24D-119 (4) Mar 26 2014 7:20PM Realty Rate/VBC 4138250219 page 3
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The Commonwealth of Massachusetts
Department of Industrial Accidents
-a Office of Investigations
I Congress Street, Suite 100
r y� Boston, MA 02114-20771
www mass gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Co ntracto rs/E lectricians/Plu in bers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual).' Adam�efldede Roohg&Siding,Inc.
Address: 1�,0 wMel-n
City/State/Zip: Phone 9: y13'S3t,- S9SS
Are you an employer?Check the appropriate box: Type of project(required)
Eal am a employer with 16 ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
1❑ 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 for me in any capacity. employees and have workers' 9 ❑ Building addition 1
[No workers' comp. insurance comp. insurance
required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.FRoof repairs
insurance required.]r c 152, §1(4),and we have no
employees. [No workers' 13.❑Other __
comp. insurance required.]
*&n% applicant that checks bo\#1 must also till out the smUun bcluw showing their wvurkars'cumix:nsation pt.licy infonnaUon.
I liomeowners who submit this affidavit indicating thev are doing all wwk and then hire outside contractors must submit a new affidavit indicating 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 hark
erttployees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is prmd&ng workers'compensation insurance for my employees. Mow is the policy and joh site
information. 1 _
Insurance Company Name: t(
�1 ( —_-
/} Expiration Date: a9 f 14
Policv#or Self-ins. Lic. #: l"1'I�t`.�OD'l Dl a�[c 1 oZDI 3 P � ---
Job Site Address. IG of City/State/Zip: — -ftq1 i
.attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
0)Ciao
Failure to secure coverage as regwred 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.
1 do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct.
Sisiattue Date a7 )I q
Phone#
th9kial 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#:
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: -dy a
eeeev a OG &Sjd1eM�jam, License Number
160 g)-)-k i I S
Address ; Expiration Date
South Had"�� ��5
Signature Telephone
,•._ - °" Not Applicable £
Registered_liome;lmprovement'Gontractor �`���._.:._`;; ��_..___�..��_�
Adam QuenneviDe Roofml&Sift let �--
Company"60 Old Lyman Road Registration Number
3 �c3�J1(D
Address Solo Hadkf, Expiration Date
Telephone gJ3 S3,6-S-JA'S
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 bVilcling permit.
Signed Affidavit Attached Yes....... £ No...... £
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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition Replacement Windows Alterations) Roofing
Or Doors Q
Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks IM Siding(Di Other(oj
Brief D cription of Proposed -' �,
Work: �D;rnbJC 4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
, - F,,..- _ t ? t'.�',�'
sa 1U New°=':house'antlror.ak I low Gt extstlna.houstna ,compl�t�the foll wlnc> ,
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 AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES'FOR,BUILDING PERMIT -
I,_ v 0aw 1 nh t ,n- a1C_°_ as Owner of the subject
property �— /�T
hereby authorize Aactm Uri cy ne yf /(Q- P—oc p' 5 ,--S"4cbyk9, .-2D)(—.
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I,. ( Q rYl l W �►fDJ� 161-•T044y -�-" tc1b rw . i C as Owner/Authorized
Agent hereby declare that the statements and information on the oregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
21� fYl l Ctl qQ.0 i 1
Print Name.
-3
Signature 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
Lot Size �T—~---�-
Frontage
Setbacks Front
Side L: —= R:= L:= R:=
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved L—!
parking)
#of Parking Spaces `
Fill: J I
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book ~� Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size,type and location: l
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO a
IF YES, describe size, type and location: i I
E. Will the construction activity disturb(clearing,grading,expavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e a ti"g n
M.
City of Northampton SCatuai*Pgm, ,
Building Department T
—;
6! 212 Main Street 54 eptic
`. sc
1 '.J Room 100 atereAva�la lllt} � w��
i APR 2 2014 '`'*:k hampton MA 01060 Tuv e s s#"
ho .13 587-1240 Fax 413-587-1272 r�i�o ZPt Yi -
L` _
F ';:,s Ir ?ter54'di j � E
ctr.c r...,. .,10£0 - - -- - -;�^-�� i�' .s��'�-
PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR D€MOLISH 6NOoq TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION :.
•-
�s
1.1 Property Address: f }�
�O b Map- ���� L '� ;�•- '�- U"rtJt
.L
�4'vit�4-if�
`Ae rtes f Qt.a� e
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT::,.
2.1 Owner of Record: k
Name(Pr'nt Curre Marli_ng��A� �dress:
(l �� IL ` 1 .S�•I
�y ( j <R(1 �t Telephone
Signature
2.2 ' �Authorized Agent:_
,dam rwy: CP "(b4')2 &-p old a-In _
Name(Pr t) Current Mailinid Address:
y13-53 L
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building `:(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 O`
6. Total=(1 +2+3+4+5) 01 Check Number
This:Section Foe Official'Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commission4finspector of Buildings Date
206 KING ST BP-2014-1021
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 119 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1021
Project# JS-2014-001769
Est. Cost: $4260.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ADAM QUENNEVILLE 070626
Lot Size(sc. ft.): 15942.96 Owner: VALLEY BUILDING COMPANY INC
Zoning: HB(100)/URC(0)/ Applicant: ADAM QUENNEVILLE
AT: 206 KING ST
Applicant Address: Phone: Insurance:
160 OLD LYMAN RD (413) 536-5955 () Workers
Compensation
SOUTH HADLEYMA01075 ISSUED ON:41712014 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 4/7/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner