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Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is def=ined as"._.every person in the service of another under an r cont=act of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the fore`oL.Q engaged in a joint enterprise, and including the Iegal representatives of a deceased emplover,or the
receiver or trustee of an individual,partnership, association or other legal entity, emploving employees. However the
)weer of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
;welling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
�r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
1GL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
!newal of a license or permit to operate a business or to construct buildings in the commonwealth for any
:)plicant who has not produced acceptable evidence of compliance with the insurance coverage required."
dditionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
.ter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
luirements of this chapter have been presented to the contracting authority."
iplicants
ase fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
essary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
uance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
abers or partners,are not required to carry workers'compensation insurance. If an Lffor LLP does have
Ioyees,a policy is required. Be advised that this affidavit may be submitted to the Department of I=ndustrial
idents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should .
,turned to the city or town that the application for the permit or license is being requested, not the Department of
strial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
)ensation policy,please call the Department at the number listed below. Self-insured companies should enter their
nsurance license number on the appropriate line.
or Town Officials
be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
be sure to fill in tie permitllicense number which will be used as a reference number. In addition,an applicant
ust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
information.(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
nt as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
here a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
og license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
:ice of Investigations would hke to thank you in advance for your cooperation and should you have any questions, '
o not hesitate to give us a call.
artrnent's address,telephone and fax number:
The Comnnonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washinzton Street
Boston. MA 0211 i
Tz1. - E 17-727-:y 0 0 e - 4.06) or 1-47 tiLkSSA
Fax= 617-7?7-77=`S
� �.=-ass.=e di4
The Commonwealth of!11assachzcsers
- " DeoartmentofInatustrialAcciderats
- ;'-=— - Office of Investi;ations
600 YPashin 'on Street
Boston, MA 02111
www.mass,,-0v1 is
Workers' Compensai�on Insurance davit: Builders/Contra.ctors/EIectricians/PIl`L bens
ADDHCant Information Please Print Le6ibly
N=t (Busness/Or?arization/Individual;: 441ez ,o� � //�/� t' S� �✓,!,
Address: %.�'S /(/�/ hem' .l'
CIty/Statt.Zlp: Prim` �' Phont , /s - 6
Are you an employer? Check the appropriate bo,: Type of project(required):
1.❑ I an a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors . New construction
2. I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
s Lip and have no'empioyees These sub-contractors have g_ ❑Demolition
working for me in an capacity- employees and have workers'
Y P 9. ❑Building addition
[N10 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. ['`�o workers' comp. right of exemption per MGL 12_�Ro_ofsepairs
insurance required.]t c. 152, §1(4), and we have no 13 Other� cl!_
employees. [�To workers'
Comm.insurance required.]
*Any applicant that checks box#1 rust also fill out the section below showing their workers'conmensation policy information.
Homeowners who subrnit this affidavit indicatals thev are doinz all work and then hire outside contractors must subrrat a new afidav t indicating such.
=Contrc on that check tiris_box must attached an additional sheet showing the name of the sub-contractor and sate whether or not those entities have
ezployees. If the sub-conzractors have e nployees,they must provide their work—mrs'comp.policy nuznber.
I am an employer that is providtn.,workers'compensation insurance,for my employees. Below is the policy and job site
information.
Irsurance Coinpan;i dame: -
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
flee up to 31,500.00 an&or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiaadons of the DL4 for insurance ccvera_e verification.
I do hereby certify under the pains and penalties ofperjury that the in.1ormationprovided above is true and correct.
Sisnar re: Date: Z4 F
Phone=• y/ �SGr _
use oral/;. Do not,,,rite in this area, to be complered by city•or town oTzzciaL
j Cry or Town: Per3:it:'License T i
I
.Issuing A ut ority(circle one):
1.Board vi Health, 2.Build:n°De-cart-Trent 3. Ciiv'i'T own Cier.K
Electrical inspector _. Pl rnbIr_Q Inspector
5. Other
I `_'orta., Per�cn• Pone= �
SECTION.8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder: ' ,0/ !a?AID') (_J /Oa fg
License Number
AI4 X19
Address Expiration Date
Signatdre Telephone
S:Realstemd Home ItnprOVemont Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone W-4
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 Exembi ion
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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 25
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [Q] Decks 2 Siding[i=] Other[p]
Brief Description of Proposed /Wo rk: CeASJf�ycT . Co.M®aAN ww.� �1G •�1y d 7"` �1a�t/CS G
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
sa.if New house and or addition to existinu housing, comalete the foliowina:
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
J1 `Q Gt u Jac 1 J "Xt L C as Ownei)of the subject
prop rty
hereby authorize _
to act on AX behalf, in all nru`:ters relative to worts autnonzed by this building permit p lication.9 -,L-lk,l,�l 141 .*----
Signat e o ner Date
,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.
Print Name
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 (P 53 lw,, S3_o
Frontage
Setbacks Front Y�' z,,r!
Side L:.3 U ' R: '�" L: 30_ R: 3 5
Rear /d G , 100 ! v
Building Height
Bldg.Square Footage 3t %
Open Space Footage %
(Lot area minus bldg&paved 0219 Z
parking)
#of Parking Spaces 2
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
AMIN
NO DONT KNOW 0 YES Q
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q 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 Q , 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 Q 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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
E)eparf use:only
qty of Northampton tus oflper".
'B itt wPermit� uildin De k
212 Main Street Sewer/sepiGAdailatAity
Room 100 Watedweil Aualla itty "
- �
Northam ton, MA 01060 Tyro sets of tn,oturalits
phone 413-587-1240 Fax 413-587-1272 PIoUStle Pans
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
Map Lot Unit
r%'I 4✓2 n�� � M /�' G�1��0.� Zane Overlay[iistrict
EtM St.Distdct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: t,
LL
f +✓. Ufa,�S $ Caws'/mac [ Dry c �j�ai�6
y � kI `(� ii GlC rr� � f�
Name(Print) ' Current Mailing Address:
(4 1
TeleTele—bone
S nature
12 Authorized Aoent:
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 � Q (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) 00 Check Number
This Section For Official Use Only
Building Permit Number. Issued:
Signature:
Building Commissionertinspector of Buildings Date
J
File#BP-2009-0377
APPLICANT/CONTACT PERSON MICHAEL FREEMAN
ADDRESS/PHONE 283 #NINE RD HEATH (413)522-5565
PROPERTY LOCATION 168 CHESTNUT ST
MAP 17C PARCEL 055 001 ZONE URA(100)/
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: CONSTRUCT 12 X 14 DECK&REROOF HOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100518
cob t-
3 FO UD ry►E
3setsof Plans/Plot Plan c?Tf{+�` S 6T
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF kMATION 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
Demolition Delay
��.._ 6 , J /0// 5�L
Signature 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.
BP-2009-0377
GIs#. COMMONWEALTH OF MASSACHUSETTS
fi . a ate,;
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2009-0377
_Project# JS-2009-000511
Est.Cost: $16000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL FREEMAN 100518
Lot Size(sa. ft.): 16509.24 Owner: MANSEAU PATRICK M&JACQUELINE L RICHARDS
Zoning. URA(100)/ Applicant: MICHAEL FREEMAN
AT. 168 CHESTNUT ST
Applicant Address: Phone: Insurance:
283 #NINE RD (413) 522-5565
HEATHMA01346 ISSUED ON:1011412008 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 14 DECK & REROOF
HOUSE(FOOTINGS MUST MEET CODE REQUIREMENTS)
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 10/14/2008 0:00:00 $90.00207
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo