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LThe Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): '#
Address: 13,0k 6p-
City/State/Zip: % 010�A6 Phone #: Y13 •-!0$-7os9
Are you an employer? Check the opriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 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 for me in any capacity. employees and have workers' 9. ❑ 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
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §l(4),and we have no 13. Other 6�
employees. [No workers'
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
Signature: Date:
Phone#: y1.3 -69.5-7 9
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 0
Name of License Holder: 96457
License Number
/0. 6,-t 627 0/496 71 312414,
Address Expi lion Date
' %13- 695--77$9
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
2105' 2 513z2�/6
Address Expirafiion4ate
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 buildin.g.permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home ner Exemption
The current exemption for"homed ers"was extended to include Owner-occupmnotbe of o e(1) or two(2)families
and to allow such homeowner to engage individual for hire who does not posseovidethat the owner acts
as su ervisor.CMR 780 Sixth Edition 'on 108.3.5.1.
Definition of Homeowner:Person(s)who own a el of land on which he/she nds to reside,on which there
is,or is intended to be,a one or two family dwelling,atta d or detached s oo such use and/or farm
structures.A erson who constructs more than one home in o- r eriod considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a fo a table to the Building Official,that he/she shall be
responsible for all such work performed under the build' ermit.
As acting Construction Supervisor your presence on fob site will be require om time to time,during and upon
completion of the work for which this permit is iss
Also be advised that with reference to Chapter 2(Workers' Compensation) and Chapte 53(Liability of Employers to
Employees for injuries not resulting in De of the Massachusetts General Laws Annotated, u ma be liable for person(s)
you hire to perform work for you unde is permit.
The undersigned"homeowner"cc ' tes and assumes responsibility for compliance with the State Buildi ode,City of
Northampton Ordinances,State d Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signatu
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all agglicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E::] Siding[p] Other[1211",
Brief Description of Proposed
.4 L ,,,,/ C[L,/e/1�i�.,.z� .1Ct!►o�ea_
Alteration of existing bedroom Yes_�No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing. com lete 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 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 X as Owner of the subject
property —`–�
hereby authorize
to act on my behalf, in all matter r ative tow authorized by this building permit application.
Ct -
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that 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.
c��vyrzi� ,Pic/t�Y
Print Name
?1.2 3 Za/
Signature of Ow gent D e
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 /S 232 /S 232
Frontage 15•Z
Setbacks Front "50 t $Gf
i
Side L: 31 R: L:ZY R: SS
Rear 86 8S
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 (g DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES o 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
Gity of Northampton Status of Permit:
OCT 2 914 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability.
Electric; rt Nom' mpton, MA 01060 Two Sets of Structural Plans
Nor} �'
phone 413-7-1240 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:
This section to be completed by office
' -'de Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
a (Pri ) Current ding Address:
X Teteph!413 3 SSG 7 F0 6
Signature
2.2 Authorized Agent:
6 62 �ne�tu� O/a y6
Name(Print Current Mailing Address:
e� 74159
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /G 85
(a)Building Permit Fee
0. ®o
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) /O Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building CommissionerlInspector of Buildings Date
6 IC
File#BP-2015-0501 td F'1 Q A
APPLICANT/CONTACT PERSON EDWARD RICKEY
� ,..
ADDRESS/PHONE P O BOX 62 WILLIAMSBURG (413)695-7059
PROPERTY LOCATION 110 JACKSON ST
MAP 24A PARCEL 057 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T.,peof Construction: REPAIR EXISTING PORCH&ENLARGE BY 120 SO FT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 96159
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 Commission Permit DPW Storm Water Management
emolition Delay
/! A 4
Si ure of Building 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.
110 JACKSON ST BP-2015-0501
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-057 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-2015-0501
Project# JS-2015-000941
Est.Cost: $10850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin EDWARD RICKEY 96159
Lot Size(sq. ft.): 14853.96 Owner: VINSKEY GEOFFREY JAY&HEATHER D VINSKEY
zoning URB(100)/ Applicant: EDWARD RICKEY
AT. 110 JACKSON ST
Applicant Address: Phone: Insurance:
P O BOX 62 (413) 695-7059
WILLIAMSBURGMA01096 ISSUED ON.111712014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR EXISTING PORCH & ENLARGE BY 120
SQ FT
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 Siiinature:
FeeType• Date Paid: Amount:
Building 11/7/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner