Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
23C-085
N I he Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L&siblv Name(Business/OrganizatiortJlndividual): r1d (L (l4/l O V eiVj'V Address: 3 q City/State/Zip: E0t 1) !, j Phone.#: �f j 3 l Are u an employer?Check the appropriate boa: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b ❑New construction 2.❑ I am a sole proprietor or partner- Iisted 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' [No workers'comp.insurance comp.insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its IO.❑Electrical repairs or additions 3.❑ I am a homeowner doing alI work officers have exercised their i I.[]Plttrrtbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12❑ f repairs insurance required.)t c. 152,§1(4),and we have no employees.[No workers' 13. Other__ 1 r'ISGt�Gtl t comp.insurance required.] °Any 2ppliC2nt that checks box#1 must also fill out the section below showing their workers'compensation policy inforrnation. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such_ iContractors 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. Jr am an employer that is providing workers'compensation insurance for my employees Below it the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: — j-AQ-- 0 QY 4-40V - 0,9\ Expiration D�:P Soh Site Address. t S 5 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 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 fate 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 Investinations of the DIA for insurance coverage verification. I do hereby cert Jy under the pains and penalties of perjury that the information provided a ove is true and correct. Si nature: " Date: I~i Phone M 4113 a 3 a J d"f - — FEOthonly. Da not write In this area, to be completed by city or town official. n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#• 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: `U �! SS �f' D J-e r�C-C—_ The debris will be transported by: The debris will be received by: //41— Building permit number: t'Y t Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts tiw2 ��fc DEPARTIWNT OF BUILDING INSPECTIONS » 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: `1 S _ :1jjY-42 /1 C J Contractor Name: 1 Address: City, State: 1 13 Phone: Property Owner kbrR-- /�v/J I/( ,,Name: ` (� �, Address: City, State: 7"!DY-2 VIC( (contractor)attest and affirm that the building I intend to insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. ntrac r signature-4---- Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: I Not Applicable ❑Q Name of License Holder: 1 t / J License Number l M4- 01 a//e% Address Expiration Date � --- y 3 3 Sigplature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ /fie& w iqw-ovewfeyT ) L&O 4o�, Com an Name Registration Number 0i 3sq q/.) ss Expiration Date O ^"^ Z 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...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(]) 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 i es or intends to reside,on which there is,or is intended to be,a one or two family Iling,attached or detached stgetures accessory to such use and/or farm structures.A person who constructs more than home in a two-yearfieriod shall not be considered a homeowner. Such"homeowner"shall submit to the Building Officia, n a form eptable to the Building Official,that he/she shall be responsible or all such work erformed under the builds rmit. As acting Construction Supervisor your presence on the ' site 71 be required from time to time,during and upon completion of the work for which this permit is issue Also be advised that with reference to Chapter 15 orkers'Compensati and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death) the Massachusetts General ws Annotated,you may be liable for person(s) you hire to perform work for you under this ermit. The undersigned"homeowner"certifies d 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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 1:3 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[p] Other[ W O G u si I -MC1CG 11s- Brief D.escriptio 9f �o Work: 1491 aa l, & Jn U X C& � ` Alteration of existing bedroom Yes f— No Adding new bedroom Yes l No Attached Narrative Renovating unfinished basement Yes __.,— No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housinotcomolete 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. 1. 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, 16r7� �IJO l h a as Owner of the subject property hereby authorize J t on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Au o�riz 4beiief. ere y declare that the statements and information on the foregoing application are true and accurate,to the best of my 1 r�iowledge Signed u der the pains and alties of perjury. /YY1E'S (I P' me x-1....1- I b l�' Signa re of OwnertAgent Date Section 4. ZONING Alt 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/Finding 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 © 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 Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: C. Do any signs exist on the property? YES Q 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 i® 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 AQ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: B�ilding Department Curb CutlDdveway Permit 212 Main Street Sewer/Septic Avaiiabft it L Ja 2 6 20 16 Room 100 Water/well Avaiiabft 4�( hampton, MA 01060 Two Sets of Structural Plans -- -- hQpe413- 87-1240 Fax 413-587-1272 PtotlSite Plans Electric, Plumping& as Inspections Northampton, mA 01060 I Other.Specify` - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property y This section to be completed by office Pro Address f a j3l(SS "(`1 Map Lot Unit 41 d rV he+e— Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Own r of Record: e brr. Na (Print) Current Mailing Addr Telephone Signature 2.2 Authorized Accent: Name(Print) Current Mailing Add ess: Signat a Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 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) ��. Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0759 APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL01354(413)863-2128 PROPERTY LOCATION 72 BLISS ST MAP 23C PARCEL 085 001 ZONE URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out 7104 _ Fee Paid Typeof Construction:INSTALL ATTIC INSULATION&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 091207 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR ION PRESENTED: proved 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 in ' Sig ture o i ial 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. 72 BLISS ST BP-2015-0759 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C-085 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0759 Project# JS-2015-001472 Est. Cost: $3592.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 17728.92 Owner: HEWAT JEREMY&DEBRA WOLOHAN Zoning:URA(100)/WSP(100)/ Applicant: IDEAL HOME IMPROVEMENT INC AT. 72 BLISS ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863-2128 WC GILLMA01354 ISSUED ON:112612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION & AIR SEAL 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 Sisnature: FeeType• Date Paid: Amount: Building 1/26/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner