17A-273 (3) The Comm oil wealth of'Alassachusetts
-- Dea►7ent of Irtdtrstrial Accidents
m
Office of hillesti("ations
600 11'crshin,ton Street
Boston, YWA 02111
N'{1'lt'.III ti s.�;ov/dla
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciatls/Plumbers
Applicant Information Please Print Ley
ibly
Name t';
Address:
City/State/Z1p l�nc -- - — - -- —
' t
Are you an employer? Check the appropriate box: "type of project (required):
1. 1 am a employer with 4. ❑ 1 am a Q,eneral contractor and 1
❑ 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contactors
2. ❑ 1 am a sole proprietor or partner-
listed uu tune aitac;hed sheet. 1 7 ❑ Remodelinp, I
ship and have no employees "These sub-contractors have S- ❑ Demolition
working for me in any capacity_ workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a a corporation and its
officers have exercnscd their l0.❑ Electrical repairs or additions
required.] j
nr1ht of exenn uutn net MGl_ 1 L[1 Plumbing repairs or additions
3.❑ I am a homeowner doing all work d { l I
myself. [No workers' comp. c. 152. §1(4), and we have no 12 0'Roo('I epairs
I
insurance required.] t etnploye.es [No , orl:ers' 13.❑ Other
camp 111suranee required.] -- —
'Any applictult that checks twx III must also lill out the section below shinning i tic ir coil en,'Col npenuation pohCy in(m mil tion.
I Homeowners who submit this affidavit indicating they 2ue doing all work and then lure outside contractors must submit a new atTidxvit indict'ing such.
lContractors that check this box must attached an additional sheet showing the nenie of the sutrum u7+clots and their workers' comp.policy i11fOr71lttion.
I am an employer that is providing n=orkerc'cornpe►isatiori insurance for ntp e►npl(geers. Below is the police and job site
information..
Insurance Company Name:
Policy#orSelf-ins. Lic. #: C' �_� �_.'i _ _ _ Expiration Date:_
Job Site Address:----__-- -- --____-- -_---- City/State/'Lip:-_— --
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 $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a ST011 WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a Copy of this statement Wray be i:orwarded to the Office of
Investigations of the DIA for insurance coverage verification-
1 do hereby certify tinder the pains and penalties of petjiu}t beat flit, itilorm aft on provided above is tree and correc t.
SiQrrature: ------- -.._ --- ----- --.. -- --- --Date.: - --- ----------
Phone#: ( l r ;r >= 1 �a_'±
Official use only. Do not write in this area,to be completed bl' city or town official.
City or Town: _ __Pcrruit/License#�
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S_ Plumbing lus>aector
6. Other
Contact Person: Phone #:
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Ayk �?
License Number
Holuohe- M()1on . Ma. nipa
r - _
Address J I I Expiration Date ^�
11) 527- q 17175
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
• na
12t2.35
Company Name Registration Number
�KolL1oke. A YeAt, - P. 0. o1 5_ A.
Address J— Expiration Date
Ma. 0 i Q 27 Telephon�+--___t
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....... 0 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
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 a'tt,'a[� e�
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable
New House Addition Replacement windows Alteration(s) Roofing 56
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[] Siding [❑] Other[❑]
Brief Description of Proposed
Work: at
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinis ed 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 Othe
b. Number of rooms in each family unit: Number of Bath ooms
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. Masschec 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 Cit 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 authorize Isle-
to act on my behalf, in all matters relative to work authorized by this uilding permit application.
Signature of Owner Date
I' , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a&lication 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
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:' L: R:I
Rear
Building Height
Bldg, Square Footage %
i
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Lpcation
A. Has a Special Permit/Variance/Finding ever been i sued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Pag and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
.. ....... ...... ..
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of sign intended for the property? YES l NO 0
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 U NO 0
IF YES,then a Northampton Storm Water Management Perm t from the DPW is required.
d\/10 Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
�
,`� 212 Main Street Sewer/Septic Availability.
Room 100 Water/Well Availability
c o
Northampton MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
O"ther 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
Map Lot Unit
Zone Overlay District
Elm St.District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
t a Che el Telephone
Signature
2.2 Authorized Agent:
• 4f� �O rn— nom
Nam �
e(Print) Current Mailing Address: Oi0-1
�-
H13) 5�7- J411.5 V
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building oOr' O ,^� �.. (a) Building Permit Fee
2. Electrical 7 V (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
34 FERN ST BP-2015-1126
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-273 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-2015-1126
Project# JS-2015-002122
Est.Cost: $10400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 74334
Lot Size(sq. ft.): 8755.56 Owner: LUCEY ALISON J TRUSTEE
Zoning URB(100) Applicant: RCI ROOFING
AT. 34 FERN ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON.•5 11812015 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 5/18/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner