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23A-123 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-contractor(s)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 legibly. 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts - Department of Industrial Accidents r 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: N a r `tc^ 1�L City/State/Zip: ���fi'-/ �- NA— Phone #: Are you an employer?Check the appropriate bqe. Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. F-1 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 g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ B ilding addition [No workers' comp. insurance comp. insurance.* required.] 5. E] 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 per MGL 12.❑ Roof repairs insurance required.]' c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 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 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: U tk\ U�_ City/State/Zip: a— I Db 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 the pains andpenalties of perjury that the information provided above is true and correct. Signature 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#: Home Owner's who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund.Where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract,which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner: Owner Contractor: "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. Owner: Contractor: rTT1o,+�.os wt C; 1 Contract Gd �j RHI Construction Inc(Rainbow Home Improvement)Proposes to hereby furnish material&labor complete in accordance b 1 S with the specifications,and for the sum total outlined in estimate number_13 G S.Payments to be made as follows: 1/3 of full total upon acceptance, 1/3 of full total upon the start of project and the balance upon completion.All material is guaranteed to be as specified.All work to be completed in a manner according to standard practices.Any alterations or deviations from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements are contingent upon strikes,accidents or delays beyond our control.Owner is to carry fire,home owners other necessary insurance. RHI Construction Inc(Rainbow Home Improvement)will maintain proper liability insurance and workmen's compensation insurance as necessary. Acceptance of Proposal will commence with the home owners signature.Prices,specifications and conditions are satisfactory and are hereby accepted upon signature.RHI Construction Inc(Rainbow Home Improvement)is authorized to do the work as specified and to be paid as specified. RHI Construction Inc(Rainbow Home Improvement)EIN#27-1544579, 128 Ryan Road Florence,MA 01062.A Massachusetts registered Home Improvement Company#137097.Represented by Thomas Malone,Construction Supervisor#55236 and Peter Cabaniol Construction Supervisor#99861 are entering into an contract agreeing upon the stated construction,reconstruction outlined in the estimate attached here in# 1 3 r-6 on this date l I by the rightful homeowners Bqv'ru � E"U N gq Co rn The work is scheduled to begin on 1 q1/14 The work is to be substantially completed by All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to; Registration Divison,Program Coordinator One Ashburton Place Room 1301 Boston,Ma 02108 Tel: (617)727-8598 The homeowners have three day cancellation rights under MGL c 93 s 48; MGL c 140D s 10 or MGL c 255D s 14 as may be applicable. All warranties on the owner's rights under the provisions of 780 CMR R6 and MGL c 142A.Home owner will reveal whether any lien or security interest is on the residence as a consequence of this contract Permit Notice: Any and all necessary construction-related permits that it shall be the obligation of the contractor to obtain such permits as the owner's agent. Electrical V Plumbing Rt Building �;j= 0-°�� 128 Ryan Road Estimate ■ ihnu i Florence, MAO 1062 Date Estimate# 2/11/2014 1365 Name/Address Barry and Emily Bacom 20 Middle Street Florence,MA 01062 Terms Project On receipt Bacom Electrical Description Non Electrical material 875.00 Non electrical related labor,overhead,permitting 1374.93 *Project Total Total $17,399.93 We propose to hereby to furnish material and labor-complete in accordance with the above specifications,for the sum total.Payments to be made as follows:half of full total upon acceptance,one quarter of full total upon the start of the project and the full balance due upon completion.All material is guaranteed to be as specified.All work to be completed in a manner according to standard practices.Any alterations or deviations from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado,and other necessary insurance. Acceptance of Proposal will commence with the home owners signature.Prices,specifications and conditions a satisfactory and are hereby accepted upon signature.Rainbow Home Improvement is authorized to do the work as specified and to be aid specified. Phone# E-mail Signature . (413)341-3838 PETER @RAINHOME.NET Page 2 ���S�R•RIIMpp 128 Ryan Road Estimate RaWbaliL Florence, MA 01062 Date Estimate# 2/11/2014 1365 Name/Address Barry and Emily Bacom 20 Middle Street Florence,MA 01062 Terms Project On receipt Bacom Electrical Description ELECTRICAL REPAIRS AND UPGRADES Estimate includes work to replace existing Knob and Tube wiring and devices located at 20 Middle Street,Florence,MA to include the following; Permit fees,60 openings(lights,switches,receptacles), 120 amp circuit for 2nd floor bath outlets, I bath fan light 2nd floor bath(NuTone QTN110L), 1 bath fan 1st floor 1/2 bath,2 GFCI outlets for bathrooms.Installation of new 200 amp overhead service. Other electrical outlet installations