36-330 (2) The Commonwealth of,11assachusetts
Department of Industrial Accidents
Office of Investigations
1 1 71, 600 JVa.sizinuton Street
41� 15
Boston, J1A 02111
jvwiv.in ass.gow'dia
I
Workers' Compensation Insurance Affidavit: Biiilderso/Contractors,'F.lectricians[Pluinbers
Applicant Information Please Print Legibly
NaMe (Bus-lness/Orgarizat'l Lcntl 5ccn e- I
Address: 5
C11tv/State!'Zip: Phone-r:
Are you an employer?C-6ck the appropriate box: Type of project(required):
1.F71 I am a employer with 1 0 4. [7j [am agentral contractor and 1
have hired T.-,e sub-conlractors 6, ❑ New construction
employees(full and/or part-time). 7. F-j Remodeling
1 am a sole proprietor or partner- listed on the attached sheet.
These sub-contractors have
snip arid have no employees S. Demolition
k C I capacity. employees and have workers 9. Building,addition
wor in,, forme in ariv ca c1tv.
comp. insurance.1
',No workers' comp. insurance 5 ❑ Electrical repairs or additions
required.] We are a corporation and its 10,.
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 1-,,7 Other
employees. [No worker,'
comp. insurance reqtlired]
ion.policy ji,
In,, applicant that checks box=1 must also f s'compensatl cy irtromiation
and then hire ou-side contractors r9ust submit a new ziffidavit indicating such.
'Ho rreowners\Nho submit this affidavituidicatin2 they r doing a!
ate n g 1�vonll
,Contractors that check this box must attached an additional sheer showing the name of the sub-contractors and state whether or not those entities have
ernpioyccs. 11 the sub-conuacwrs have ernployees,they mus-,provide their workers'comp.policy number.
I ain an employer that is providin�.,,,workers'compensation insurance for ni�v employees. Belo)v is the policy and job site
information.
frisurance Company Name:_ Be"
,ork-5�1 6--Irz
Folicv�or Seff-ins. Lic, \tj 6 Expiration Da e: (�4)
r 15
Job Site Address: uock city,�Statelzip: V��0(e--ntf— 0 10
Attach a copy of the workers' compensation polic)l��e(sho-wing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of 1MGTL c. 152 car, lead to the imposition of criminal penalties of a
fine up to 51,500.00 and or one-year iniprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tip to 5250.00 a day against the-violator. Be advised that a copy of this statement may be forwarded to the Office of
Tnvesti�2ations of the DIA for insurance coverac-,e verification.
I do hereby certify tinder the pains and penalties ofperjui3-that the information provided above is true and correct.
Sic-niture: Date:
Phone
Official use only. Do not write ir this area,to be cv?npleied by city or towns official
City or Town:
Issuing Authority(circle one):1. Board of health 2.Building Department (-'jtyrro,,Yn Clerk 4.Electrical Inspector 5. Plumbing Insp ector
6. Other
Contact Person: Phone Y1r:
r
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 £
Zy m 20°Z l..�cvaScAPC can�i 2uC"tZ,�)11
Company Name Registration Number
Address Expiration Date
1A f--,, t4NA WOW Telephone 413-Its-,g31Z,
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. HomeOwner Exemptions
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
Or Doors i]
Accessory Bldg. ❑ Demolition New Signs [0] Decks (M Siding[O] Other[p]
Brief Description of Proposed ,
Work: he.rvo 1% 41 an & rC',MJV C-'V n G(Z L
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and.or,addition to eistig o V opiete the iihuc owing:
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
CA Owne Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the f my knowledge
and belief.
Signed under the pains and penalties of perjury.
D
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
TIiis column to be filled in by
Building Department
Lot Size
^
Frontage
Setbacks Front r-)
Rear L-1
Building Height
Bldg.Square Footage %
Open Space Footage % ------
(Lot area minus bldg&paved
#of Parking Spaces
(volunie&Location)
A. Has a Special Permit/Variamce/Fi ndingeer been issued for/on the site?
�� ��
��
NO �~� DONTKNOV� �~/ YES �~/
IF YES, date issued:(
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ) DON7 KNOW YES�^ __
IF YES: enter Book Pag and/or Document#1
�� ��
B. Does the site contain a brook, body of water nrvvetiands! NO ����' DON7KNOYY �~/ YES �~�
'
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �-� Obtained «-� Date � |
�~� �°/ ' /
��
C. Do any�gns exist on the property? ��,y� YES �_� NO
IF YES, describe size, type and location:
D Are there any proposed changes to for the property 7 YES ^r� NO �~�
D. �~/ �~/
IF YES, describe size, type and location�
E. VW||the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1acre? YES NO C)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
' '-
Department use only
\\
r�
i of Northampton Sfa#usofPermd
r Egli, ing Department Curb CutlDrlye�vay Fermi#
`!, Main Street Sewer/SeptieAvallablllty +
�
j L' oom 100 ...... abtlity
Electric, Fiurnuing&Gas In
pton, MA 01060 Two fiefs of 5#rucfural Piatts
Northamp1�7t]m(p* (8-5 1240 Fax 413-587-1272 P[of/Slte Pions
Other 5pec�fy � s'�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectlorrto be completed by office
1.1 Property Address: -
I SZ Cc�rZ4iNr-\L UOM Map Lot Unit
O 10(0 2 Zone Overla Distrtct°
Y_ _
Eim St Disfnct _GB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1&2CgP-01NQL L))M MA 0 t0(2
Name(Print) Current Mailing Address:
Lit3 4
C 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 aggqqant
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) s9 Soy Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1080
APPLICANT/CONTACT PERSON SULLIVAN DENNIS A&KAREN D
ADDRESS/PHONE 182 CARDINAL WAY FLORENCE01062(413)584-7819 Q
PROPERTY LOCATION 182 CARDINAL WAY
MAP 36 PARCEL 330 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: DEMO INGROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
oved 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
ion clay
Signa ure of Building fficial 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.
182 CARDINAL WAY BP-2015-1080
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-330 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP-2015-1080
Project# JS-2015-002046
Est. Cost: $7500.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19253.52 Owner: SULLIVAN DENNIS A&KAREN D
zonin : Applicant: SULLIVAN DENNIS A & KAREN D
AT. 182 CARDINAL WAY
Applicant Address: Phone: Insurance:
182 CARDINAL WAY (413) 584-7819 O
FLORENCEMA01062 ISSUED ON.5/11/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO I NGRO U N D POOL
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 5/11/2015 0:00:00 $20.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner