32C-304 (7) The Commonwealth of Massachusetts
Department of Industrial•,Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.pplicant Information Please Print Legibly
laine (Business/Organization/Individual):
iddress: 4
o�075 Phone #:(q13)
re you an employer? Check the-appropriate box: Type of project (required):_
�1 am a employer with Z O 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
] I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling
rtn
ship and have no employees - These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp, insurance. 9• ❑ Building addition
[No workers' comp. insurance 5• ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself [No workers' comp, c. 152, §1(4), and we have no 12. Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp, insurance required.] J1 I
iy applicant that checks box{I l must also fill out the section below showing their workers'compensation policy information:
Dmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit bidicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp,policy information.
man employer that is providing workers'compensation insurance for my employees. Below is the policy and.job site
'ormation.
urance Company Name: f�
licy#or Self-ins. Lino #:`W�' C-_ y O 5 Expiration Date: 10 - S . J 44
Site Address: 1 VIA+�e_ _ City/State/Zip: Nor�lJ� "__r _ C 1Q�C1
tack a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
•e 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 fine
up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA for insurance coverage verification.
io hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct
gnature: �
Date:
tone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town; Per #
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 Supervisor: Not Applicable ❑
'
Name of License Holder: M aY� (S ��� rI I J4 33 4 •
License Number
Address Expiration Date
Signature Telephone
1
9. Registered Home Improvement Contractor: Not Applicable O
. c nQI i 2 b 235
Company Name T]- Registration Number
Wks It 5
AaOraaa Expiration Date
�ag� 016 n. M2L. Q 1 o-,73 Teiephon
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....... 4Z 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
st uctures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homcowner"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.
Aiso 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 2 .t�C�iPd
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [Q Siding [❑] Other[o]
Brief Description of Proposed Atta..c.h 1�
Work:
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
I, kcni_ Scwbxez
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
Signature of Owner Date
I, 1 as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a4lication are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
� IQIC1,
Signature of Owner/Agent Date
\'
Department use only
City of Northampton Status of AAAM `L 6 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
P t,r
Room 100 UUaterlWell Availability
Elects N r, _ _ Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
r7 Vt.....1le S)+t-ee+ Map Lot Unit
N,_ _ , p_�1� Zone Overlay District
(J�(`}-11 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
No MH
1�e.��� Sc�nc)°►e z �
Name(Print) Current Mailing Ad ss:
o1 MaChed W6—
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: O�d _
�-�-- ( q 13) 527- J4 775 tJ
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building RQ0F1 3$ .ov (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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
7 VALLEY ST BP-2015-1178
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-304 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2015-1178
Project# JS-2015-002207
Est. Cost: $3800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 9931.68 Owner: SANCHEZ VERNA C&HANS W LEO
Zoning: URC(100)// Applicant. RCI ROOFING
AT: 7 VALLEY ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:512712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 5/27/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner