28-030 (3) Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
i
An employer is defined as"an Odivid
ual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." ;r
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall'
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited LiZility Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,apolicy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write."all locations in (city`or
town)."A copy pf the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required.to complete this affidavit..... '
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone-and fax number.
Tie Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Poston,MA 02111
Tel. #617-727-4900 east 406 or 1-877-MASSAFE
Revised 11-22-06 Fax#617-727-7749
vrvw.mass.gov/dia
` The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
' 600 Washington Street
Boston,AM 02111
' www.massgov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( Please Print Legibly
Name(Business/Organization/Individual): J �-C l,n c, vN yI C 0
Address:
City/State/Zip: MA (GC Phone"#: 3 7 -9 -7 Li
Are you an employer?.Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] 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 t3' t , 9. ❑Building addition
[No workers'comp.insurance comp.insurance. 10. Electrical repairs or additions
required:] 5. We are a corporation and its ❑ eP
3.[� I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption'per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no ii
employees.[No workers' 13.®Other . c i�� f 'y�f
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 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob 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
Investaeations of the DIA for insurance coverage verification.
I do hereby ce fy under the pains and penalties of perjury that the information provided above is true and correct
Si tore: i Q� Date: - 13
.3
Phone#:
Official use only. Do not write in this area,to be completed by For 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#:
>afnz#l��mrtrr z
� � �rlassac}�usctts
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DEPARTMENT OF BUILDI. TG; INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3A to
act as !:Is/her construction sups , isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour) a rough building inspection (before work is
concealed) insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, (�, _L understand the above.
(tVome owner/residents signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 11/ 3/6,4
Address of work \
location R�ti RU.
Olenc �� lP �U�
2 0� _
U.Tf�7 IIf ��C?T:f Ijc1111�t011 _ _
Af i;c aa,<rh nc r l l a!
DEPARTMEIN T OP BUILDfNC fNSPECTIol:s -
212 Alain Strect Municipal Building a
Northampton, A1ass, OlOGO
W It1Ci :Z'S coIYfPENSAT ON 'DtSU -A-NCF Al,
\vILL, a prui lcipal place of busmess/residencc at:
(phone')
rJ la2icla p)
do hereby certify, under the pains and penalties of perJury, har
( ) I am as employer providing the followine ti,orkcr's comocnsaz3on covef-2 c for Iny
emplovecs worUng on tills job:
Qnsuran Conr ) (PeLic: Nurnocr) -- ( :-pinion Dz�)
- ,
( ) I am a sole proprietor, general contractor o hotneown . (clicip. one) and have hired
the couiractors listed+ below wbo have the follo%vinQ workers comoen-,-P-iion policies:
+'1rilC O. CG^t:�CiO"1 (IIIR!Plll:: COIIIOa,�}'lPGUC'i ?�tt1II1CC) (I'_?:Jti'JtiQi! I�IIC)
(Name of Concamor) (Insurance C.omoaov/Polio tiunc^r) (—Expir..6on Dale)
(game of Connaeto,)
(1-asuraocz ampanoyiPo)icy Numbzr) (Expimrioo Dam)
(Name of Contractor) (Insurance ComDZ.aylPoucy Numbs) (Expiriioo Darr).
(aas�_d,it C j exc if ncc aO-to incur iaformi'i oo W aJ l cccr-_�o n)
{ ) I am a sole proprietor and have no one working for me. s
( ) I am.a home owner performing all the wort- myself.
NOTE:PIS be t,-uc o-wj-c bemxMVCra w,cmPlny Pcn4=to d� - -,n= csrjoo a rcpa.ir wort as r d"c1L=Z of
not mere th_o t L-1rx in tassel the bomoo vnc rcido«ca tht p vsn6 z,put�tlr av r r ox G=>,lty ccasd.-ni to be
cnPIoYczUn--two,u-�c:�mArl GLl52s=t(5
( )),=pptinbw bra 6omuoava r=e bc=--=or pam�i zy ridgy tL-
IcIP3 naau of as-=Ploy-under df Workole C.ompoma.tioa.Ae(_
r undcriand t6s x Dopy of thin-1—o y be for xovded w tb.op_,..,of 1-6-rid Accd.=Y C IM-of Irrs�for the
oovcr3'Sc vQjym'cc"d a%--'L-J=t to sccvrs tov-Mi,c zaa sod oa 25 A of MGL 152 c.lcnd to Lb.=qoaitioa of cimiaal Pco -
000sis,mg of a find or UP to s 1^S00.00 a110«i={ai.,oK=0cy of UP to Doc Y,3 end ovil pco.kia in t5c form of a Stop Work Ordcr and a
fim
0(S 104.00.d_y LP 1=1 mc-
For dcpu-.m��u.c Doty .
Pcrm1 l Numb-r
Lot
Sip�zttut of LiccnscrJPcciniucc —L�-� J
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
..
ract Not Applicable ❑
9 Register`e'd}fam'e,ltnproarerrient=Cont .. , . ,
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...... ❑
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 Gf Homeowner:Person(s)_who_ovm-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-vear 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 F-] Addition 71 Replacement Windows Alterations) Roofing ,
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other[0]
Xrief Desuiption of Proposed r
Work: 1 �S�ti l�ti h'r.., r ad,J L�
Alteration of existing bedroom Yes N No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes k No
Plans Attached Roll -Sheet
.,: =. x w:.rs'� "* i�" s r
6a t �fdw;ause rrt acic(lff hil rs rnct loo lams oti i e4��t ie#�Cc�w�nw:
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
L 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
SECTI0 N:74=OWN WA- UTHORIZATION TO BE COMPLETED:WHEN
0I,..NNERS AGENTQR`C ONTRACRA ?LIEO `PERUkMIT-
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
I, r,rYlne ��,�nc� ( t�t fc� 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.
ce+Y1�icnt�c i�fG n
Print Name
ignatur o OwnerlAgent 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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varia nce/Fi ndi ever been issuedfor/nn the site?
NO ^���� DONT KNOW v���� YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry orDeeds?
NO �� DON'T KNOW\�� m mv ,cu
IF YES: enter Book PoUo and/or Document#;
��
B. Does the site contain u brook, body of water orvvot|ands? NO �_��� DON'T KNOW ��/ YES v~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tnbeobtained �~� Dbta�med �-� Date
\_� v~� ' �
C. Do any signs exist on the property? YES 0 N0
IF YES, describe size, type and location: '
D. Are there any proposed changes to or additions of signs intended for the property? YES _ NO rD
IF YES, describe size, type and location: �
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orisit part ofo common plan
that will disturb over 1 oom? YES [ } NO ( )
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
G
-� [ epartmentse-orgy:g �=
City of Northampton
Building Department
212 Main Street ,
5
Room 100
Northampton, MA 01060 0 z
x
phone 413-587-1240 Fax 413-587-1272 Ito rte 4
{��t�ie�'`S � -_� `��,��: ` �� �� ..�:•gam`
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 -SITE.INFORMATION
Thrs sectwnta be complefsd by office
1.1 Property Address:
wo
M �k
R ye,n ap Lcrt ` Ur�t
PF
a ;
qq �Z�ne� �Ouertay Dr�ct
f
_
SECTIOW2-PROPERTY`OWNERSHIP/AUT,HORIZED AGENT
2.1 Owner of Record: _
�4nno-r��iTISC�v� �� �� E—�odenc'Z_ AAA 616
Name(Print) Current Mailing Address:
LTelephone
Signatur
2.2 Authorized Aqent:
Name(Print) Current Mailing Address:
-Signature Telephone
SECTI ON,3-ESTiMATED•.CONSTRUCTIOw COSTS
-
It m Estimated Cost(Dollars)to be Official Use Only
7 com leted-b--ermita- licant
1. Building (a)Building-Perrin it"Fee
2. Electrical V (b),;Estimated-'Total Cost of
Construction.frorm(H,:.
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check,Number Jr'
This Section For Official Use=Onll
�.J _ . _ T
Date.
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
r
File#BP-2007-0524
APPLICANT/CONTACT PERSON CANNONCARLSON JOANNE
ADDRESS/PHONE 668 RYAN RD FLORENCE (413) 584-6548 Q
PROP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL PELLET STOVE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved 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 Commiss
S'l.
Signature of Build' g ficial 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.
668 RYAN RD BP-2007-0524
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28-030 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0524
Project# JS-2007-000761
Est.Cost: $3700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 41991.84 Owner: CANNONCARLSON JOANNE
Zoning: SR(100)//WSP 11 Applicant: CANNONCARLSON JOANNE
AT. 668 RYAN RD
Applicant Address: Phone: Insurance:
668 RYAN RD (413) 584-6548 Q
FLORENCEMA01062 ISSUED ON:513112011 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE
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 5/31/20110:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner