18-002 (4) The Commonwealth of Massachusetts
Department of Industrial Accidents
Ff`
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
w www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiv
Name (Business/prganirationr`Individual):
Randall E Roberts DBA/Window Works
Address:321 Russell St
City/State/Zip: Hadley, MA 01035 Phone #:413-530-2703
Are you an employer?Check the appropriate box: Type of project(required):
1.R I am a employer with 5 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 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 ty ca aci employees and have workers
P _ 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.°
required.] 5. ❑ We are a corporation and its 10,E] Electrical repairs or additions
officers have exercised their 1 1. Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work A"
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, y 1(4),and we have no
employees. [No workers' 13.R Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation police 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.
=Contractors 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,thev 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: Wesco Insurance Company �_--
Policy#or Self-ins. Lic. #: WWC3070070 _ i i Expiration Date: 10/19/2014
Job Site Address: All Locations 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 MGI,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 e tify der pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: o
Phone# 413-530-2703(ez(I
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.CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. n Not Applicable ❑
Name of License Holder: Randall � lQ0f0e� 0 �7 `95 73
License Number
m a c , 8 f a5, Sol y
Address I Expiration Date
1f13-53o-9703
Signature Telephone
Not A licable ❑
9�:Reaistereil:;lzl'oiiie Cmnprovemenf''i r ortt.racfor PP
/5Q> L2 of 4nheH-s Eienera t (Lo - __ /Oq k 73
Company Name Registration Number
q1 42men.r)acl iez( L.-e Uere# Vhf o 1 q!�( 7/l a�
Address Expiration Crate
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....... LR No...... ❑
11. Hale waEte1r. X '
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 1083.5.1.
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
p «:�:��
com lesion-o-fthe- � 's-per.���-.��ae --_.-.-----__
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 Wufdows Alteration(s) ❑ Roofing ❑
Or Doors
Acce33ory Bldg, t_ Demolition ❑ New Siyos [0i
�
Section 4. ZONING Alt 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
Setbacks Front
Side
Rear
Building Height
Bldg.Square Footage r
(Lot a=minus bidg&payed
9 of Parking Spaces
A. Has a Special Pennit/Vahance/Finding ever been issued for/on the site?
%'C�v �� ��
NO w�� DONT ��KNOW YES ��
|F YES, date izmed:
IF YES: Was the permit recorded atthe Registry of Deed �
NO »=� DON7KN{nN YES _
--
IF YES: enter Book � � and/or Document#} !
B. Does the site contain a brook, body of water or wettands? NO DONTKNOW 0 YES C)
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs bobeobtained »-� Obtained v�� Da�ebsued' /
�~� �_/ ' '
C. Do any signs exist on the property? YES �~� NO Azy_
/F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended-for the property? YES O
IF YES, describe size, type and Location:
E VWU�econ�r ��na���'d���(clearing,grading, . mfiNng)over 1ec�or�bpa�nfacommonp an
that will disturb over Iacre? YES ���) NO ���
��
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Statunl E'etrt k
Building Department tv�iCeaerr�tit 4
5
M l 212 Main Street sevi{erfseptrc Rrtaitabittt'
I Room 100 waterpNelrAvatlabtlrtg
2$ 2014
�iorthampton, MA 01060 Two Sets°rrfst►vcturaf,01,
pho 13-587-1240 Fax 413-587-1272 Pto#�S Plans`
leCtric, Plumbin Otlier5peafy�
APF'Lt� CO STRUCT,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
!)
t17 `- � :Map Lot Unit
Zone - Overlay District
EIm'.5�District CB District
SECTION Z-PROPERTY fJJWNERSHIPJAUTHORIZED AGEW.
2.1 Own of Record:
-------- _ s' _ MA
Name(Print) Current Mailing Address: Q�L
Telephone
Signature
2.2 Authorized A ent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3=-ESTIMATED CONSTRUCTtON•COSTS
Item Estimated Cost{Dollars}to-be Official Use Only
completed by ermit applicant
1. Building I t O (a).Building Permit Fee
2. Electrical (bj I Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) ! Check Number r
?kris"Section' I rail"uso:Onl
Building Permit Number: Date Issued:
Signature:
Building Commissionerlinspectorof Buildings Date
75 PINES EDGE DR BP-2014-1120
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-002 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeory:window replaced BUILDING PERMIT
Permit# BP-2014-1120
Project# JS-2014-001898
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RANDALL ROBERTS 042573
Lot Size(sq. ft.): Owner: DUGRE LAUREL
Zoning: Applicant: RANDALL ROBERTS
AT. 75 PINES EDGE DR
Applicant Address: Phone: Insurance:
321 RUSSELL ST (413) 530-2703 O WC
HADLEYMA01035 ISSUED ON:412512014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE EXISTING SKYLIGHT
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 SiEnature:
FeeType: Date Paid: Amount:
Building 4/25/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner