION: Cry
tiowasitYppaanowtundt �..?
SAE)3 �7�7 «>>fy nw/oar*Asture T;elovv,'I/We sg+ree toailow Rome Depot to
cbwV the above mfouncoo ara&cwd the fo
. •Wbea you trda a abode err al 460 Mlmtiae as ddw
to uw iohama ice tram year chcd 14mW a a owadme doe000k Citdb
` Hnd m6 ft ftam raw Now Oita unison die psyn ow o a
arnmcuae.cobra ere taK is> maNa►from yow cheat to or HI)CC Aa Codas
meta r Baruoon Gad oomfa.reads axY b e wwwro n fiam
your aawa t v rasa re the payw&4 is reoiv4 and you will mot Final payment
naivoyanvdtmkbaeJt. # #
Pnta:haser agters that,itmrtediehefg'upon oaaomnpplotion of the work,Pnrehtmer will mwm to.)E:Carapietion Cartifieatm and pay any
balance due Purchaser aka to be yointiy cad teroersRy abRdit and Ikble lretcuntlpr
Eatim •This aX%cm ut sod its awwWparyt..ia�s>pY oilplate agraatrleat
between the parties trod tan apt be anandod or atodified unkae--in writing in a separate agreRmteot dgned by both parties.
N O110E TO PIARC'$A38R
Do not alga this wadract bd aV yea read IL You srr eettttted to s co Mk"espy of the contract at the time
you sag, Keep it to pro*your.%b Do not riper a Completion Card lgate brt�re this project h eompleto. Law
proldhu boss repair coat{aetatht tram rquesdag ar speeplhaa s:Compledon Cerd tare s wli by the owner prior to
the actual completion of the work gob*performed wader the contract.
YMr nay cancel this Iran utlow say dun prior to udd alot of die acid business day#tar the daft of this contract. See
Nntiee of Caneegadon for sa explsaaden of this rW There wlll be a r[reke3 pre equal to 10%of the contract
netonat N job is oals"Red b)!Purchaser AFTER the thbd business day,bit BE maserink are ordered.Tbam will
be a service charge equal%4. 5%.ot the contract amount N job.b cancelled by Pueebaw AMR notatisbn are orderaiL
BY MY/OUR SIGNATURE$BLOW,VWEt UNDERSTAND THAT THE AGREEMENT MAY HE SUBJECT TO REVIEW
OF MY1OUR CREDIT tu%rORY ARID I/WE AUTHOPIZE jdQUE DEPOT TO VI ERWY AND REVIEW MY10TJR
CREDIT RECORD WITH Aj`I MEVENDENT CREDIT REPORTING AGENCY AND RELEASE THEM-FROM ALL
LIABILITY INCURRED FROM WADVERTENT OMISSIONS OR ERRORS.
BY MYJOUR SIGNATURE BELOW,VWS AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. YWE
ACKNOWLEDGE RECEMr OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF HE NOTICE
OF CANCELLATION.
suEm TIED BY: v , DO= �Z Aft
qnx �r
ACCEPTED BY: Dste: t1
Parchseer
Date:
thadfaxr
NOTICE:ADDrj1OKALTERMS AND CON DITIONS,ARM STATED ON THE REVERSE SIDE
AND ARS PART OF THIS CONTRACT
9-21-07 tev4-2-017 C-W % te—eranchFio Ydbw—Caetaher AltVt—S WConsutlant
S •d XUJ 13C83SH-I dH Wuu0 cG 8002 S2 .add
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Suoerrsor: Not Applicable ❑
Name of License Holder.
License Number
Address Expiration Date
Signature Telephone
9_Registered Home Improvement Contractor: Not Applicable ❑
Comoanv Name Registration Numb r
Addre Expiration Date
Telephone Q
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. Iio .e Qwne"r Egempd6n
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. SLZth 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
SEC T!ON DESCRIPTION OF PROPOSED WORK{check all aoolicabie)
I
New House Addition ❑ Replacement Wipdows Alteration(s) (� Roofing
I—t Or Doors f F
Accessory Bldg. l Demolition ❑ New Signs [I]] Decks [CJ Siding [Gi Other[Q]
Brief Description of Proposed .-}---
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if New house and 6' r addition to'exist►ng housing, coriialete 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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATIONTO:BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property G—•
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applic tion.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the state, ents a—FE information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under tfuains and penalties of perjury.
Fri Nam
e
i'
icnat, e cf Owner/Agent Date
. ^
�
1 Section 4. ZU)NIN(i 1 All Information Must Be Completed. Permit Can Be Denied Due To incomplete Informatt' n
Exist;nz Proposed Required by Zoning
This column to be 511ed in by
Building Department
Lot Size
Setbacks Front
Rear
Bldg. Square Footage %
Open Space Footage %
us
(Lot area minus bld-2&paved
A. Has aSpeciai Permit/Variance/Finding ever been issued for/on the site?
/=� YE� �~��/�
NO \/~� DON7KND0/ �~/_�
IF YES, date issued:-
IF YES: Was the permit recorded at the Registry of Deeds
NO �� DONTKNOYY YES\.�
!F YES:` enter Book ( | Page/ / and/or Document#|
B. Does the site contain a brook, body of water orwetiands? NO 0 DONTKNOYY 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tubeobtained x~-\ Obtained v-\ Date |ssued' '
�~� �~/ . .
��
C. Do ahysigns exist on the property? YES \ NO \�/
IF YES, describe size, type and location: �
D. Are there any proposed changestooraddidonsuf signs intended for the prope�y7 YES �~� NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,Sading
va�on. orfiUing)over 1 a�eor�itpa�ofa common�an
that wi|disxu,t over 1a�e? YES NO
IF YES, then a NcrtGamEtomGw��0Vafe—r M�—n-agemdhf Permit from the DPW isrequired,
I Department use only
City of Northampton Status of Permit:
;s
;> �tLjl�inV Department Curb Cut/DmrewayPermit
212XMain SueEt SewerlSepficAvaiia6ility
R om 100 WaterlWell.Avallability
pion, Mr. 01060 Two Sets of Structural Plans
`v, phorie 41;x-587-1240 Fax 413-587-1272 Plot/SitePlans
Other Specify
APPG�l71"6N TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
P
SECTION!,-,SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
Rico zone Overlay District
Elrtt St.District CB District
SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT
2.1 Owner of Record:
V,fV 4cln r=6m �Z;,q ODOM2 Y1,0 low
Name(Print) Current Mailing Addrlss:
Telephone
Signature
4Name rized ent:
ca
cal
Current Mailing Address:
R9z��
Telephone 3-'ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use Only
--completed by permit applicant
1. Building (a)Building Permit Fes
2. Electrical (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fir= Protection
6. Total= (1 +2+3+4+5) Check Number
This Section For Officiat Use Only
Date
Building Permit Number Issued:
Signature:
8uilding,Commissionee/Inspetor o w aings- - - Gaffe
BP-2008-0969
_GlS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: BUILDING PERMIT
Permit# BP-2008-0969
Project# JS-2008-001461
Est. Cost: $1280.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq_ft.): 29577.24 Owner: SCARBOROUGH HENRY F&LUCILLE
Zoning: SR Applicant: HOME DEPOT AT HOME SERVICES
AT. 764 RYAN RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935-2633 O Workers
Compensation
WORCESTERMA01607 ISSUED ON:51512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 si nature:
FeeType• Date Paid: Amount:
Building 5/5/2008 0:00:00 $25.0022557
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
'
764 RYAN RD �� BP-2008-0969
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 151 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0969
Project# JS-2008-001461
Est. Cost: $1280.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(.sg. ft.): 29577.24 Owner: SCARBOROUGH HENRY F&LUCILLE
Zoning_SR Applica OT AT HOME SERVICES
A 77: 7F4 RYAN Rn
Applicant Address: Phone: IUSUrallre:
345 GREENWOOD ST (4)1)935-2633 0 _ Workers
Compensation
WORCESTERMA01607 ISSUED 0N.51512008 0:00:00
TO PERFORM THE FOLLOWING WORI{:INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Phunbing 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:
Ro:a�ir: a'1: Insulation:
Final: Smoke: Final: OK
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
rte,.
Certificate of Occupancy X"4 Signature:
FeeType: Date aid: .Amount:
Building 5/5/2008 0:00:00 $25.0022557
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo