05-024 (8) FROM Gou9ean&Locke Builders FAX NO. : 413 268 0354 Feb. 07 2007 03:10PM P1
.�
Die Conizfion wealth of Massachusetts
Department of Industrial Accidents
Office of Inveitib ations
_ 601) fYashin ion Street
Boston, AM 02111
W1V;V.mass.g0v 1dia
-Workers' Compensation insurance Affidavit: Builders/Contractors/Electri'ciaxxs/Plnmbcrs
Applicant Information Please Print Leaibiv
Nate(Business/Or�-,anir;aion/I.ndividual): (91 O—V A9 N 41
Address: 24y SD_V_q'7_{� 611 -0
city/state/zip l,+ i,th/S`�^n�F 3 U — jar' Thor i Z
Are you an employer?Check the appropriate box: Type of project(required)..
1.qT--;m a cmployeP with `t ] F and a�,ea2er3l contractor and I New construction
employees(full and/or part rime).* have hired the sub-contractors
2_Q I arY a sale proprietor or partner- listed on file attached sheet. 7. ❑Remodeling
ship ind.have no.employees lliese sub-ooatractors leave 8- Damolitou
wor]fizig for me in any capacity =Vloyees and have workers' 9_ Q Building addition
[Na workers' comp_instiraz7tee camp_insurauce.t
Z 5. We are a corporation and its 10.E]ElectricaI repairs or addidons
3_[] 1 am.a ho'mzowner doixig a..11 worts officers have exercised their i I_E]Plumbing repairs or additions
myself.[No workers'comp_ right of exemption'per MGL 12.L]Roof repair
insurance required_]t c. 152,§1(4),and we have uo
employees.[No workers' 13_[]Other -
comp.insurance re:Ei ]
'Any applirant that checks bat 41 r m=also W1 out the section below Showing their workers'eorq=ssdon policy iii f*rrn dcm
T Hommvners who subm;this affidavit indicating they arc doing all worK and then him outslile oxitractors roust submit x new affidavit indicating math
°Gonu=u:rs that check this box mom[auached in additional sheet showing the name of the sub-cenpaclws aad sate whether or not those entities have
=Vloyses_ g are sub-eanuaptars have cmp7oyers.they nwstpravida their`work='coma.policy number:
I am an employer that is provirfXng workers'comrpe rsadon Lnsrerance for my employees. Below is thepolity and joh site
tnformally�
Lasurznce Company Nacre: ( �✓�lrc C� ,
Policy#or Self'ins.Lic. z. � �� ����a i�•�7� �' Expir don Date:
Job Site Address_ - YYt �ity/State/Zip:
Attach a copy of the workers'compensation policy derlarstion page(showing the policy number and expiration date).
Failure to see=coverage.as required under Section 25A of MGL c_ 152 can lead to the inVosition o'fclimirial penalties of a
fine up to$1500.00 and/or one-year iroprisonment,as well as civil penaltics in the fo=of a STOP WORK ORDER and a fmc
of up to$250.00 a day against thq violator. $e advised that a copy of this statement may be forwarded to the Offfee of
Investintions of the TDL&for insurance covmzc verification.
I do hereby cgYWfy tender the pairts and pens pf penury that the informarion provided above is true and correct.
Date: -
Phone# -2— V -3
Official use only. Do not write in this ar+'a,to be completed by city or town offraial
City or Tower: NrmitUcense r# -
Issuing Authority(circle one):
1.Board of Health 2.Building Deparnuent 3.Cityfl'own Clerk. 4.Electrical inspector 5.Plumbing Inspector
6. Other r
Contact Person- Phone#r-
r ►' it
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: p Not Applicable ❑
Name of License Holder:- /, �c� �l, 2--
License Number
fl aO U� %2 - 6
Address Expiration Date
16r--? 32,3,
Signatur Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
/00 ZO y'
CompanX Name Registration Number
GOUGEON & LOCKE
Address 26 South Street Expiration Date
Will a-msini rg, NIA 01096
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...... ❑
1.1. 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 buildine 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 taws 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) j� Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[0] Other[O]
Brief Description of Proposed
Work: (�UJGII(' �i'C DtTIC�I necv �1 �� E Sv2�i� , d�vr
Alteration of existing bedroom Yes V No Adding new bedroom Yes (/ No
Attached Narrative Renovating unfinished basement Yes 1/ No
Plans Attached Roll -Sheet No /CPAIP— 64-'&61
6a.If New house and or addition to existing housing, complete the followincr
a. Use of building : One Family f/ 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 i--� 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, 2Ct3 as Owner of the subject
property /�
hereby authorize /� S 1�iJC.ti�� 4 eyjl--e'er'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
J as-9w+ter4Authorized
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.
Jkfittfls �_-
Print Name
Signature of Awnef/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colunm to be filled in by
v 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)
4 ol'Parking Spaces
Fill:
(volume&Location) _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW (J YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW YES Q
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW C) 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 O 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, excav tion, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
04
Departn ent use o ly
City of Northampton Status of Permit:
Building Department Curb CuVDriveway Permit
212 Main Street Sewer/Septic'Avallability `
Room 100 WateNWeli Availability
Northampton, MA 01060 Two Sets of Structural Plan
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other SpecifyT
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
I�� T'�(�`� 6 P(J� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
z6 y 4r>,-jc,bL-x_ P-1
Name(Print) Current Mailing Address:
bv AIAXI s9 y
Telephone
Signature
2.2 Authorized Agent:
rJ>/Lt "s�--
Name(Print) Current Mailing Address:
Z�- E' y32-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /O 3 J — (a)Building Permit Fee
2. Electrical N lQ (b)Estimated Total Cost of
/ Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)N�
5. Fire Protection A
6. Total=0 +2+3+4+5) Check Number O
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
77 7
File#BP-2007-0781
APPLICANT/CONTACT PERSON GOUGEON& LOCKE
ADDRESS/PHONE 26 SOUTH STREET WILLIAMSBURG (413)268-9323
PROPERTY LOCATION 264 AUDUBON RD
MAP 05 PARCEL 024 001 ZONE RR
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: REPAIR FRONT PORCH NEW FLOORING,SCREENS&DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 001992
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPRMATION 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 Stree ommission
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-2007-0781
264 AUDUBON RD
# COMMONWEALTH OF MASSACHUSETTS
GIs :
GIS#:
Map-.Block: OS -024 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Category:
Permit# BP-2007-0781
Protect# JS-2007-001255
Est. Cost: $10315.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED T
Contractor: License:
Const. Class_ 001992
Use Group: GOUGEON & LOCKE___
Lot Size(sq. ft.), 25_ 482.60 Owner: KORZA RONALD WILEEN 3
Applica nt: GOUGEON & LOCKE
Zoinng:F1� — -- -- -
fii ': Lair H+.:�`v�..i�`d '�•'-' Insurance:
Phone:
Applicant Address: — X413) 268-9323 Workers
26 SOUTH STREET --
Compensation
WILLIAMSBURGMA01096 ISSUED ON:21912007 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR FRONT PORCH, NEW
FLOORING,SCREENS & DOOR
POS"I' THIS CARD SO 1T IS VISIBLE FROM TIIE STRFFT Building Inspector
Inspector of Plumbing W
Inspector of irin«
P b
Meter:
Service:
Underground. Footings:
Rough: Rough:
House# Foundation:
Driveway Final:
Final: Final: Rough Frame:
Fireplace/Chimney:
Gas: Fire Department
Insulation:
Rough: Oil:
Fina1:0K 116 'C7—&v
Final: Smoke,
THIS PERMIT MAY BE REVOKED BY THE CITY O NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION
i�nature: ---
Certificate of occupancy Date Paid: Amount:
Feel e:
Building
2/9/2007 0:00:00 $50.0015012
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo