31A-233 The Commonwealth of Massachusetts
Department of Industrial Accidents
F Office of Investigations
w
d I Congress Street, Suite 100
W
;= Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \ ` Please Print Legibly
Name (Business/Organization/Individual): J 05� _I Pi J M A`^
Address: AU R
Udt 3 D � �6° y City/State/Zip: r_1 o r\`nrr �d N %one #: I
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 g, ❑ Demolition
working for me in any capacity. employees and have workers'
9. E] 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.❑ Plumbing repairs or additions
m self. o workers' com JVY right of exemption per MGL
Y
insurance re uired. t c. 152, §1(4),and we have no
12. Roof repairs
q ] 13. Other rrC 1C1 Ck drl tYly
w k�\ opt S o employees. [No workers' P
�A\ 1P t,P- 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.
$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,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 the pains and penalties of perjury that the information provided above is true and correct.
Siv,natu re: A,4: Date: 13
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 Applicable
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Rett# ter�d Nldi tiIrriproeiirl�n +Ciiit�rCtc�r"C ." �^ !: . = �� iy Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 �me':: . F ir�tpian
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 Lo al Zoning L ws 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) ED Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[ ]
Brief Description of Proposed X't?1gGen $ 1,J^('J�- ra'- Wao 11ri 'C ro'J'V por 'V' AI-4 sue)
Work: rtUVFa)fG� 4Ujj fodJ' v���� V al A/( � fl"C/ W
Alteration of existing bedroom Yes No Adding new bedroom Yes _�No
Attached Narrative Renovating unfinished basement Yes jN No
Plans Attached Roll -Sheet <
I!,,,al I Ne base ans!6'' idi*im�! `,6zi ilea"'.lions 'nrl, complete the�foli"ll":'wl
- : tj
(A°I )<L acrd
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms \Q T"Ic (No
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, , as Owner of the subject
property
hereby authorize
to act on my 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.
Signed under the pains and penalties of perjury.
S
Print Name
s7
Signature ofoknYr/Abent Datb
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
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces —A
(volume&Location)
A. Has a Special Permit/Variance/Fi ndi n g ever been issued for/on the site?
NO »���� DON'T KNOW YES ����
�
'
|F YES, date issued:
IF YES: Was the permit recorded nt the Registry ofDeeds?
NO 0 DO 7KNOW YES
IF YES: enter Book Page and/or Document#1
�� ��
B. Does the site contain a brook, body ofwater orwetiands? NO K�� DON'T KNOW x~� YES «_�
IF YES, has o permit been or need to be obtained from the Conservation Commission?
��
Needs tobeobtained Obtained Date Issued:
�~�0 '
C. Du any signs exist on the property? YES 0 NO
IF YES, describe size, typo and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES «�� NO �5�^
,
|F YES, describe size, type and location:
E. Will the construction activity disturb( ring. grading, dnn. or filling)over 1 acre orioit part ufo common plan
that will disturb over 1acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�II�111� �IIII9q{
City of Northampton
�, x1111 �I�i�q�Y' a(YY I��Iv y Is
Building Department
I
MAY 3 0 2W4 212 Main Street t ; +� I I l"i^ �i tt�'i W'YY�IMII�°�1 Ih�11 IIIIIIIIII VIII 7
Room 100
plumbing Gas I�Y`nectiA rthampton, MA 01060
ectr{G. n l —
� Northamptc.. .t� 587-1240 Fax 413-587-1272 ' I
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
kt'�►StN� N �d eI�J� yep Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
q)} - 30l - 86gy
Telephone
Signature
2.2 Authorized Agent:
N 1A
Name(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 Z S—� 0 (a)Building Permit Fee
i
2. Electrical Al�� (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) Z 5-6 O Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2014-1275
APPLICANT/CONTACT PERSON SMITH JUSTIN
ADDRESS/PHONE 17 KENSINGTON AVE NORTHAMPTON (917)301-8694 Q
PROPERTY LOCATION 17 KENSINGTON AVE
MAP 31A PARCEL 233 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction:_SHINGLE PORCH ROOESTAIRS&DRY ROT WOOD
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
B FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
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
D lit' n Delay
Si ure of Build' g 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.
17 KENSINGTON AVE BP-2014-1275
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-233 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateizorv:renovation BUILDING PERMIT
Permit# BP-2014-1275
Project# JS-2014-002140
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 7884.36 Owner: SMITH JUSTIN
Zoning. URB(100)/ Applicant: SMITH JUSTIN
AT. 17 KENSINGTON AVE
Applicant Address: Phone: Insurance:
17 KENSINGTON AVE (917) 301-8694 (�
NORTHAMPTONMA01060 ISSUED ON:61212014 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE PORCH ROOF,STAIRS & DRY ROT
WOOD
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 6/2/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner