22D-053 (2) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affida-vit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work., K'
The debris will be transported by C' V,
The debris will be received by:
Building permit number:
Name of Permit Applicant C, V
Date Signature of Permit Applicant
105/29/2015 06;34 6035013510 HIPCUSTSVC PAGE 04/04
1
AC62Y CERTIFICATE OF LIABILITY INSURANCE DATE(MM/Dofyyyy)
05/28/2015
THIS CERTIFICATE IS ISSUED AS A MA NEGATIVELY A INFORMATION ONLY R ANb CONFERS NO RIOHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE
OES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THR COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE
OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESS ICJFS E OR PRODUCER,ANb THE
CERTIFICATE HOLDER.
IMPORTANT•If the certificate holder Is An ADDITIONAL INSURED,the policy(les)must be endorsed.if SUBROGATION IS WAIVED,subject to the terms
attd conditions of the pollcy,cefktlln polkies may requite an endOMement.A statement on this certificate does not confer rights to the certificate holder
in Iiou of such ondorsrmont e,II Waiver P4 Spbro atfon is a Ilcablo,k onl A flea to the a#ent Allowed b law.
PRODUCER CONTACT NAME:Erica Wolfe
MfSittlW Ineurai)CO Service,Inc.
363 N.Ckkrk Strrot PHONE FAX(AX,N0)
ChICa80,IL60e64 847-444-2599 847-444.2723
E-MrAIL ADDfRS$s;cWOlfe0me5irowflnencidLCOm
INSURER AFFORDING COVERAGE NA1C$1
INSURER A:The Hartford
INSURED INSURER B:
Nome r3rOnda,Inc.
300 COnStitutfon Ave. INSURER C:
Suhe 200 INSURER D
Portsmouth,NH 0390,1 INSURER E:
COVERA0116 INSURER F:
CERTIFICATE NUMBER;39450 REVISION NUMBER;
WIS 64 70 CERTIFY THAT THE POLICIES OF INSURANCE LIST[D BELOW IagvE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI,IGY p>RID
INDICATED,NU I WITHSTANDING ANY REQUIREMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMCNT WITH RESPECT To WHICH TW
CERTIFICATE MAY BE ISSUED OI@ MAY PERTAIN,THE INSURANCE AFFORDED BY TFIE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMR5 SHOWN MAY HgvE OEEN REDUCED BY PAID CI gIMS.
INSR TYpE4FINSURANCE ADDL$UBR PQLICY POLICY EPP POLICY-
��R lJMrr$
GENERAL LIABILITY INSk WVD NUMBER MMMDlYYY MUD"
COMMERcfAI,GENfi Ai`LlAgWy �MAGF-T R RENTED
F
DAMAGE TO RENTED £
CLAIM$-N OCCUR PREMISES(oath
occurrence
MED EXP(Any one $
person)
GEMLAGGREGATE LIMIT APPUE$PER; PERSONAL t&ADV 3
POLICY PRQJECT LOC INJURY
GENFRALAGGREGATE $
PRODUGTS•COMP(OP $
AGG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
�y .,....
ANY ALIT jEetch accident
AI,I.OWWEDA HEDULLDAUTOS BODLY INJURY(Per $
HIRED Al1TOS NON•OWNED AUTOS BODILY INJURY(Per $
ACcldent
PROPERTY DAMAGE(Per$
accident
„ .... _,__...... .,
UMBRELLA LIAR OCCUR EACH OCCURRENCE
EXCESS LIAR CLAIMS-MADE GGRFGATE S
DED RF7 ELATION$ I I I 0
...... ,_,. ... . ... ._..........,,_-._...........,.�...... ... ..... ...... _ ,.w.
A WORKERS COMPENSATION AND EMPLOYERS, 83WEBP7653 04I01015 04/0112016 x WC OTHER
LIABILITY STATUTORY
ANY PRO PRIETORIPARTNER1ECFGUTNE LIMIT _
O FFICER/MEMBER EXCLUDED?(Wkndatory in NH, YIN NIA E.L.EACH ACCIDENT $500,040
If yes,doscrlbe under DESCRIPTION OFOMPA71ONS N E,UDISI;ASE-EA $600,000
below, EMPLOYEE
E.L.DLGEASE.POLICY $500,000
LUTT
... ........_. .........., ....__..__..._, __.. ..........
Other
DESCRIPTION OF OPERA7 IONS I LOCATIONS/VEI4ICLES(Attach ACORO 101,Additional Remarks Schedule,if more space Is Tegl)imd)
Certificate issued as Information only.
CERTIFICATE HOLDER CANCELLATION
51401JLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Chy of Northampton ACCORDANCE WITH TWE POLICY PROVISIONS.
210 Maln St, AUTHORIZEDREPRFSENTATNE
Northampton,MA 01060 John 1-1�rncy
ACORD 25 207,0/05 Ths ACORD name and too are re IstereP rnarks of ACORD W 1986,2010 ACORD CORPORATION.All ri hts reserved.
Pa e I
A ;1�cant.In�`ormaa!aon
Name (Ausiness/Organizdtion/jndtva dufl��'
'hone#.:
Are you an employer?Check the appropriate box:
1. I am a employer with_ (0')__
4. Q I am a general contractor and t
have hired the sub-
mployees(full and/or part-ttme).*
contractors
2.Q i am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub-contractors have
working for me in any capacity,
employees and have workers'
[No workers' comp.insurance
comp. insurance.$
required.]
S. Q We are a corporation and iits
3.Q I am a homeowner doing all work
officers have exercised their
myself, [No workers' comp.
right of exemption per MOL
insurance required..] t
c. 152, §1(4),and we have no
employees. [No workers'
corm. insurance reouired.l
Type of project(requrh
6. /O.New construction
7. Q Remodeling
S. Q Demolition
9, Q Building addition
10.Q Electrical repairs or additions
11.❑Plumbing repairs or additions
12.[:] Roof repairs
13.7 Other
*Arty applicant that ohccks 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.
TContractors 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,
l ant an employer that is providing workers'compensation insurance for my employees Below is the polict�ant job site
information.
Insurance
Policy#or Self-ins. L,ic.#: t __ _— Expiration Date: < (p
Job Site,Address: LAC City/State/zip: Mt- Z71-9 didbb
' - -�-• ��+he workers' compens• Lion policy declaration page(showing the policy number and expiration date).
-
"A -fiMGL c. 152 can lead to the imposition ofcrianinal penalties of
- "1T3 ,'MR K ORDER and a fine
Failure to secure coverage as required under Secuon,& �,
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form or a o x,,x
of up to$250.00 a day against the violator, Be advised that a copy of this statement may be fonvarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do her ,, t fy under the pains anti penalties o perjury that the information provided above is true and correct.
Si n to e•
Date: /J
Phone#° ��13 �� )
Official use only. Do oot write io this area,to be completed ley city or town official,
City or Town:_ _ Permit/License#
Issuing Authority(circle one):
X.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person-, #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dweIIing house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who,employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses_ A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#6I7-727-7749
Revised 02-23-15 www.mass.gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
M www.mass govldia
Workers'Compensation Insurance Affidavit:Builders!Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): / t/C /P1 A C,
Address: / �C y t CJ -
City/State/Zip: it �dJ� Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.M I am a employer with employees(full and/or part-time)." 7. Q New construction
In I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.[D I am a homeowner doing all workmysetf.[No workers'comp.insurance required.!t 9. ❑Demolition
10 Q Building addition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11f�Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p
Roof repairs
These sub-contractors have employees and have workers'comp.insurance?
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. l /
Insurance Company Name: vaAro
Policy#or Self-ins.Lic.#: IoV - ✓ ✓ Expiration Date:
Job Site Address: OQ City/State/Zip: VO4A.10A
Attach a copy of the workers'coi6pensation policy declaration page(showing the policy number an expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pai and penalties of pe�ury that the information provided above is true and correct
f
Si ture:
40—w- Date. S ZI kel 5—
Phone#:
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#:
05/29/2015 06:34 6035013510 HIPCUSTSVC PAGE 02/04
The Contmo tweulth of,lMassttchusetts
Department oflndustrialAccidents
Office of InveSfigationS
.l Cotagress Street,Suite 100
Boston,AAA 02114--2017
www mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E)eetricians/Plumbers
Applicant Information Please Print Legibly
Name (Busine.W Organization/Individual): D/12e (aa,J L �f?�
City/State/zi : �l Phone##: '� M /3
Are you an employer?Check the appropriate box: Type of prgject(required):
1. I am a employer with �_ 4. 0 I am a general contractor and i
L employees(Rill and/or part-nixie).* have hired the sub-contractors Nero construction
2.❑ 1 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 tY• 9. Building addition
[No workers' comp. insurance corap.insurance.:
required.] 5. 0 We are a corporation and its 10.F-1 Electrical repairs or additions
3.El .I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions
thyself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees. rlo workers' 13.❑Other_
comp.insurance required.]
*Arty applicant that checks box#1 trust also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and thou hire outside contractors must submit a new affidavit indicating such,
tContractors 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.
lain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. (Y J
Insurance Company Name:,-6�. �!r/s��Ll"�d�fi �1�r J "7,
Policy#or Self-ins. L,ic. #: Expiration Date:—J�1/6/z a-2 —
Job Site Address: City/State/,dip: �jy � �friY�
Attach a copy of the workers' compens tion policy declaration page(showing the policy numbcr and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of critninal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of 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 verification.
I d e t o ' under the pains andpena/ties o perjury that the informationp,rovided above is true and correct.
Y
Si n to e' r Date: A
S
Phone#:_ 063 ME 36b
Official use only. Do not write hi 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: #:
24 RYAN RD BP-2015-1199
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-053 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-1199
Project# JS-2015-002271
Est. Cost: $4800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13590.72 Owner: WELCH EDWARD J&MARGARET A& PAUL KELLEY&TRACY
KELLEY
Zoning: URA(100)/WSP(100)/WP(12) Applicant. WELCH EDWARD J & MARGARET A & PAUL KELLEY &
TRACY KELLEY
AT: 24 RYAN RD
Applicant Address: Phone: Insurance:
24 RYAN RD
FLORENCEMA01062 ISSUED ON.61512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR GARAGE FOUNDATION, CONCRETE
FLOOR,REPAIR STEP & RETAINING WALL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
Feel e: Date Paid: Amount:
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2015-1199
APPLICANT/CONTACT PERSON WELCH EDWARD J&MARGARET A&PAUL KELLEY
/&TRACY q
ADDR SS/PHONE 24 RYAN RD FLORENCE01062 7J t� �yQ� l "5 s� l
PROPERTY LOCATION 24 RYAN RD �r 1 1,4a —P4- ®®JS
MAP 22D PARCEL 053 001 ZONE URA(100)/WSP(100)/WP(12)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR GARAGE FOUNDATION CONCRETE FLOORREPAIR STEP&RETAINING
WALL
New Construction
Non Structural interior renovations
Addition to Existiny,
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$MATION PRESENTED:
Approved 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
m ' ion Delay
'gnature of Building dfficid Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
—! USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Tivo-Family Dwelling
°4 This Section For Official Use Only
� ing Permit Number: Date Applied:
o-
Iding Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
`— roperty Address:
c
1.2 Assessors Map& Parcel Numbers
RX 1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40 §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: — Outside Flood Zone?
Check if yes❑ Municipal 0'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHrPI
2.1 Owner]of Record:
Name (Print)CCCity,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building I ' O er-Occupied ❑ Repairs(s) )4 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ s Other ❑ Specify:
Brief Description of Proposed Work 2: 11i,,
G Fe l as y-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ r' 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost(item 6) x multiplier x
�. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su cession) $ Total All Fees: $ .�
Check No. QCheck Amoun Cash Amount:
6. Dotal Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONS'T'RUCTION SERVICEIS
z
5.1 Construction Supervisor License(CSL) 5 a zifI3 Z
#—
-3
Gi -117 icenseNumber Expiration Date.
ame o CSL Holder q 1,(
C_7J List CSL Type(see below) v`
o. d S e t Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town, S te,Z M Masonry
RC Roofing Covering
WS Window and Siding
// SF Solid Fuel Buming Appliances
4/0 0104 5&C�IL'h G�� ��(V I Insulation
Telephone Email addresV D Demolition
5. Registered Home Improvement Contra for(HIC)
C '
HI egfstriftion Numbpr txpiration Date
HI Comp y Name or�1 Ie, eggs Name /
No.and treet- mail a91"o"16 .s 0
-//i30272�s
Ci otvn, Statdf,ZIFf Telephone
SECTION 6: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: .....:... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUUILDING PERMIT `
I, as Owner of the subject roe ,_hereby authorize [4-131- - /! 1'F�L Tl�i� �7��/"� A"31
to act on my behalf,in all matters relative to work authorized by this building permit application.
'\,:z- S z pis
Print Owner's Name( ]ectronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Autho ized Agent's Name(Ele tronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass.aov;oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"