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36-056 (11) 42, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Or Address: ' �Anr .3rco ra S© City/State/Zip:Wo P- r1►+Q1l'1 . `T Q(QC5Z Phone#: 1314 - 30&- q 4 2n Are you an employer?Check the appropriate box: Type of project(required): 1. _V I am an employer with_o 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 7. 0 Remodeling 2. 0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers'comp.insurance comp.insurance.T required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions 3. 7 I am a homeowner doing all work officers have exercised their 11. 0 Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12. 0 Roof repairs employees. [no workers' 13. Other comp.insurance required.] �.-tl cCJ Is "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContactors that check this box must attach 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 my employees.Below is the policy and job site information. n— Insurance Company Name: O� �—r5ukran c P C: P Policy#or Self-ins.Lic.#: 3 6 6 I Expiration Date: / o� Job Site Address:."I ( Red iJ f� r. City/State/Zip: �' 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. _Signature: Date: Print Name: 1�u,-�CQr�Q �[�ev�t �p`no 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 Heath 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]n t r V I I dg2122— License Number Address 7 Expiration Date )SIC Telephone 9.Reaisstered Home Improvement Contractors Not Applicable �❑/ Company Na Registrat on Number ` I t\Cm � 1 � •J �r - Gil Y1 ,C—( C�Id) 2- // / S I �p Address Expiration Date l Telephoneq�jU 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 buildingi5ermit. Signed Affidavit Attached Yes...... 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 — SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) E] Roofing Or Doors l] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other j 91- Brief D scription of Proposed�`�UAa��N• ii ✓I Work: Cl ' 1 �'a \��a�1l g I �ncc�r LFl[�-1� a,A i C ac-cess d ✓�Gic� 11ef7r�Ll1C t 1K� vr1WCR (Z S�cf\ taaif 5��� 1 Alteration of existing bedroom Yes No Adding new bedroom Yes No hStz�t 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 V Two Family . Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? A- d. Proposed Square footage of new construction. r 'Dimensions e. Number of stories? /� f. Method of heating?C ct Fireplaces or Woodstoves 'L Number of each ' g. Energy Conservation Compliance. e r, 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 Q A- 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 as Owner of the subject property J hereby uthorize 1�� ( U n i C) to act on my behalf, in all m ers relative to work authorized by this building permit application. Signature of dwnVr Date I,1 1 ►i � C) LM as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. I I t 1 Print Name SiWatyre of Owner/Agent -/ Date r Section 4. ZONING Alt 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: Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: v IF YES: Was the permit recorded at the Regi try of Deeds? NO 0 DONT KNOW . YES IF YES: enter Book Page and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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, grading,ex ion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO ? IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ -- - n I Department use only City of Northampton Status of Permit: JUN I0�� Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability J Room 100 WaterMell Availability Electric, rthar plumbing,Ma 01060ofiops rthampton, MA 01060 Two Sets of Structural Plans Northamp p one 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 -�orcA Dv.lvc/ Map Lot Unit Zone Overlay District "1VQ, CA002-- Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 50-f ; "a . 41 Red:CD(d -ty , 1C jinc,rn Na nt� �nt(ulailin 1 ddr ss: .g ILI* 17 Telephone L�Si 2.2 Authorized Agent: Name(Print) Current Mailing Address: 3igryilli 1-11 �C- �— Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building Beg (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 ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-1319 APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC ADDRESS/PHONE I HARTFORD SQ SUITE 206 NEW BRITAIN06052(877)306-4483 Q PROPERTY LOCATION 41 REDFORD DR MAP 36 PARCEL 056 001 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 BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108212 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO AMATION 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 Demol' ' ela Sign g i al 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. 41 REDFORD DR BP-2015-1319 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-056 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate ory: INSULATION BUILDING PERMIT Permit# BP-2015-1319 Project# JS-2015-002412 Est. Cost: $889.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VICTORY ENERGY SOLUTIONS LLC 108212 Lot Size(sq. ft.): 12501.72 Owner: ALHASSAN SOFIYA Zonin : Applicant.• VICTORY ENERGY SOLUTIONS LLC AT. 41 REDFORD DR Applicant Address: Phone: Insurance: 1 HARTFORD SQ SUITE 206 (877) 306-4483 () WC NEW BRITAINCT06052 ISSUED ON:611812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL BASEMENT INSULATION 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 6/18/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner