24A-181 (2) The Commonwealth of Massachusetts
----7 Department of Industrial Accidents
?-
� V ice of Investigations
1 Congress Street,Suite 100
rr Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information t�,1 n / t Please Print Leeibly
Name(BusinessOrgmtizatiotu`Individual)_,"I.1 .V, l 1$TVI t 4-t. —
Address: 149 C -4_Y—It.V"0r aC.
City/State/Zip:V '>N` I.2-i'nOv\-- W OM9 Phone#: 4'1 b
Are you an employer'Check the appropriate boa: Type of project(required):
1.[R'1 am a employer with Ll 4- ❑ I am a general contractor and 1 & ❑New constinction
employees(full and/or part-time).* have hired the sub-contractors
2.❑1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working or me in an capacity, employees and have workers
-
[No Y pa rcY- 9. ❑Building addition
[No workers'comp.insurance comp.insurance.-
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
1❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'comp, right of exemption per MGL 12❑Roof repairs
insurance required.]' c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
'Contractors 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 employem they,must provide their workers'comp.policy namber.
/am an employer that is providin g workers'compensation insurance for my employees. Below is the palicar and joh site
information
Insurance Company Name: As, OGtAt-_,-k E 10 "s /VI S U Ira n(e //
2tRO &n.i —
Policy#or Self-ins.Lic.#-: --s Ob 5-;6 Expiration Date: `r(-Z I ao i l,o
Job Site Address: `f�' J[d S� CitylState/Z.ip:_��'r� rYl� It l?t��i b
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider 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 line
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 DIA for insurance coverage verification.
I do herebv certify under the pains and penalties of perjury that the information provided above is true and correct
Sienature: D1'VJz:_ Date -.Y I �� I/5
Phone#: 1 1 (, ,'5' a S/(°
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
t Supervisor: Not Applicable ❑
i�'l
Name of License Holder Ma-A<— 6rm if-K GS L `7�(%g
License Number
1l-f°i Gl�arl�mr�n-4 lied. b\aT-(R-Yvt0rCL P�+ n ! 1 s ks
Address Expiration Date
L41 5 1
Signature Telephone
9. Reoistered Home improvement Contractor: Not Applicable ❑
M. l . 5 . �yn s tyl- c �-a�'1 I mss -3L
Company Name Registration Number
149 Cf\.CLf1 -non-u Imo. ✓ none YViA D 1�� 1 1 I►CP
Address Expiration Date
Telephone�r�`�o � ��
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....... (Y No...... ❑
11. - Home Owner Exemption
I'he current exemption for"homeoxNners"yeas extended to include Owner-occupied Dwellings of one(1) or two(21 families
and to allow such homeowner to engage an individual for hire lk ho does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 10835.1.
Definition of Homeowner: Person(s) kNho oNNn a parcel of land on%0ich he/she resides or intends to reside,on which there
is,or is intended to be,a one or mo family du=elling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-vear period shall not be considered a homeowner.
Such-homeoNN ner"shall submit to the Building Official,on it form acceptable to the Building Officials that he/she shall be
responsible for all such work performed under the building permit
As acting Construction Supervisor}our presence on the job site\N ill be required from time to time.during and upon
completion of the v%ork for which this permit is issued.
Also be adv ised that with reference to Chapter 1-52(Workers*Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Li ms s Annotated,you may be iiabte for persons)
you hire to perform work for you under this permit.
ne undersigned"`homeowner'certifies and assumes responsibilin�for compliance�4ith the State Building Code,City of
Northampton Ordinances.State and I„ocal Zoning Iaws and)itate of Massachusetts General l a%%s Annotated.
Homeowner Signature l ��-ti1 �i� --
v V
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement nidows Alteration(s) Roofing ❑
Or Doors {El
Accessory Bldg. ❑ molition ED New Si ns [p] Decks E3 Siding F-]] Other[[a
i
Brief DescriptiW of Propo ed
Work t L,� 4"(--Li ' ►� �Lf(P r:� 1� j�-�i,�1t�DLr�
Alteration of existing bedroom Yes ,✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes -- No
Plans Attached Roll -Sheet
6a. 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
1,
as Owner of the subject
property
hereby authac' e
to act on my bdhalf, in all matters relat ork authorized by this building permit application.
Signatu'h,4 Owner 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
Tliis column to be filled in b,.
Lot Size
Frontage
Sethacks Front
Reur
Bldg.Square Footage
Open Space Foola,,,e "Y
it of Parking Spuces
A. Has aSpecial Permit/Variarce/Finding ever been issued for/on the site?
\���� ��
NO \���� DON'T VV KMO YES \�/
|F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
�� ��
NO \�7�� DONTKNOVV \�� YES \^�/
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tmbeobtained \_�/-� Obtained �-\~~/� Date' '
~. Do any signs exist on the property? YES 0 NO /D^
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ��/�� NO
IF YES, describe size, type and location:
E� Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre nrieh part nfo common plan
that will disturb over 1 eom? YEE ��� ) NO C,���
IF YES.then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
v. uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
ROOM 100 WaterANeIi Availability
hampton, MA 01060 Two Sets of Structural Plans
phonl3- 87-1240 Fax 413-587-1272 Plot/Site Plans
M01119 Gas k 'ge6on Other Specify
Chain
ION 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
Z �Li( ksL t� Si Map Lot Unit
l�t u, t,� rrti I, A4 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Vh la F v2 c' � �'� #; i; F ig vr' �'SE '1 y Z_ .f�.� 5t+ � eta ct n %t a`l GL�C1
Name Print) Current Mailing Address'
t C�ta'/ S � Lt U L GLCLG C'' Telephone
nature 0
2.2 Authorized Agent:
M, I. 'a. Consi,-uci 1 00Wk.60(mIet' 1461 G adex"ar\_k 12.c:A C- alrI&nam+ b M
Name(Print) CurryLent Mailing Address
L ( _
1 13
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(NVAC)
5. Fire Protection
6. Total=0 +2+3 +4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
E Issued: _
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-0972
APPLICANT/CONTACT PERSON MARK CORMIER
ADDRESS/PHONE 149 CHARLEMONT RD CHARLEMONT01339(413)625-2516
PROPERTY LOCATION 42 JACKSON ST
MAP 24A PARCEL 181 001 ZONE URA(103)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid l
kpeof Construction:_RENOVATE FRONT PORCH&REPLACE PORCH WINDOWS(SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 075688
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Delay
/O
Signatu of uil m '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.
42 JACKSON ST BP-2015-0972
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 181 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
CategoU:renovation BUILDING PERMIT
Permit# BP-2015-0972
Proiect# JS-2015-001876
Est. Cost:$22800.00
Fee: $137.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK CORMIER 075688
Lot Size(sq. ft.): 9234.72 Owner: HARRISON MARGUERITE I&PAMELA J PETRO
Zoning: URA(103)/ Applicant. MARK CORMIER
AT.• 42 JACKSON ST
Applicant Address: Phone: Insurance:
149 CHARLEMONT RD (413) 625-2516 WC
CHARLEMONTMA01339 ISSUED ON.411612015 0:00:00
TO PERFORM THE FOLLOWING WORK.RENOVATE FRONT PORCH & REPLACE PORCH
WINDOWS (SAME FOOTPRINT)
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 4/16/2015 0:00:00 $137.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner