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36-093 (2) 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),address(es)and phone number(s)along with their certificate(s)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 Iegibly. 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 (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 dog 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 Department of Industrial Accidents' Office of Investigations 600 Washington Street Boston,MA 02111 Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass_govldia The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 `'� s• '� www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organm G'tion/Iudividual): c- �- Address: City/State/Zip: /-`C v r`Zf1 4� zl6l, Phone.#: �3 S�`7- �d- Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.0 I am a employer with 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g, Demolition working forme in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. required] 5. We are a corporation and its 10.0 Electrical repairs or additions 3 I am a homeowner doing all work officers have exercised,their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required]t C. 152,§1(4),and we have no employees.[No workers' 13.0 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 then hire outside contractors must submit a new affidavit indicating such. iContractors 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 employee& 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$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 Investisations of the DIA 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: /G� Date: /,2- y-/� Phone#: �/ 1� 5 % 7 t7 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#: .�'Ct1Aa1P�. Lz#y of Nart4allipfor �A'33ACh1i8ttf9 5T DEPARTMENT OF BUILDINTG INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 , HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to act as iris/her construction sup,::.- sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough bulling inspection(before work is _concealed), insulation inspection (if required) and a final building inspection.The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made �, S Cu understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 1 IL,��I& z Address of work location j rt o req C � �"� a r-e e e l7,4 o /o z Fleury Lumber Co., Inc. 231 Main Street Easthampton, MA 01027 Thu Jun 07 15:35:13 2007 3D View This view is a three dimensional view of the deck. Consult your local building department for your correct building code and fastener requirements. Portions Copyright v 1989-2003 Cad Quest, Inc. Big Hammer DeckDot, Version 5.5.0, Copyright © 2003 Big Hammer, LLC. Fleury Lumber Co.,-Inc. 231 Main Street Easthampton, MA 01027 Thu Jun 07 15:35:13 2007 Deck Layout I IL This view is a general outline of the dimensions and/or substructure layout of your'design. If a deck is to be attached to your house, make sure a solid connection can be made. , Your design should be checked by a qualified professional or .inspector. Consult your local building department for your oorrett building code and fastener requirements. Some local building codes require different beam to post connections than what is shown. Portions Copyright ) 1989-2003 Cad Quest, Inc. Big Hammer DeckBot, Version 5.5.0, Copyright O 2003 Big Hammer, L'LC. Fleury Lumber Co., Inc. 231 Main Street Easthampton, MA 01027 Thu Jun 07 15:35:13 2007 Deck-Dimensions for Deck 1 � N N N Deck 1 - - -- ---- -- --- - - - --- 16, Joist Spacing = 16 in. o.c. Baluster Spacing = 3 3/4" Toe Spacing = 3 3/4" Railing Height = 48" This view is a general outline of the dimensions and/or substructure layout of your design. If a deck is to be attached to your house, make sure a solid connection can be made. Your design should be checked by a qualified professional or inspector. . Consult your local building department for your correct building code and fastener requirements. Some local building codes require different beam to post connections than what is shown. Portions Copyright n 1989-2003 Cad Quest, Inc. • Big Hammer DeckBot, version 5.5.0, Copyright c�) 2003 Big Hammer, LLC. • Fleury Lumber Co., Inc. 231 Main Street Easthampton, MA 01027 Thu Jun 07 15:35:13 2007 &Post Layout View for Deck 1 12' - BasePoint CO-- — -- — - . N • N O This view is a general outline of the dimensions and/or substructure layout of your design. If a deck is to be attached to your house, make sure a solid connection can be made. Your design should be checked by a qualified professional or inspector. Consult your. local building department for your correct building code and fastener requirements. Some local building codes require different beam to post connections than what is shown. Portions Copyright 1) 1989-2003 Cad Quest, Inc. Big Hammer DeckBot, version 5.5.0, Copyright 1) 2003 Big Hammer, LLC. Fleury Lumber Co., Inc. 231 Main Street Easthampton, MA 01027 Thu Jun 07 15:35:30 2007 Construction Specifications deck 1: Cohstruction Method = Beam to Side of Post Footing Type = Pier In-Ground Footing Depth =48" Live Load = 40 Dead Load = 10 Decking Spacing = 0 1/4" Joist Spacing = 16" Beam Spacing = 120" Post Spacing = 84" Decking = 5/4X6 .40 Treated Southern Pine No. 2 Beams = 2X8 .40 Treated Southern Pine No. 2 Joists =2X6 .40 Treated Southern Pine No. 2 Posts =4X6 .40 Treated Southern Pine No. 2 Deck Height = 84" Diagonal Bracing =Yes Deck Skirt= No Joist Overhang = 12" Beam Overhang = 12" Decking Deflection Factor= 360 Joist Deflection Factor = 360 - Beam Deflection Factor = 360 Diag Brace Height 1 = 24" in Diag Brace Height 2 = 24" in Railing 1: Railing Height = 48" Baluster Spacing = 3 3/4" Toe Space = 3 3/4" Railing 3: Railing Height = 48" Baluster Spacing = 3 3/4" Toe Space = 3 3/4" Railing 5: Railing Height= 48" Baluster Spacing = 3 374" Toe Space = 3 3/4" Big Hammer DeckBot, Version 5.5, Copyright©2003 Big Hammer, LLC. . Portions Copyright© 1989-2003 Cad Quest, Inc. ' THIS PLAT IS COMPILED FROM DEEDS. PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED Arl 5Z kr TO: GMAC MORTGAGE CORP. & FIRST AMERICAN TITLE INSURANCE COMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTAnON ALL MSIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY # 250167 —NOTE— SURVEYOR THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY —MORTGAGE LOAN INSPEC11ON PLAT— Of NORTHAMPTON, MASSACHUSETTS RAN PREPARED FOR IZER #35032 SCALE: 1 "=50 ' APRIL 29 , 2004 <( SURV HAROLD L. EATON AND ASSOCIATES, INC. REGISTERED PROFESSIONAL LAND SURVEYORS - SECTION 8-CONSTRUCTION SERVICES loe 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Reaistered Home Improvement Contractor: ' , Not Applicable Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completo 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. - Home Owner 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 1 C.�1a c tQ ,. L✓Cr i L . SC,({— SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [ Siding[0] Other[0] Brief Descrif�tio of Rro os_e�! / i Work: a �a G�GV\ C. I a` X 1 �' -t y--e«r o-F house. cyPVs"rc om A_krgtioxisting bedroom Yes Adding new bedroom Yes No tached Narrative Renovating unfinished basement Yes No oll -Sheet 6a. If New house and or addition to existing housing, complete fhe 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date LOC 1 L—' J C,2 as Owner/ 4 AApat he by declare that the statements and in ormation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ev:a l � C Prin Name btf�� - 6 Si nature of Owner/Agent 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 Setbacks Front Rear Building Height (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Vuhance/Finding ever been issued for/onthe site? �� NO ��Y DON7KNOV� �~� YES �~� IF YES, dateissue& | -----------'— IF YES: Was the permit recorded at the Registry of Deeds? NO ~_~� ) DON7KND YY 0 'E S |FYES' enter Book � Pagel | and/or Document#� } . �� B. Does the site contain u brook' body o[vvoterorwetlands? NO ��/ DDN7 KNOW �_� YES v~�� IF YES, has permit been nr need tobe obtained from the Conservation Commission? Needs tpbeobtained y~�� Obtaned �-� Date �-� ' ' ' L____--_____J C. Do any signs exist on the property? YES K ] 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: | L__-_____-_--------'-------- E. Will the construction activity disturb(clearing,gradin on. or filling)over 1 acre oriait part ofo common plan that will disturb over 1 acre? YES �� ) NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 1 City of Northampton __---- r h}X4 4 �j �Building Department x:12 Main Street � -�"l""" j Room 100 Ifil�� I yailabt � �T �a U'v `+ 2 N&Mampton, MA 01060 phone 413-5871240 Fax 413-587-1272 F-APPLICATION TO-CDN'TTRUCT,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 (1'Q- c-e—K Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ste}0 L 6c k L,Sc--,-ff R3� Ala(e-V)Lt- , Name(Print) ✓ Curren Mai i '—ng Address;, I S 8'1 � 1 �5— t t n Signature a epho 2.2 Authorized Agent: Na 1mr/e(Pn t) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building- deic-K- �� (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 cr 6. Total=(1 +2+3+4+5) (0 o , �� Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-1272 APPLICANT/CONTACT PERSON SCOTT RICHARD A&LORI L ADDRESS/PHONE FLORENCE PROPERTY LOCATION 839 FLORENCE RD MAP 36 PARCEL 093 001 ZONE SR 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: CONSTRUCT 12 X 16 DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FO OWING 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 ssion zoa ''J 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-2007-1272 Gl$#: COMMONWEALTH OF MASSACHUSETTS Map:B = 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-2007-1272 Project# JS-2007-002033 Est. Cost: $969.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 32234.40 Owner: SCOTT RICHARD A&LORI L Zoning: SR Applicant: SCOTT RICHARD A & LORI L AT. 839 FLORENCE RD Applicant Address: Phone: Insurance: FLORENCEMA01062 ISSUED ON. TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 16 DECK 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 7/13/2007 0:00:00 $50.00452 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo