30B-035 (2) The Commonwealth ofl4Massachusetts
Department of Industrial Accidents
r Office of Investigations
d 600 Washington,Street
Boston,MA 02111
www.mass.gov/dia
WorkerO Compensation Insurance Affidavit: Builders/Contractors/ lectricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): / �, f LfA/d
Address: r�y1
City/State/Zip:c O/115/0 /W V Phone.#: 2--
Are you an employer?Check the appropriate box: Type of project(required):
1.[c. I am a employer with /J� 4. [] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E]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, 0 Demolition
working for me in any capacity. employees and have workers'
coin insurance.$ p• ❑Building addition
[No workers comp,insurance p.
required.] 5. [] We are a corporation and its ME]Electrical repairs or additions
3. 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.❑Roof airs
insurance required.]t c. 152, §1(4),and we have no 13.�,Other V
employees. [No workers'
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.
tcontractors that check this box must attached an additional sheet showing then ame 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.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
Information. may/
Insurance Company Name:
Policy#or Self-ins.Lic.#:I rWZ..Yoo gee, 5,37_1c1_e/ee _ Expiration Date: 01"0 -,ZeI 3
Job Site Address: \� �'MQ, � City/State/ZipN e` �'(�
Attach a copy of the workers'compensatioir 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•and enalties of perjury that tl a infortnation provided above is true and correct.
Si nature: < Date:
Phone#:
OffPcial use only. Do not write in this area,tb be completed by city or town officlal. .
City or Town: _. Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £`
Name of License Holder:C ���--� `3� 1
License Number
Address Expiration Date
Signature Telephone
9 Re istered Home Im rovement Contractor Not Applicable £
Company Name Registration Number
Address \��� _ � Expiration ate
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...... £
1L :Home Owner Exeznptiott
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 [0] Decks [0 Siding [EI] Other[> ]
Brief Desertion of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:if New house and'er addifon topexistinq:housinq, complete tfie followlng:
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
as Owner of the subject
property
hereby authorize
to act on behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Si ned under the pains d penalties of perjury.
S�:�11�LL4_t"
VrinT Name � �� � � •+ `
Date
Signature of Owner/Agent
"
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
r
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage "0
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Pennit/Vahance/Finding ever been issued for/on the site?
~�
�~� \� «���
NO �� DON7KNO YES �~�~�
�
|F YES, date ioued:| \
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ) D
��
IF YES: enter Bonk Pagel and/or Document#
�� ��
B. Does the site contain a brook, body of water orwetlands? NO �~��� DON7 KNOW �~� YES �~�
IF YES, has a permit been or need tnb*obtained from the Conservation Commission?
Needs to be obtained v~� Obtained x-� Date Issued:
�~� �_v ' .
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 0
IF YES, describe type >
' ' . [___-_____-___-__-_____........ ---------------
_____ �
E. V0U\he con ahuubnn activity disturb( ring,gnodinU vadon.orfi|Kng)over 1 acre orisitpartofaoommonpIan
, that will disturb over 1acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�����
_ u r Ir �r f 1 1Department useronl� � - 1 �Y '
of Northampton Status OfPermlt x {r� r!n €I F
-7 i ing Department �trrT�CutEDri�ce�ua�r Permt# �� }
t
2 Main Street Sewerl5gptiGAwalfabllity1 r,
I�AY - 12014
Room 100 Ulfaterll/ttel(Avaflabtlity }
All N rth mpton, MA 01060 Two'Sef`s of Structural "
Electric Plumbingntsy4Bic�F6 -1240 Fax 413-587-1272 PIof7SCe t'lans!h1Y� '�
Northampto A 01060 zx }, y y 1,�F ,
Other S�eclfyr n *hiaJ 1, 4
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Th'IS section to be completed by gfflce
r .. F i
Unit }
1
Overlay D►strtct .
I
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mai ll g Address:� o� ` r`
Telephone
Signature
2.2 Authorized Acien
�;� ���
ame(Print) Current Mailing 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=(1 +2+3+4+5) Cj�� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Cam misMoner/inspector'of Buildings Date
File#BP-2014-1144
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION I 1 NORWOOD AVE
MAP 30B PARCEL 035 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: INSTALL WALL&CRAWL SPACE INSULATION
New Construction
Non Structural interior renovations At /it
Addition to Existing
Accessoty Structure
Building-Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLL ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,Opf,XTION 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
4 e o Bui ding 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.
11 NORWOOD AVE BP-2014-1144
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-035 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-1144
Project# JS-2014-001936
Est. Cost: $3250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 25308.36 Owner: MEAD SAMUEL A&KATHERINE CRAIG MEAD
Zoning:URB(100)/ Applicant URBAN & SONS INSULATION CO INC
AT. 11 NORWOOD AVE
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.51512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL & CRAWL SPACE INSULATION -
final inspection required
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 5/5/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner