24B-004 (10) The Commonwealth of Massachusetts
DeparMAent ofIndm,trial Acciden15
Office of Inve51iga1ians
600 Washington,Street
Boston,AM 02111
y'- www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ;ff 1 � iL.G _1��/1%��!r l��/yl t J 2711 ,5—
Address: ,1 IF
City/State/Zip: fail/k 61/06 0 Phone#: 2-
Are you an employer?Check the appropriate box: Type of project(required):
1.U9 I am a employer with )5 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 or me in an capacity. employees and have workers'
g Y P tY• $ 9. E]Building addition
[No workers' comp.insurance comp.insurance. 10.❑Electrical repairs or additions
required.] 5. ❑ We are a corporation and its P
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 121-1 Roof 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.
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 tray employees. Below is the policy and job site
information.
Insurance Company Name: /� 11141!
Policy#or Self-ins.Lic.#: f ° % %G% Expiration Date:
Job Site Address: �� V'irt`'tt�7J City/State/Zip: a
Attach a copy of the workers'compensation policy declaration page(showing time policy number and expirzdoan 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 hemby c4 '• der d pains Lnd e Naldes . pe ' ry that the information provided above is true and correct.
� / Date: r
Signature:
Phone#: zr/ J�rnT / ,� i z–
Official use only. Igo not write in this area,to be completed by city or town offacial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.?l'lumbinAg Inspector
6.Other
Contact Person: Phone#:
` ~
.1 Licensed Corstrtx Not App.icFbla 13
340 Riverside Dr' MA 01.0-6-0 9/22/if-
Signature Telephone
ractor: No
_I ont
Valley Home 105543
Comp ny Name Rc.aistation Number
340 Riyerg�;Ldo Drive—
Address Expiration Date
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L. c. 152, 25C(6))
Workers Compensation Insurance affidavit mist becompleted and submitted with ih.;s application. Failure to providethis affidavit
Will result in the denial of the issuance oi the buiiding perrnft.
'
11. - Home Owner Exemption
The CUrrent exemption for"homeowriers"was extended minclude Owner-occupied [one(Dor -,wo(2) {arnillies
uodnoaJloxsuchhmmoowocrtoox-a'-cuoindh/idualCorkirov/hudoosnotpooursxu6cxnxe,
as sui)ervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel oC land on which lic."she resides ar into-nds to reside,on which there
ic, oriuisteoJodiohc. uuoeornvoQ//oJydwel>ioz.uttoohcdordetochudaunotureruocmxorv�,o:u:huvcund/ur�oo
A per,,gfn wbo consfrDe!Is more than one howe it) a two-year v)eriodsh?,11 nat-be Considered a homeowner.
Such "horneowner" shall submit to the Building Official,on a form acceptable to the Buildin-Official.that helshe shall be
responsibie for all such work performed under the buifdhg�permit,
As-acfin-Colistritetion .qtiperviso your presence on the job site will be required fi-om thne to time,during and upon
completion of the work for which this permit is issued.
Also bc advised that with reference znChapter i52(Workers' Compensation) and Chapter 153 ([jo6iiicyufEmp/oyumto
Bnop|oyc:s for injudcsnuz/cco}dngio D�-ut ) ofthe.Vlussac6usetts General Laws Annotated- jbrpoxon{m
yuu hire|o perform work For you under this pnrmil.
l'6cundoroi2ned"homeowner"certifies and uaaomrsrespoosibi}icy for compliance v/itb the State Building Cu4c.City uf
��nnhamp�nrrJinaor�s. !�atrmnd Lom| Zuning/.ows and State nf\4aeuei�aseosGeneral Laws Annotated.
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tp,,. SC.IE'.r (., I`o 'r.': "a`t. E r't:i': E !_" :'y^ .J:. E'"i� S t'..�.'.le: �.'.` _.....�..._...._v.. i:. ._...__._._._._.. S""'"`
SECTt,CN 7a • Mf KER AUT DCREZA7�ON . TO C'C COMPLCTED W1104
hem L
ey Horar Inc
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: ) L: R:
Rear
1
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 ever been issued for/on the site?
NO Z DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
T YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued::
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
do
IF YES, describe size, type and location:
L=' l I�_ Department use oni,
I
,�7 !S�
�Y� J �� I y of Northampton �:atus Permit:
iiding Department (Curb Cut'Driveway Permit
Zfll4 (; 212 Main Street Sewer/Septic Availabi:ity- -
t� ,1.�� Room 100 Water/Well.Availability
—_....._.��or hampton, MA 01060 T %v.Szts of Strcrct oral Plans
L ___t .. pho'� (4fIc& 87-1240 Fax 413-587.2272 not/Site Plans
0ther Speci6
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAIVi1LY DwELLNG
`l�ry/pd�% �>(fs� �� cJ�'cGi n� -- � �Jr�'-� l c/,w y/ �S•off.-'i
SECTION I -SITE NFORMATION
1,1 Frnpertt�Address:
This section to be completed by office
�,�vr- Map Lot Unit ,_
� Zone.- Overlay District
i
Elm St.District_._, CS District f
SECTION! 2- PROPERTY OWNIERSHIP/AUTHORIZED AGENT
2.! Owner of Receed:
k L\-Y gwiQ7) �
Nam° i ) Curren,N4ailinrg Address,
Telephone
2 A-utlttarized A.gert: Nelson Shi f f Z e t t
1xe€Fehr Some Zm�-ogrement
P.O. Box 60627e Florence, _�f=� Q1062
{; F
Name(Print) Current Acdress:
58x4-7522
Sigratur Telephone
F EC71 KF 3_---EST[M,,A T E CCf1STF`e_lCTION COS 15
ligr 1 1 1, T :C st(Dsii rS) ill_S Us 0r" �..
ca:nnl,eted by ermit a c,licant
1. 3710ding (a) Building Perth Pee
2. Electrical (!b) Estimated Total Cost of
Construction from(6
�3. iu:nbing ( Building Permit Fee }
4. Viechanica! (HVAC)
-3. ot..1 ,, + 2 - 3 a- 4 . 5) � j Check RGmber i
c.
'°`tic Ccr.i::rr r�r(,��iCF%I Use 4 ''Slt`
'B"''Idirg 'art`1!I Nu'7;ber: Date lssUGC::
of
i �
83 BARRETT ST BP-2015-0011
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B -004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2015-0011
Project# JS-2015-000017
Est. Cost: $15000.00
Fee:$90.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sg. ft.): 57107.16 Owner: BROWN FRANCES LOUISE C/O FRANCES L. LEAHY
Zoning: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 83 BARRETT ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.71112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 7/1/2014 0:00:00 $90.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner