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2008`0346 22.39 4135275970 1413 527 5970
Page 1
The Commonwealth of Massachusetts
Department of Industrial Accidents
r"
Office of Investigations
600 Washington Street
Boston,MA 02M
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
llcant Information Please Print I ibl
Name(Btama miza ion/lndividual):
Address: ---
City/State/Zip: u'/�
Are,,ru an employer?Chec the appropriate bov Type of project(required):
II am a to with 4. [] I am a general contractor and 3
� � �s have hired the sub-contractors �. C]New construction
employees(full and/or part time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑R=nodeiing
ship and have no employees These sub-contractors have S. 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 I0.13 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Phtnobing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.C1 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.(No workers' 13 Other
comp,insurance required.]
;Any'Arty applicant dut checks box#i1 Waist also fin out the section below showing their workers'compensation pok7 information.
who submit this affidavit indicating dwy Are doing Ali work and then him outside contractors must submit a stew lffidpil#atlialatg VrA
k aftaftlrE tbit&Ad this box tnust atisew an Additional sheet sbowing the name of the subcantrwun and state whether or not daAe entities have
etnplayam. lfthe sub-contractors have empkyws,they mast 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#o Self-ins.Lic.#: Expiration Date: /�i n
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 S 1,504.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.40 a day against the violator. Be.advised that a copy of this statement may be forwarded to the Office of
bMLtj&atiopj of the DIA for insurance covgMye verification.
I do hereby certify sunder the pains andpenalties ofperjury that the information provided above is true and correct._ Date:
PhLne#• 7j�i`�
tc' use on . o not write In this area,to be completed by city or town offwlaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Page No. of Pages
Propw6al
THOMAS C. McCARTHY
GENERAL CONTRACTORS, INC.
3 Broderick Street
Easthampton, MA 01027
(413) 527-5141
Fax (413) 527-6893
WWW.RUGGLUMBER.COM Email: TCMGCI @AOL.COM
PFtoPQ lam k'AToj yKa graves PHONE 413-586.0785 D 1112008
STREET t10� ti JOB NAME
194 North Maple Street
CITY,STATE and ZIP CODE JOB LOCATION
Florence, MA 01062
ARCHITECT DATE OF PLANS JOB PHONE
MA H14#100364 Exp 5/16/10 MA Const.Supervi or#053221 Exp 5/23/09
We hereby submit specifications and estimates for:
. Estimate for_the_following renovations to the first.floor.den at the_above listed_address,
_....T.his Estimate.includes-removing-some of the-12'_x_24'ceiling for the-electrician_to install new wiring and switch -
for the ceiling light.
- - We will then fir down the openings for the electrician, then-supply-and install 1/2 sheetrock-over the 12' x 24'- -
ceiling, tape three coats and sanded and sponged, ready for primer and paint.
We-will-primer the ceiling,then install-2 1/2"-primed-crown molding around the entire ceiling,paint the ceiling
and the molding white.
The Estimate includes installing a 1 1/2"cove molding going up the stairwell on both sides,primed and painted
The Customer will strip the wallpaper, (10"down from ceiling anyway), and supply the light fixture that we will
hang. The room to be emptied by others.
All rubbish removal is included. There will be dust from the sheet rocking. We will plastic off the openings to
help keep some of the dust down.
The Northampton Building Permit is included, we will get.
WC J31rOV05C hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
Three Thousand Eight Hundred Seventy and xx/100................. dollars ,$ $3,870.00
P ment to be made as follows.
a
a0% Down : $1,935.00 50% Upon Completion: $1,935.00
All material is guaranteed to be as specified All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from above specifications Signature 4�_ r
involving extra costs will be executed only upon written orders,and will become an extra
charge over and above the estimate. All agreements contingent upon strikes,accidents Note:This proposal may be 45 Days
or delays beyond our control. Owner to carry fire,tornado and other necessary insurance withdrawn by us if not accepted within _days
Ourworkers arefully covered by Workman's rCompensation Insurance
Z(CCePt,111 Ce Of V r0POSdC-The above prices,specifications
and conditions are satisfactory and are hereby accepted.You are authorized
to do the work as specified Payment will be made as outlined above. Signature —
Date of Acceptance Signature
SECTION 8-CONSTRUCTION SERVICES j
8.1 Licensed Construction Suoe:-rsor: / Not Applicable ❑
Name of License Holder: �p% l�) NA
License Number
adcress Expiration Date
Signature Telephone
1.Reuistere rit
Home tmpraveent Contractor r Not Applicable ❑
x
:omoan Name Registration Nu ber
Z) Itl
ddress Expiration Date
T/ t/�+: i� 7TelepI l,!
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.152,§25C(6))
'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
cried Affidavit Attached Yes....... No...... ❑
µ Iome' e - gcbau
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.CiNIR 730. SLith Edition Section 103.3.5.1.
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 Ofncial,on a form acceptable to-the Building Official.that he/she shall be
responsible for all such work performed under the building hermit
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 pernut 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 undersizted"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 anolicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
tt--11 Or Doors 0
Accessory Bldg. a Demolition ❑ New Signs [7] Decks [[:I Siding[p i Other[ED]
Brief Description gf Prepcs
Work: �i?5tT l//f f� J � f�l�t'! (CG!✓7e�� ✓ i' � f� 1Lil �Jr[_f � f y�/rt`Gr,r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if Ne"w house and or addition to exis ana-housino 'comDflete th41606wina:
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 Weodstoves Number of each
c Energy Conservation Compliance. Masscheck .Energy Compliance form attached?
h. Type of construction
i. Is construction within 1GO ft. of wetlands? Yes No. Is construction within 100 yr. fccdplain 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. GEE..COMPLSTEIx Wf EN
OWNERS AGENT OR CONTRACTOR APPLIES FOR LJILDINC:PERM1T
GL ! t ; S as Owner of the subject
property
hereby authorize
to ct on. y behalf, in ail attars relative to work authorze by this building permit application.
Signature of O Date
Cas Owner/A.uthcnzed
Agent h reby deciare that the statements and it ermation on the foregoing application are true and accurate, to the best of—my my°TRncwledge
belief.
Sicred under the pains and penaiti, s of perjury.
I ---
Pnn a .e
I
cnaiure cd Cwn el Agent Oae! Q
^
`
Section 4. ZONING At[Information Must Be Completed. Permit Can Be Denied Due To incomplete Information
Exisin;ng Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontaze
Setbacks Front
Rear
Building Height
Bld,-. Square Footage %
Open Space Footage %
(Lot area minus bidg&paved
(volume&Location)
A. Has a Special Permit/Yariance/Finding ever been issued for/on the site?
NO \~/~�� DONTKNOYY YE9 �~y��
�
�
IF YES, date issued:-
IF YES: Was the permit recorded at the Registry nfDeeds?
NO �� DONTKNOYY YES
\��
IF YES: enter Book | ` Page | and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO 0 DONTKNOYY Q YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained 0 Obtained 0 ' Date Issued:
C. Doan^ v��
ysignsexistontheprope�y? YES NO
\~�
IF YES, describe type ,
' ' ' L_______-____________---------------------�
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO -(g->
/F YES, describe size, type and location: .
E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orisit part ofa common pi-.n
that will disturb over 1acre? YES � ) NO,711=7
IF YES, then'a NortG�mp-tcn35-oFFl0d-te—r'-*����md6t-p�hnit from the DPW iorequired.
/+p5 6�G
Department use only
City of Northampton Stags of Permit:
Building Department Curb Cut/Drnreway•Permit
212 Main Street Sewertsep tit,Avarlability I
i
Room 100 -WaterNVellAvailability
Northampton, Mr, 01060 Two Sets ofStructural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Ste Plans
Other,Spe'c*
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Prooerty Address:
?�
g t �(/r AL� �fa� 2C P,8' Lot Unit
Zane I i Overlay District
CB District
SECTION Z-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 owner of Record
f: ' /✓Jj/y
Name(Print) Current Mailing Address:
Telephone
Signature r
2.2 Authorized Agent:
6-/C"
Name(Penn Current Mailing Address:
1i /cam 1(ll a �._ 2 ?
Signature Telephone / 57,
SECTION 3-ESTIMATED CONSTRUCTION'COSTS
Item ! Estimated Ccst(Dollars)to be Official Use Only
completed by permit aoolicant
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) s , �1, Check Number Z99.
l
This Section For OfficiafUse Only
_ Date
Building Permit Number. Issued:
Signature:
_.__ ----------wilding,:Cammissioner[Inspectoi or vi amgs Date
File#BP-2009-0177
APPLICANT/CONTACT PERSON Thomas C McCarthy
ADDRESS/PHONE 3 BRODERICK ST EASTHAMPTON (413)527-5141
PROPERTY LOCATION 194 NORTH MAPLE ST
MAP 17A PARCEL 223 001 ZONE URB
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: REPLACE WATER DAMAGED CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 053221
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Signature of Building Offici 1 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.
194 NORTH MAPLE ST BP-2009-0177
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-223 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pemut: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0177
Project# JS-2009-000232
Est. Cost: $3870.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Thomas C McCarthy 053221
Lot Size(sq. ft.): 12806.64 Owner: HARGRAVES WILLIAM J& HOLLY R
7Clt?i�l St•i i:?i? :ry.�::�,ry..s. TS��w,...� !` 1\�r^�:r.l�„— —
AT. 194 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
3 BRODERICK ST (413) 527-5141 _Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:812112008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE WATER DAMAGED CEILING
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:
xougn: U;i► Insulation:
Final: Smoke: Final: Bk CT- as-e I5'
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA T NS.
Certificate of Occupancy signature:
FeeType: Date aid: Amount:
Building 8/21/2008 0:00:00 $55.002984
212 Main Street,Phone(413)587-1240,Fax: (413)581-1272
Building Commissioner-Anthony Patillo