to be provided at time of this work,are NOT included in this estimate,but will occur simultaneously.All walls and plaster will be patched using gypsum wallboard and dura bond joint compound, sanded smooth,and primed for future painting.All fixtures not listed in this estimate are to be supplied by others.Any additions or changes will be charged as extras.All electrical devices to be standard white or ivory duplex or toggle style.Estimate includes removal and disposal of all waste associated with project. Permit fees for work are included in estimate. Electrical upgrade and new wiring remove knob and tube 1841 SF Electrical work for service entrance connection.200 amp service including meter socket,main switch,2 GFCI and 15 single pole breakers in 40 breaker space exterior panel box 1 LS Roof vent kits for bath fans 8-foot length 2 Ea Gypsum interior plaster repair on walls 20 SY Repair of plaster ceilings 10 SF Sand smooth plaster and priming 122 SF Building permit fees 2 LS Project material,labor,subcontract Material,per job Labor,per job Subcontract,per job Electrical Subcontractors 13050.00 Total We propose to hereby to furnish material and labor-complete in accordance with the above specifications,for the sum total.Payments to be made as follows:half of full total upon acceptance,one quarter of full total upon the start of the project and the full balance due upon completion.All material is guaranteed to be as specified.All work to be completed in a manner according to standard practices.Any alterations or deviations from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado,and other necessary insurance. Acceptance of Proposal will commence with the home owners signature.Prices,specifications and conditions are satisfactory and are hereby accepted upon signature.Rainbow Home Improvement is authorized to do the work as specified and to IV paid pecified. Phone# E-mail Signature — (413)341-3838 PETER @RAINHOME.NET Page 1 �''"� SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: —C–S— ds��234 License Number \ - ►6--Zo 1 b Address Expiration Date Signature Telephone ' 8 Registered Horne Improvement Contractor: Not Applicable^❑ Company Name Registration Number Address nf� nn Expiration Date \ \•Y�l.� 1`� ( � Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§2$C(6)) Workers Compensation Insurance affidavit must be completed d 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 Exempflon 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 EJ Or Doors E] Accessory Bldg, ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[O] Brief Description of Proposed l— Work: Cttyn 4C, V%^A ASbc,, ,Mac's Q,'ft4-'?QA.h'i Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a If Now house and or addition to,existing housing, complete'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. 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, 4 ��� (\ as Owner of the subject property 1 /n hereby authorize 70tt"" „M,&kcg--- to act on my behalf,in all matters relative to work authorized by this building permit applicatiorf. Signature of Owner Date I, ^ .C- 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. mc-, Print Name Sign ure of ner/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 Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding jever been issued for/on the site? NO 0 DONT KNOW Of YES IF YES, date issued:" IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW l YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained i Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. artment.use only U V City of Northampton tatusot`P -11- Building Department Curb CutlCiriveway Permit ' 4 212 Main Street Set r/Saptic Availability Room 100 Vilate rlUUell Av ability- _..- S orthampton, MA 01060 Two Spats of Structural Purls Electric Rlnmr ny Gas Irfsp n 3-587-1240 Fax 413-587-1272 Plottsit ;Pians Othe€; cify 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 Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Owner of Record: (( {� ► )Ci ° �M.\y �x4=qn Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Solrature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 0 \ (a)Building Permit Fee 2. Electrical CJ (b)Estimated Total Cost of �30S�o `06 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) \131 Cl-Ud Check Number a This Section For Official Use Only Building Permit Number: Date .Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1054 APPLICANT/CONTACT PERSON THOMAS MALONE ADDRESS/PHONE 128 RYAN RD FLORENCE (413)885-9038 PROPERTY LOCATION 20 MIDDLE ST MAP 23A PARCEL 123 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Build in Permit Filled out g06:e d4941 Fee Paid Typeof Construction: REPAIR SHEETROCK New Construction Non Structural interior renovations Addition to Existing Accessory Structure - Building Plans Included• Owner/Statement or License 055236 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 �� Sign Bui d. g Offic al 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. 20 MIDDLE ST BP-2014-1054 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A- 123 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-2014-1054 Project# JS-2014-001809 Est. Cost: $17399.00 Fee: $104.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS MALONE 055236 Lot Size(sq. ft.): 13503.60 Owner: BACON BARRY&EMILY Zoning. URB(100)/ Applicant: THOMAS MALONE AT. 20 MIDDLE ST Applicant Address: Phone: Insurance: 128 RYAN RD (413) 885-9038 FLORENCEMA01062 ISSUED ON:411612014 0:00:00 TO PERFORM THE FOLLOWING WORK.REPAIR SHEETROCK 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: FeeTvpe: Date Paid: Amount: Building 4/16/2014 0:00:00 $104.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner