22B-106 (2) The Commonwealth ofMassairchusetts
Department of Industrial Accta'ents
Off ice of Investigations
600 Washington Street
Boston,A L4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
M-Plicannt Information Please Print Legibly
Name(Business/Organization/Individual): /�L��f L� _727
Address: tJ i�� 16�� •� C/� ��!��
City/State/Zip:_/✓�j�/'/J7)4 MA p/0 Ca G Phone#: 4�:3-✓���' ?S�Z Z.
Are you an employer?Check the appropriate box: Type of project(required):
1.[ I am a employer with J' 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. E] 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 1211 Roof repairs
insurance required.]t C. 152, §1(4),and we have no } �--/�--�
employees.[No workers' 13 gOther Ln )O_ w' �
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 any employees. Below is the policy and job site
information. ,y _
Insurance Company Name: i!ell_ rl ' _1_117 25614 W"G z -
Policy#or Self-ins.Lic.#: 1 Z , E:piration Date: -711117
G
Job Site Address: 15, S' -1 n, �`� City/State/Zip:No rfh 1, M C�1b�
Attach a copy of the workers'com-pensatflom policy deckratlon gage(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition ofcriminal 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 c a�der t gains and enaldes p ' ry that the information provided above is tease and correct
Si mature: /r .�!� Date: ( � .s
D te: 1
Phone#: ql,'✓ 2 Z
Official use only. Do not write in this area,to be conTleted by city or town official
City or Town: Permit/License n
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chi/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector �
6.Other
Contact Person:Phoaaa #:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. \_ (� Not Applicable ❑
Name of License Holder: �L° l �1\�a�1 0(0 0aco
vCLk e , �ko� License Number
\ore�ur NL ON O b2 91 z ` I
Address Expiration Date
Signature Telephone
9.Registered Home Improvement` Contractor: Not Applicable ❑
al,
Company Naffie Registration Number
�Pj ,qg� � . �oreX-lct 0�0�2 -t 1 ri 1 l
Address cq Expiration Date
Telephone�Wb-W4.7,722
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....... X No...... ❑
11 - Home Owner Exemption
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 Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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 Spaces -
Fill:
volume&Location)
A. Has a Special Permit/Variance/Fi din ever been issued for/on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin ex vation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (Q Siding[0] Other
j5�
Brief Description of Propos
er vetrl, u-svla e c7 ic w 9N ce//v1os� rn evil PqI
Work: 1nSulak Fill i ('n(J 61 f 01i"<5'eq.1 anj Ltw(p4hU"1 Z�-f-
Alteration of existing bedroom Yes-7x--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, 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 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
, JD(1 Hi 4e Loi-{62) Floas wo P1y+h ort-t Q ,as Owner of the subject
property
hereby authorize N0 SW'U tee 4 1� �► �1ynPro iemer�-to act on my behalf,in all matters relative to work authorlded by this building permit application.
� Nease see Fri-}-
Signature of Owner Date
1, L� ��+'r�2� v Q�,�+tpcY�L �Cr• ,'TCIC ,as Owner/Authorized
Agent hereby declare that the statements an nformation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
NekSon '�-4()Ve��
Print Name I
Signat re of Own!oXge nt Date
j
1 Department use only
` City of Northampton status of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailability
Room 100 WalerM/eli Ava�labtl�fy
orthamptOn, MA 01060 Two Sets`of Structural Plans
p 13-587-1240 Fax 413-5$7-1272 [?Iot/Site Plans
C(j Other SpeClfy
APPLICATIO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PropertV Address:
This section to be completed by office
Map Lot Unit
151 Spring Street
Florence, MA 01062 Zone Overlay District
Elm St.District CS District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
X Jon Hite, Exectitive Director Northam ton�Aousing Authority 49 Old South St.
Name(Print) AtL Cu fg 13 jiling84tlr4030 x 382
Telephone 7
i
2.2 Authorized Agent:
Welscln shRIi-j ha I I&
j ?�yme7rnpr�veme 346 �tyt�std FlarenCc; Ntf�a�o�
Name(Print) Current Mailing Address:
YA 4/3-584 - 75;�a
Signature 10 0z Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS Insulation Work
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building a d4b0�C?C�
_! ( )Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(WAC)
5.Fire Protection
6. Total=0 +2+3+.4+5) a ( Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-0727
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE (413)584-7522
PROPERTY LOCATION 151 SPRING ST
MAP 22B PARCEL 106 001 ZONE URAO00)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION AIR SEAL&WEATHERIZE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077279
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOY,MATION 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
De tion De y
Signa e o ildi g fficial 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.
151 SPRING ST BP-2015-0727
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:22B- 106 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-0727
Project# JS-2015-001414
Est. Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 077279
Lot Size(sq. ft.): 7927.92 Owner: Northampton Housing Authority
Zoning URA(100)/WSP(100)/ Applicant. VALLEY HOME IMPROVEMENT INC
AT. 151 SPRING ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON.111512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION, AIR SEAL &
WEATHERIZE
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 1/15/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner