29-493 (5) The Commonwealth o Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
= ¢r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A C)\r , l
Address:_
2
City/State/Zip: 0`Q P one i#:
Are you an employer?Check the appropriate box: Type of project(required):
1. % I am a Y em P to er with �9 4. F1 I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working or me in.an capacity. employees and have workers'
g Y P h'• 9. ❑Building addition
[No workers' comp.insurance comp.insurance."
required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
3.❑ 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.] t c. 152, §1(4),and we have no �,( 1
employees. [No workers' 13.(�(J Other
comp.insurance required.] r'
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site
information.
ormation.
Insurance Company Name: 6be•�Ao,, D 1
Policy#or Self-ins.Lic.#: oGGJCJ 0 5 a 0� Expiration Date: a ' d(,
Job Site Address: CL ['\(_4 City/State/Zip: R o rC.nc e MA O i(xv,
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 STOP WORK ORDER and a fine
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 rrification.
I do hereby certEfy f the pains a rld penalti perjury that the information provided above is true and correct
Sizna fore: Date: L 1 J
Phone#• `!\2D—SQ q �5 c am•
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \\__ r` Not Applicable ❑
Name of License Holder: 1, _\56n°t �T`��"� ` e)(p o
License Number
57 krenCr 1-(a 0\0 162- 91-22-116
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor:.,. Not Applicable ❑
O,A mac. do�s�3
Company Naffie X Registration Number
Q ,� 7 i:__t c r e A-I e c aob2_ -I 1 n 17�
Address �� Expiration Date
Telephone�k2CJOrr��A 1SZZ
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. H6M' a Owner Exe1;1 1Dflon
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 gets
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 veriod 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 maT 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 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:
Rear
Building Height
Bldg. Square Footage
Open Space Footage °
(Lot area minus bldg&paved
Parkin.-)
#of Pal-king Spaces _..
Fill:
volume&Location _:...:....._._............___...:__............:<................._......__..............._._.._._._._..._.....:,._:...._.............._......._.....
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0..
IF YES: enter Book Page and/or Document#
B. Does the site contain ra brook, body of water or wetlands? NO DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:v...
C. Do any signs exist on the property? YES 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,gradin e;:c ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
s
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition [] Replacement Windows Alteration(s) Roofing
Or Doors ❑ l
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks IM Siding I01 Other J{1Sv( ' t01^
Brief Descri ti n of Proposed
Work: erLZC , -e In 5,/115
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If Flew house and or addition toexisting housona, coinplete 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
1. 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, rC�K'1 i ► 1 t L)CW- l ,as Owner of the subject
property rr
hereby authorize W SW.4let 4 ,�, V6"<-a7m ero (reni- ,ZIA L
to act on my behalf,in all m tters rel tine to work autho ' ed by this building permit application.
:w/S
Sidinat6re of Owner Date
I, LS,X15h� �ek� y tx.�t� t�OMC ��M P� , C1tr as Owner/Authorized
Agent hereby declare that the statements an information on the foregoing application are true and accurate,to the best of my knowledge
and beYlef.
Signed under the pains and penalties of perjury.
Ne bon cS..V•-41'\.e A
Print Name
Signature of Owner/At Date
(5it4_ ofl>rrtlttltt}�ton
� �,. t �i4ttsattr!tuaetta �f' �` Yr �}
M
DEPARTMENT 0Y BUILDING
INSPECTIONS
212 Main Street . Municipal Building
Northampton, MA 01060
LOUIS HASBROUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21,2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for I"floor
.30 " 2"d floor
.20 " 1A floors,attic, basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$61K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
Department use only
`1 City of Northampton Status of Permit
t� Building Department Curb Cut/Dnveway Permit
r ,'I 2Q15 �J 212 Main Street Sewer%Se- Availability
JUN
ptid
Room 100 Water/Well Availability
ptumbin9&Gas Ins Northampton, MA 01060 Two Sets of Structural Plans
Ete to Northampton'�nA° one 413-587-1240 Fax 413-587-1272 Plot/slte
Other Specify r
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
y�
�a3 �9an r ` Map Lot Unit
-lorcc2, M Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing dress:
Telephone
Signature
2.2 Authorized Agent:
Va,MA Horre lwrbvemem+lblelson- '�- 3qO R `VeK51 C& l-lorern Cei a 1,)4-)—
Name(Pri Current Mailing Address:
kh/,tALlk i 4�13 `5131 175 a
Signdtur e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete by ermit applicant
1. Building (a)Building Permit Fee
X500, bc3
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)
O�So o c7c> Check Number
This Section For Official Use Only
Building Permit Number. Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-1219
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522
PROPERTY LOCATION 423 RYAN RD
MAP 29 PARCEL 493 001 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
Typeof Construction: INSTALL ATTIC INSULATION,WEATHERIZE&AIRSEAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 060300
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
pproved 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
D aiif
Signa a of Builc1mg 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.
423 RYAN RD BP-2015-1219
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-493 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeoa: INSULATION BUILDING PERMIT
Permit# BP-2015-1219
Proiect# JS-2015-002303
Est.Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: VALLEY HOME IMPROVEMENT INC 060300
Lot Size(sa. ft.): 20124.72 Owner: THIBAULT KAREN A
Zoning: Applicant: VALLEY HOME IMPROVEMENT INC
AT. 423 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:61512015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION, WEATHERIZE &
AIRSEAL
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 Shmature:
FeeType: Date Paid: Amount:
Building 6/5/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner