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30B-048 The C'ommonwealta of massaciwseas °- Department of Industrial Accidents tam Office of f Investigations 600 Washington Street Boston' MA 02111 .•T A.J�y yj www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ��� �� ,�1i1(l.o Y o\,Y&ne, 4- _1�0 Address:_ j'-�C, City/State/Zip: 1 P ones#: 22 Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with I� 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 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 for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.: 9. []Building addition required.] 5. ® We are a corporation and its 10.[1 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.F1 Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13XOtherin544an 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that Isprovidin workers'compensation insurance for grey employees. Below is the policy Band job site info rmad0ns Insurance Company Name: Av be•�_�o,, X1 5 )1 - Gary - _ Policy#or Self-ins. Lic.#: G��� °D 02— Expiration Date:: alt �n 30b Site Address: 7 L11 0 1<Zem St. City/State/Zip: r10Y`M�V MA-- aCt& Attach a coley of the-workers' compensation policy declaration page(showing the policy number and expir adon 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 WORE_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. 1 die hereby certify i•��tf.e palte a s el per4altl � perj�!ry that the Information provided above Is tree and correct Signature: � �� . �1#i (� / 47� Date: 913/1s 0f ecial L,se o fy. Igo not write in this area, to he completed by city or£own of ccZaL d I City or Taws: ceii ee# i lsgui ng Authority (circle one): 73-ard of ! Hezt!n '9 TT_1!ngF ti. Cfy/Taw n Clerk ,,Electi ra rTTC�ector 5 �wrapeckor f 6. Other i jContact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Crarastrarctasan Supervisor: Not A�}pIrcat>!e D - Name of License Holder ���--���_� ....,. _.. -C !`�V./�� � „w i License tdurntie[ tom. 'tore-to( t��- o��� �- .. t weat'm rye 1 ai' i° ure Tefela ron .Registered Home 1p vmet C ntmtpr a Not Appkable IWI \WWAA Rome l4 nnm-,4 � 1 D `1 Ctarrtta t o Registration Number 31+0 t� ode_ Tic, 1�71nreAce NA a�acoa-- -7/17// Aetd ess Expiration Da e elephone 1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(I .C.L.c.152, 25C(ss)) k'Voriters Compensation Insurance affidavit must be completed and submitted wit'i this antilication Failure to provide this affi ays4 li'esuft in the denial of the issuance of the building permit, i Signed Affidavit of ached Yes No. 0 11. Home Owner 'Exemption The currtniv\t:rt PiiCin ibr-horn'€eoa? lers was Cx2endcd to im:ludc t}wnclr-o eta pied i)wO igg3�of'ciuc(l) or and to LI1cast ;A J-1 holnevitiwr tot it az-e an individual fio hirc who does r:1 z vo%i , .,a licer sct provided that the tr'1i leer acts suite"isor.fi'14 7h"o 1"ttlTlt: :stv*ioaa r efmitiao 0 I4ome-oi&nz6 r. ,h ,3r 1,aia.€id= ,a-":on A=.het hit i_.....xa.iti.eca. Asa tc....F"n�,-,iu. �. ,,.,-s. .........-..»x �.. .>.-.._. .. - •'`_ -- _Ji r[sz,� .-s_`35,..,. S" : -,n t.n bttt :f,. , s rs,on %,r ho emixtreaii� mor€thou near Boma in a tm to-vt%r ncriod not tsc coosidered as hcirraeft-v irr. S a h"l i i, asi tiC. (9.itl su}3n.it tFa Li t jujie ,on a l€` o the jU er Official-tb t h0she a:hull fie T 3c r"ponsihit for all sueb work erftia-med Bander Lht liuildiw, ter riiti� As aciin 0owaraection Supervisor l iald3"l,'.t'�C`..'�4a:t's"111 dli kb,iiw v,,ill 144, 11-0n; ..a',:w to.s.,'1 .i.i-;z-'o.j..1i;7 i:k 2ati la'6"'?,?let.iw"of dl:4 ork Ti rz M)"Ch Also pt,kxz 4-1,z"d i,.>: t.'?t'^§as3'v:'Wi..�*?i3=.`Y?aT.1�3c°: tSA�T tt` t3€s,.�' s:Y ..k',st tiT, ..C'ds. iI 4cj. you biry ti?parfib.m wor%kw d l CSSl&r,his lit:rnlit. The uniliTsh—red-ilorritxr nc:r- %-r6fie and assunic's responhibilii% for co rip!iance v itlt 010,.suic Buil61 1,4{.k l.,C:"i(1 of Nt riba i-nj ton Ordinances,;Mitt,:and Local t'koni;x Law-'s '-"+°.«3t°T;':e {'i�i.t,a.`�:.-�.�itt:.Z°L.`v i..;4.1'..'r ai L'a—ws Ilotneovvver�;t ri.attra SECTION S-DESCRIPTION OF PROPOSED LAtORK lcl�eck all� £,3ic�t�1�) New Morose 17 Addition Repiacen-£ent Witrdow:s � Alteration(s) � Roofing El Or Doors ED Accessory Bldg Demolition New Signs IlD] Decks rc-1 Siding 101 01her!t� _. Brief Desc r ptkon of t", ra era GIIrSc?a tns ' a C /1"ce��e� - i'� v /rlsc� s:ll c� �n c Alteration of existing bedroom Yes � 140 Addrog rrew hearoom Yes /� No Attached Narrative _ Renovating unfinisbed baser ii-nl es �_No Marrs Attached Roll -Sheet Ga,If New house and or addition to existing housinci,complete the foflowing� 3 a Use of building : One Family .._, Two Family Cither I b. Number of rooms in each family unit— Number of Bathrooms � I c, Is there a ga`age atta:ctied? d Proposed Square°o S age of new construction Dirner sion e. Number of stories? { 1 r f Method of hea`ng Fireplaces of Woodstc yes __.��..._ Number of each _. i g Energy Conservation Compliance I ass,)teck Fnero Compliance form attached? h, Type of construction 1, Is cu+r1=°4fucliC3r vvi hln la,ft of wetla:1d:S Ye's .,._...........___No 15 G+`°7t`it`}t,B..iS^n V.°..' -a 100 yr. fl odlbl.^nk?1 Yes,................N,Ct I, Depth of b:aserr€errl or ellar floor beilo finishea grade k Will bukdinq conform to the Su tding and Zoning regular ions? ;`es Wo, 1. Sept c Tarsi C iiy Sewer Private well Cny water Supply ! SECTION 7a-OWNER AUTH RI .TIDt -TO W--COMPLETED tti[c°EN 3 iqC:;"f�a3t.a,ri"Z.e 0,�4 " .Si Ct'u ....»....��.o,.._ tss Ourrer of the su1'}a~tt g (� I h.-r t y au a H �� t tCi i� ixn zT11 L ltc:ci� in cat tze. Uia",.C:±�4a£..a<�:?;a 3.,..€..,; �} .�� 1 �. .�..�...,... ,» ._.�.e i Sign are of Owner l�ate f= � _ 3� € gT si �',rT,S..,,, au. Se Y f 4L g ..,F a%:e 2 d§` t d '_�F#� _ _�t..>ar7r_.u., . "4. r ,',`�"e nr ^�is�. .,�_>.;1 ,,� a.,�G=.��'tx,��� ,.E -��"3�.._, 6n!Nam r s c,t3 l 4. 20NING Ail d gt,nationi mo*Se L tom€a Kf Yr et Car.Fz, ; mss.,d Du r 3 It coT trte le 3' rrtzatacar+ �. _.�___.,.,_�..w.,..__—__,____-_. _._.�_n I.:».t.:c;it..�..•.,.�,�.,. � F'a's.�?€>.r:,tr:Ca �� s }.'_i, .(taa�t't�l`�� f ltiltTl�; I rn ,auazr to IV r€d d viz h+ 1 t �u i rtarat,1ue Rear t 1311ticltn�Height 3 Bid'-.Squarr foot gc N Il Ana.z i cvttrtwc wti i A. Has a Special P rmit/Var°iance/FlnCi rr ever been issued fcrrlon the site? too 0 DONT KNOW YES IF YES, cute:issued IF YES: Was the perm4t recorded at the Rir�ist:ry of Deeds?' NO 0 DON7 NO � YES 0 I IF YES: sr"te" i'3r. : 4n ar?dInr 1"Llt•I"F"y °nt CY, ._ -R.:?.Ay Cl; 1.�.."",s t,a. IF YES,:has a Permit beery or,need to be obtained from the Conservation Commission? Needs to be obtairied Obtained 'i Date issued: F YES, tiles ribe s:ze, type ani location: U, Are there any proposed changes to or additions r s tYf si ns irrterided for the property? YES NO tt' YES, 4rt Sr,;"i be StZt , ty`�rS. ;��f Bt �, fi5 f _:.i t�r'�>cty r, r�6 +s ? C3 wir}�} �"%a �r"k.FS�,"t � ;t�tE€2� _3�""�„'r c,L ..°:x,33 ,.n ;.�,.,�.t.G �_}%1 Bi??,s?i r. :x•.,. �u ,x e F sus r 'o *, i, jj f(�,r� 4 �iFI88MC�LISPttB ��' r: t , �t{ii�w 4 sJ �• itre_ DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street . Municipal building °stjy jai? , Northampton, MA 01060 LOUIS)H SBROUCK 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 1st floor .30 2"d floor .20 " %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 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. $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$6/K 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 . — l Northampton Status of Permit: t(diligbepartment Curb Cut/Driveway Permit 212 09+n Street SewedSeptic Availability Room 100 WaterAV 11 Availability. Nor'thaMptot , MA 01060 Two Sets'of Structural Plans phone 413-587-124011 Fax 413-587-1272 Plot/Site Plans Other Specify APOLICATiON 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 : H-tnkig t `�- - Map Lot _—Unit -toceue �_— OW(D,� Zone Overlay District__ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ran"/ str»MM'5 7 H1nk1& S1 Florence" MA orava Name(Print) Curre t Mailing A ess: rq,5_ S `t - Co 3a l Telephone Signa ure 2.2 Authorized Agent: \bjIE t �rrne I �Lw,n -ors q1ORive sdelr Florence.Ma of o(e�t. Name(RdAf) Current Mailing Address: hm- 4/3-g�g-752a Sig ure Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building (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=0 +2+3+4+5) ©, Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissionerlinspector of Buildings Date File#BP-2016-0339 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 7 HINCKLEY ST MAP 30B PARCEL 048 001 ZONE URB(100) 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&WALL INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108772 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO$A4ATION 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 De elay Si re o Buildin O ficial 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. 7 HINCKLEY ST BP-2016-0339 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-048 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0339 Project# JS-2016-000548 Est.Cost: $6000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 108772 Lot Size(sg. ft.): 3789.72 Owner: SIMMONS RANDALL G&LINDA A Zoning. URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 7 HINCKLEY ST Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.911512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & WALL 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 9/15/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner