04-014 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
} 600 Washington Street
Boston, MA 02111
x www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information // Please Print Legibly
Name (Business/Organizatid
Address: P6 B-t� L
City/State/Zip: l ,4C4 0/")s3 Phone#: 74
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
e oyees (full and/or part-time).* have hired the sub-contractors 6. E] New construction
2. 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'
[No workers' comp. insurance comp. insurance. 9. ❑ Building addition
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 1 l.❑ Plu5b>g repairs or additions
myself. o workers comp. right of exemption� ' per MGL p 12. ,5of 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 Gerd a pains and penalties ofperjury that the information provided above is true and correct.
Si ature. Date: L 2% /
Phone#: zT
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 Applicable £
Name of License Holder: 0 5-
License Number
Address 4 Expiration Date
1-J 1 ��
Signs ure Telephone
9.:Registered Home ontract
Improvement Cor: Not Applicable £
Company Name Registration Number
b / z -/S---/D
Ad�dresss,, xpiration Date
Telephone )w
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 Egemptioi
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 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs (CO] Decks [M Siding[o] Other[0]
Brief Description of Proposed I (� et)-e-
Work: 9Pi�
ky� +yL�S}�`�t olzzo�k,i c � pn5l�clr� y,,�,„ b►tc,�a'� rvL �tti ��,/ '(7th j Od''' -
Alteration of existing bedroom_es No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. lf.New house an Ora t6 ezistfnq h"ou"sing, complete the tollowing:
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
�L 1 R CI&L A-17— as Owner of the subject
property
hereby authorize
to act on my behalf, in all mattersqative to work authorized by this building permit application.
Sign ure of Owner Date
AQenti- _ as Owner/Authorized
hereby diec hat t s tatements 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.
: :Y l�>
Print Name
Si Owner/Agent Date 4
`
Section 4. ZONING AU Information Must Be Compteted. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tliis column to be filled in by
Building Departnient
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage 01'0
Open Space Footage %
,
(Lot area minus bldg&paved
of Parking Spaces
(volume&Location)
A. Has a Special Permit/Varinnoe/Fimding ever been issued for/on the site?
NO 0 �DNTKNOY 0 YES 0
IF YES, dateissue&
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � Dum / xnuv 0 ,ES
IF YES: enter Book Page end/or Document#
B. Does the site contain a brook, body of water orwetlands? NO 0 DON7 KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any d �� ��gnsexis�on �hepn»perty7 YES �~/ NO �_�
IF YES, describe size, type and location:
D. Are there any proposed c h anges to additions of signs intended for the property/ YES 0 NO
/
IF YES, describe size' type and location:
E. VW||the construction activity disturb(clearing. grading,excavation,or filling)over 1 acre oriait part ofa common plan
'
that will disturb over 1 acre? YES K ] NO 0
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
e artm ht u X ,
ity of Northampton Status ofPerm�t k,w" A '4 �` s
J �ilding Department GtrFa Cut/Drl�ce�nlay Perrrti#t' �}'
ti l 212 Main Street Sewer/SepticAvailabllity `s 1 f
Room 100 1Nater/1lIte7lAvailablllt
t
ort ampton, MA 01060 Twa Sets q Structui-al Ptans
Electric,Plumbing& � s9 ' 7-1240 Fax 413-587-1272 Plof/Slte Plans
NorthamC tC,ri �1 y
Ot>�rer Specify° _ _ 3 1
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
/ ivGV�"J��►,- � Map€ Lot Unit
... ....
... ........
. ..........
..............
..A
....................
y
Zone Overla Distract
Y
Elm$t District -3 CB District.
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i
Name(Print) Current Mailing Address:
Telep one
Signature
2.2 Authorized Agent: L
Name(Print) Current Mailing Address:
�2 ��' l �
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2 01" (a)Building Permit Feb
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) `L (q Q ° Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerlin.spector'of Buildings Date
547 AUDUBON RD BP-2014-1159
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 04-014 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-2014-1159
Project# JS-2014-001964
Est. Cost: $2160.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sc.8.): 522720.00 Owner: MCBRIDE ALAN F&HEATHER B
Zoning: RRO 16)/WSP(63)/WP(14) Applicant: TIMOTHY J LUCE
AT: 547 AUDUBON RD
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON.51612014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE REAR LOW SLOPE AREA
MEMBRANE 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 5/6/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner