17C-083 (2) The Commonwealih of iblassachusetts
Department of In dustrialAccidents
r
/ Ofce of Investigations
I'
bOQ Washington Street
Boston,AL4 03111
www.massgov/dia
Workers" Compensation Insurance A-..flidati-it: Builders/Contractors/Electricians/Plumbers
AmAicant Information Please Print Legibly
Name(Business/Organizuow1ndividuai):
d d&ess:
City/State/Zip: Phone,-A':
Are you an employer?Check the appropriate box: Type of project(repaired):
?. I am a general contractor and I
1.El I am a e�loyer with ❑ - 6. ❑New construction
emniovees(full and/or part-time).* have hired the sub-contractors
?.❑ I am a sole proprietor or partner- listed on the attached she— 7. ❑Remodelin.g
ship and have no e-�leyees These sub-contractors have g- ❑Demoliuon
Iworking for me in any capacity. employees and have worker 9. ❑Building addition
"No workers'co=.;ms- once comp.insurance.*
required.] 5. ❑ We are 10.a corporation and its ❑Electrical repairs or additions
❑ I am a l:,omeowner doinv all work officers have exercised their 11-❑Plumbing repairs or additions
myself. [_N-0 workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]T C. 152, §1(4), and we have no
employees. [No workers' 1317 Other
Comb.insurance requited.]
--" iy apppdcant am neco Dox�i trout aura rw out tae season oe:aw snowma their worms'cor don.policy informadon.
T Homwwners who submit this affidavit indicating they are doing all work and then hire outside coutractors must submit a new affidavit mdic a ng such.
*Contractors that rhea's this box must-attached an additiaaal sheet showing the name of the sub-contractors and state whether or not those eatities have
employees- If the sub-connuctors have enmioyees,they Host provide their workers'corm.policy number.
lam an employer that isprovidin,.workers'compensation insurance for my employees: Below is thepolicy andjob site
information.
Insurance Company Name:
Policy It or SeLF ins-Lic. Expiration Date:
Job Site Address: City/State/Zip
Attach a copv of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure cove-rase as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as wet-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 DLL for insurance coverage verification.
I'do hereby certify under the pares and penalties of perjury that the information provided above is true and correct-
Date: _
Phone#:
L e oniv. uo not wrzte rn this area, to be completed by city or town offzdal
wn: __-- P-erruit/License
thority(circle one):
Health 2.Building Department 5. City/Town Clerk 4.Elect.ical Inspector Plumbing Inspector
son: Phone
_�, ,!Yi ' seta=sat�usr s 2 -'
DEPA I'VfENT OF EUML JI�G LINSPE=ONS I IU'
212 Main Strut • Municipal E uilding N`
INSPEC±C- \�
Nortbamptou, MA C1060 _
The State of Massachusetts allows the homeowner the right under 780CIMR 108.3.4 to
act a�- construction sups_ --i°;or. T lie stare defines "Homeowner' as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
&,yelling, 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 hone owner exemption, to act as thew-own const ucal on- supervisC, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process rewires that the building department be called
to inspect work at various stages, which include foundation/footings (before bacMll).
sonotube holes (before pour). a rough building inspection (before work is
co-ace.fled). insulation.insraectio-n (if required) and_afnal-buildine insnecti.o.n. The
building department requires the inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
u-jitil.-the-work ean-be_inspected._
If the homeowner hires other trades to perform work(electrical, plumbing&Jas) 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
understand the above_
(Home owner/resident's signature requesting exemption)
I will call to schedule a1I required building inspections necessary for the building permit
issued to me_ y
Date
i
Address of work
location ►�� IG�i l
; F
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
woo
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 162,§26C(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(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, tate 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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[11T
Brief Description of Proposed 1 ��Work: In;' a DMO
I V
Alteration of existing bedroom Yes_�No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
Sa.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
I, 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
rah Y 'N as wne Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the bes of my knowledge
and belief.
Signed under the pains and penalties of perjury.
5do irl�60
Print Name A�— [ �
Signature of Owner/ gent 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
40 C,"AJ-44C—S� Building Department
Lot Size 0 0,244. &r.
Frontage
Setbacks Front z .
Side L: R: L:Ik_R: _ r
RearE' '`�-
Building Height r
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 0 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 DON'T KNOW YES
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 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,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.
n t Department use only
City of Northampton Status of Permit:
C� Building Pepartment Curb Cut/Driveway Permit
M in Street Sewer/Septic Availability
Rqqrb 100 Water/Well Availability
- N6hhaTiipton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
1.---
other-Spec
ify
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
)h* 9 roe f Map Lot Unit
t'! r Zone Overlay District
to (p ` Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5ar Ah 6MO 100 CP Iti4
Name(Print) Current Mailing dress: �-l3
Telephone
Signature
2.2 Authorized Agent:
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 (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= 0 +2+3+4+5) 600 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-0484
GIS#: COMMONWEALTH OF MASSACHUSETTS
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-2008-0484
Project# JS-2008-000722
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 10715.76 Owner: TAYLOR SIMON M&SARAH F
Zoning:URB Applicant: TAYLOR SIMON M & SARAH F
AT: 53 HIGH ST
Applicant Address: Phone: Insurance:
53 HIGH ST (413) 584-1373 O
FLORENCEMA01062 ISSUED ON.111612007 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 SiEnature:
FeeType: Date Paid: Amount:
Building 11/6/2007 0:00:00 $25.00611
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo