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25A-074 (5) The Commonwealth of Massachusetts Department of Industrial Accidents i 6A Office of Investigations 1 Congress Street, Suite 100 - Boston,MA 02114-2017 �M yv6y' www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,��4�k_-, ��„\��e t<` Address: q �,,,, �.. Vm lec,CQU w 5' �0, Q\0 3 City/State/Zip: Phone #: 1+3- �-a (,} Are you an employer?Check the appropriate box: Type of project(required): 1.E2 1 am a employer with a 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 h'• 9. ❑Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.El 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 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 my employees. Below is the policy and job site information. Insurance Company Name:--G 2 e_ _ Policy#or Self-ins. Lic.#: �v �( � �� Expiration tip Date:_i 6 Job Site Address: 2_12)L0 Q`_c�/c_��� City/State/Zip: i.1 o(owo 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 tip 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 cof peajury that the iraji=rarauaist a Oi r,_f_i=u =•_ Ol"ic iol use ttaalj?. Do not write in this ar eai to be completed bi'€io-ar tzown r ff7 i 1. l� � p FE 1t U city or,row t: P�t stait,''l,iestt>c f it i i"Nuitiv I U`601ii} t_+:t ch:uric' : t it 1, Roard or Health 2. Buiidints iltenartment 3.Citvf own Cierk 4. Viectricai inspector 5. Piumninn insnector ill is ts.t:ath:•r _ _ � _ _ - - f# it of City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 3 43u �� ��, P 2OCNcJ The debris will be transported by: -Jw,rz„4F\" --\�"ACQ'e v z The debris will be received by: \\ l ec c�•,� r Building permit number: Name of Permit Applicant \4- Date Signature of Permit Applicant Li /70 CA 3 9.R.istered Home tmorovement Contractor: i Nut Anmir qmr- S 1Av2 0►�I✓1 OU, (cS'4dt i i uoitipiainy iiame V4 V0 G- Address Expiration Date i — 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...... 1 11. - Home Owner Exemption €;� r r,s •t,i l.,in- ' is °l .�a�Ei�.�.,t; t -„; a i{- :seclude Owner-occupied Dwellings of one(1) or two(2)families a,iil ,,,.,llwj ,i:il to eno -e an individual for hire who does not possess a license,provided that the owner acts 3 s titsereisos L M1'?R its , 3_)cftagt#tan of tla:itac:rwi r« P,, .. .,„ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoalicable) New House ❑ Addition ❑ Replacement Windows ration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[p] Brief Descript9n of Pro e ( ) �, Work: O �Q f'X\ T.n ➢ ` C�^2✓� � k \ J7 I Alteration of existing bedroom Yes�_No Adding new bedroom Yes _/4- No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: 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 attache d. Proposed Square footage of ne onstruction. Dimensions e. Number of stories? f. Method of heating? Fireplac r Woodstoves Number of each g. Energy Conservation Compliance. scheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetland Yes No. Is construc within 100 yr. floodplain Yes No j. Depth of basement or cellar below finished grade k. Will building conform 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 OWNE'R'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, \>V V\1 S'_ ' \6&�o V�_ as Owner of the subject property �y hereby authorize to to my behalf,in all maltgrs relativp to work authorized by this building permit application. ignature of Owner Date II�l/r'k `�If}�IAA ✓� 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 rider t e pains and penalties of perjury. 04 Print Name -aa -� Signature of Owner/Agent Date 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 Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking S aces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW � YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 00\ DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained 0 Date Issued: 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 ® NO (� IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. .+ Department use only o Northampton Status of Permit: in Department Curb Cut/Driveway Permit Main Street Sewer/Septic Availability ROOM 100 Water/Well Availability, oeckj\�1ott Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: (� j This section to be completed by office 3�b¢>Y2\bt:(,e SA-"''P T Map Lot Unit ba ktAc"',r VO,-, , V\A,.� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1�Owner of Record: /y pry Name(Print) Current Mailing Ad ess• Telephone Signature 2.2 Authorized Ascent: 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 b (a)Building Permit Fee 2. Electrical l•°') , , (b)Estimated Total Cost of Construction from 6 3. Plumbing Oo, Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) ('C. Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: _ Building Commissioner/Inspector of Buildings Date 386 BRIDGE ST BP-2015-0271 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A-074 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0271 Project# JS-2015-000512 Est. Cost: $13500.00 Fee: $81.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK SARAFIN 053434 Lot Size(sq. ft.): 6011.28 Owner: KENNEDY DENISE A AKA DENISE A HAUGHTON Zoning: URB(100)/ Applicant: MARK SARAFIN AT. 386 BRIDGE ST Applicant Address: Phone: Insurance: 42 Pomeroy Meadow Road (413) 527-7812 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.91912014 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL KITCHEN 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 9/9/2014 0:00:00 $81.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner