31C-002 (5) The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street,Suite 100
ir Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information c (� Please Print Legibly
Name (Business/Organization/Individual): 7 V��lae
Address:�( 0
pt31�
City/State/Zip: Phone#: 4 Q)
Are you an employer?Check the approp ate box: Type of project(required):
1.211 am a employer with (S 4. E] I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. E RRemodeling
ship and have no employees These sub-contractors have g. Demolition
working or me in an capacity. employees and have workers'
g y aP h'� � 9. ❑ Building addition
[No workers' comp.insurance comp.insuurance.
required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t C. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*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 my employees. Below is the policy and job site
information.
Insurance Company Name: Ca
Policy#or Self-ins. Lic. /#:..��^^U7� rj I t cy�..i 1 — l0 Expiration Date:��0-o'g— I c-
Job Site Address:'49 l l_.C_.�rcA fit,w_ I)C�11haM Q City/State/Zip: NCar—T bS"7ZX_)
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 da against the violator. Be a4vised that a copy of this statement may be forwarded to the Office of
Investigations ofjhyb1A for insur9ce cove/ra
0verification.
I do hereby under s and allies of perjury that the information provided above is tr a and correct
Si ature: Date:
Phone
Official use only. Do not write in this area,to be completed by city or town offlcial.
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder V er n n4l 991'tiA!�ioo r (}q�1,5 q
License Number
.7 C'oo des 14UG 5, De'fr �keld MA o 13 7 -Q z)- I (c,
Address Expiration Date
Signatur rXelephone
9. Registered Home Improvement Contractor: Not Applica ble l0
` I iS1Q-J.s
Company Name Registration Number
S ('02h-, c a - 1-, - I -�
Address '' ii Expiration Date
Telephone-((3 (D�s'rt�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....... V 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 10835.1.
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 Alteration(s) ® Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs a::]] Decks [❑ Siding [3] Other[[3
Brief Description of P oposed jj ll /
Work: Re Mnode/ -thecG � K
haihroo
3 eiJ Jck en
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. 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, '-> 'r e as Owner of the subject
property
R
hereby authnm�5
to act on mlative to work authokj by thi s building permit application.
Signature of O r Date
I. 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.
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:
Rear
Building Height
Bldg.Square Footage - % d
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
�ty of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit
f _ 12 Main Street Sew'
ewer/Septic Availability
,
1 ,
`I r+ Room 100 Water/Well Availability,,
AUG 1 2015
Nrt ampton, MA 01060 Two Sets of Structural Plans
Electric Pnrnu r9 e.s n p t
7-1240 Fax 413-587-1272 Plot/Site Plans
N haiT pt�n, MAC 1060 Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION i b l G' ��rv-s
1.1 Property Address:
This section to be completed by office
I V ward AV-F Map,- Lot Unit
/V o r k ah(7-1 w,, /t'/4 01163 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C�
Petry- Co ckl 3 a Acka re 1- I C( C e NOrj�OMJGM
Name(Print) Current Mailing Address:
sos L1so -4 q a B'
Telephone
Signature
2.2 Authorized Agent:
V r �? Co2t0S
Nam t) Current Mailing Address:
Sigrffiture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building .--- (a) Building Permit Fee
IL
2. Electrical (b) Estimated Total Cost of
(//cz> . Construction from 6
3. Plumbing 1 _ Building Permit Fee j
4. Mechanical(HVAC)
5. Fire Protection - ' 6
6. Total =0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2016-0186
APPLICANT/CONTACT PERSON THAYER STREET ASSOC INC
ADDRESS/PHONE 8A COATES AVE SOUTH DEERFIELD01373 (416)665-4018
PROPERTY LOCATION 48 WARD AVE
MAP 31C PARCEL 002 001 ZONE RR(78)/WP(59)/URA(28)/
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: REMODEL 3 BATHROOMS&KITCHEN
New Construction g
Non Structural interior renovations
Addition to Existine
Accessory Structure
Building Plans Included:
Owner/Statement or License 045159 �j
3 sets of Plans/Plot Plan LL:e G
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
D lition lay
Si e uil cial 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.
48 WARD AVE BP-2016-0186
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 C-002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorrenovation BUILDING PERMIT
Permit# BP-2016-0186
Project# JS-2016-000315
Est. Cost: $65200.00
Fee: $1072.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THAYER STREET ASSOC INC 045159
Lot Size(sq. ft.): 50529.60 Owner: COHEN PERRY
Zoning: RR(78)/WP(59)/URA(28) Applicant: THAYER STREET ASSOC INC
AT. 48 WARD AVE
Applicant Address: Phone: Insurance:
8A COATES AVE (416) 665-4018 Workers Compensation
SOUTH DEERFIELDMA01373ISSUED ON:811712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL 3 BATHROOMS & KITCHEN
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 8/17/2015 0:00:00 $1072.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner