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22D-005 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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 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: 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under t pains and penalties of perjury that the information ovided above is true and correct. Si ature: Date: 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not C.5—Applic�!a**ble £ Name of License Holder: &vi C C,3a,) e b� 7 2(06q License Number Address Expiration Date Signature Telephone ",_"ci 9,Registered Home'ImarovemenYGontractor Not Applicable £ Ji,4,fc Co,,L R c 4-1 o v) 17 (a g Company Name Registration Number C /0- Address S� � Expira� tion Date Wl Telephone 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 Home Owner:Egemption 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 Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other[❑] Brief DescriBtion of Proposed Work: K k(e Kfictier, �Hbh/ i i iaat��t� cvcoX C SAFE" Alteration of existing bedroom Yes No Adding new bedroom Yes �No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a,if Nevin house and'or.add tion to exist 0,housing, complete the foiiowing!: a. Use of building : One Family Two Family 'V Other b. Number of rooms in each family unit: cZ Number of Bathrooms ' c. Is there a garage attached? WrIvo d. Proposed Square footage of new construction. Dimensions e. Number of stories? 6 / f. Method of heating? Cwt-s A'111(le Fireplaces or Woodstoves .Nei 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 i 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 as Owner of the subject property he by authorize t act my beh , in all matters relative to work authorized by this building permit application. Signature of Owner Date 1 � /�y �✓�1 ,as Owner/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. E-e✓I e Print Name 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 Frontage Setbacks Front Rear Building Height Bldg. Square Footage 010 Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces LLD A. Has a Special Permit/Vahance/Finding ever been issued for/on the site? �� �� NO �~/ DON7KNOV/ YES �~�� � IF YES, dateioued� / ' � IF YES: Was the permit recorded at the Registry ofDeeds? NO � DONTKNOV YES IF YES: enter Book Page and/or Document#1 B. Does the dt econ t i n abrook, body of wa t erorwetlands? NO DONTKNOY � YES C) IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tnbeobtained v=� Obtained �-` Da%e |�sued. ' �^� �_� ' �� C. Do any�gnsedston the property? YES v=� NO |F YES, describe size, type and location: D. Are there any proposed changes to or additions of signs inte/ ded fnr the pmperty? YES 0 NO (7k IF YES, describe size, type and location: � J. E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan ' that will disturb over 1acre? YES NO K~ �0 IF YES,then a Northampton Storm Water Management Permit from the DPW iarequired. i�3 s sF . , €7epartmeht use only r. .-°' � of Northampton $atus ofPermit r'"� wr "' Iding Department Gtir cut/Drie�ira'y Perntt#kr' F h 12 Main Street Sewer/SepticA�airabillty Room 100 Water/IAtelCAvatlafJthty I� 08!- rth mpton, MA 01060 Twets QfS#ructuri Plan$' a -1240 Fax 413-587-1272 PIot/Slte Plans A Plumbing Otfier_5�eci#y' _; � f . ' hampton,M�01080 _ APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION 1.1 Property Address: Tfiis section to be completed by office &-7 RyC�,� Cn Map Lot Unit; ° Zone Overlay District A-1 fi ru-►nW,Nlc� Elm St District CB District = SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT - 2.1 Owner of Record: p A—�C1 (19:2 I1 VC4 k) F l6 C64.✓t C t el e(P' �l'aZt!� Curr��..J���t Mailing Address: nt/� Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mang Address: 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 6. Total=0 +2+3+4+5) Check Number This Section For Official Use'Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1063 APPLICANT/CONTACT PERSON RENE GAUTHIER ADDRESS/PHONE 82 PEQUOT RD SOUTHAMPTON (413)455-5580 PROPERTY LOCATION 67 RYAN RD MAP 22D PARCEL 005 001 ZONE URA(100)/WSP(100)/WP(0)/ 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: REPLACE KITCHEN CABINETS&FLOORING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 098654 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 o " el 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. 67 RYAN RD BP-2014-1063 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22D-005 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-2014-1063 Project# JS-2014-001823 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENE GAUTHIER 098654 Lot Size(sq. ft.): 40380.12 Owner: DECKER RACHAEL Zoning: URA(100)/WSP(100)/WP(o) Applicant: RENE GAUTHIER AT. 67 RYAN RD Applicant Address: Phone: Insurance: 82 PEQUOT RD (413) 455-5580 SOUTHAMPTONMA01073 ISSUED ON.411612014 0:00:00 TO PERFORM THE FOLLOWING WORK.REPLACE KITCHEN CABINETS & FLOORING 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 4/16/2014 0:00:00 $90.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner