10-011 (4) 09/15/2015 12:08 4137321249 GZA GEOENUIRONMENTAL T N PAGE 03/03
SECTION 8-CONSTRUCTION SERVICCS
81 Licanced Construction Supar050r: Not Applicable 0
Name of License Hdldcr:
License Number
Addr a Expiration Date
Y
Signs re Telephone
9 Ree istgred(Home improvr3rrtent'i onlra kat Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephona
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L..G.152,§25C(6))
Workers Compensation Insurance affidavit must be complPtPri and ci.,hmitted with this application. Failure to provide thie affidavit will result
in the denial of the issuance of the building permlt-
Signed Affidavit Attached Yes.....,, ❑ No...... C
oml+ 6jwj er,Exe�iil�t>to
. .�. ,
'I Ile current exemption for"ho neown.ers"was extended to include Owner-occupied Dwellint?s of one(1) or two(2)families
and to allow such homeowner to engage an individual for hirr who does not possess a.license, Provided that the owner acts
as sunervisar,CMR 780 Sixth Cditlop Section
Definition of Hoteowner: Pcrson(s)who own a parcel of Land on which he/she resides or intends to reside,on which there
ig,bl"i5 intendcd.t0 lie,it uric or two Tdmily 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/shr.ahalt_bP
responsible for all such wprlt performed tinder the building permit.
As acting Construction Sup irylsor your presence on the job site will be required from time to time,during and upon
vnmT,lPtion of the work for which this permit is iseued-
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting i.n Death)of the Massachusetts General.Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
fhe undersigned."homeowner"certifies and assumes responsibility for compliance with the Statc building Code,City of
Northampton Ordinances, State and Local Zoning.Laws and State of Mass-achngow,6rnp.ml Laws Annotated.
Homeowner Signature __.....
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The COmm-()nwealth Of Merssirchusetts
Department of hitlwaialAccidents
x Office of Inves
T � /igations
d
J Congress Street, Suite 700
Boston, MA 02114-2017
fvFVW.nt[rSi:gU vr'rl►1r.
Workers' Compensation Insurance Affidavit: i Boulders/Contl ractors/FIectlricians/Plumhers
Aubliunt Iaformation Please Print Le il)1
Name (13tisincas/Organi7,ation/individual); e le
Address: „
City/State/Zip: t i/ 14A 0/777 Phone J�/,? f�'
Are you an employer?Check the appropriate box:
Type of project(reyttired):
1, ] I atn a employer with�— 4. ❑ 1 am a general contractor and [
employees (full and/or part-time),* have hired the sub-contractors �' ❑ New construction
2,[D i am a sole proprietor or partner- listed on the attached sheet, 7. [2 Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working fui me in any capacity. employees anti have workers'
[No workers' comp, insurance comp. insurance.l: 9. 0 Building addition
required.] 5 ❑ We are a corporation and its 10.x] Electrical repairs or arlrlitions
3.❑ 1 am a.homeowner doing all work o'ffcers have exercised their 11.❑ Plumbing repairs or additions
myself. No workers' con right of exemption per MCrL
p' l2.❑ Roof repairs
insurance required.] 'l' c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp, insurance required,]
'A applicant that checks box 41 must also fill out the section brlow showing their workers'compensatirm policy information
"I lomeo`vncrs.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContracrors that check i his box must attached an additional sheet showing the name of the sub-contractors and state whether or not those cntttics have
employees. lithe suh-contractors have employees,they must provide their workers'comp.policy number.
I nor air employer that is providutg wurken'cumpewarion insurance for my employees. Below&the policy acrd fob site
in formation,
I,nsUTAnCC Company Name 7J--r+•--9 -,2 e
Policy#or S�If ins. Lic, 4: YO 7 00'Y �O _..__. Expiration Date:-7— 7.Z—4
Job Site Address: 67z_3 va r City/State/Zip: A f4 _
Attach a copy of the workers' compe sation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 1.52 can lead to the imposition of criminal penalties of a
fine up to $1,500,00 and./or one-year impriscmm.ent, 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 ofthe D1A for insurance coverage verification,
T do hereby cerd rider the Matins and penaldes of perjury that the information provided above is true and correct
Sip—nature: Date:
Phone#: 'V9 17g�171 -- —Of ficial use onty. Do n.or write in tlric area,to he eormpletcrl by city or town o vial.
City or Town: Pcrmit/License 9
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 ft:
09/15/2015 12:08 4137321249 GZA GEOENVIRONMENTAL PAGEg 01/03
li t r� l
� ? l
FAX
SFp
lvcraf
To: City of Northampton Building Department
.n /
.,.�ctla
Fax#: 413-587-1272
From: Nathaniel Arai
Phone. 413-335-6477
Date: September 15,2015
Re: Owner's Contractor's Affidavit and License
Existing Building Permit for Deck
S23 lfennPdy Road
Pages: 3 Including cower
Per our phone conversation this morning, I am sending you informatlon required for Andy
Cole Builders,a contractor I am directing to do work on my deck project for which a permit
has already been issued to me. Please see the workers Compensation insurance Affidavit:
Builders/Contractors/Electricians/Plumbers form completed and signed by Andy Cole and
Section 8 of the Application to Construct Alter, Repair, Renovate or Demolish a One or Two
Family Dwelling furnishing his license information.
Please let me know if you have questions. Thanks.