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29-450 (12) The Commonwealth of-Hassacizaselrs �= Department of Industrial Accidents Office of Investigations R 600 Washington Street a ' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ca lr1A ;it Tm y o\,Yme?n,4-° , T Address: `�� �y'`�V�� � ��,-� City/State/Zip: C)Rhone Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with �' 4. E] I am a general contractor and I employees (full and/or parE-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. E]Building addition required.] 5. ❑ We are a corporation and its 10.F1 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.] t c. 152, §1(4),and we have no _pp- employees. [No workers' 13)4 Other LnSl��C �IC7(-) 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 is providing workers'compensadon insurancefor arty employees. Below is the policy and joh site htformadon, Insurance Company Name: N,rbe��O_ Policy#or Self-ins. Lie.#: t,�C����JC��C~`� �S Expiration Date: ale l �� Job Site Address: A Cres4we j Dr� City/State/Zip: HtAMC P MA ULIXa:;�- Attach a copy of the workers' compensation policy declaration page(showtng the policy number and expiration elate). 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 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 vpiification. do hereby certy tF a pain a.t�d penalti, � �perjz that the -ove is true and correct Signature: '� Y`f it 4 ?ii /!fv'`bi Date: (3 3 b--- Official use cnyy. Do not write in this area,to be completed by city or taws afjrcial City ar T a.Fvn: ?der rlL een�ce# Issuing Authority (circle one): i 1.n—card efr Trace tPyn 2 Riv2dln-Depar, -=yf v_ 0tv/Town C�er Z.-Plectt-i-e l Ins13- ecter S.MnzRbTW—laspecto ' i 6.Other !1 Contact Person: Phone#: SECTION 9-CONSTRUCTION SERVICES 8.a t,..€candid Con tractilon S gryisor:: � Not Applicable 1"`i hr'1 e(sS ' Hbtd r Q ._ _ . _�.._�, ,_.u_, n_ ___ m_ w License Nurst€xej 3Lto 'R.vers,Je. `fir. coc-�r,ce , c� c ' - .N._ Alfiq---- .. . r 'd E.ersaaattcars Date t £xt t 31ar Telephone S.Re I tSMd Name Ippripyernent,Contractor � Not Apphrable D , Number iNumber ompany me Registration Number 3q F �v ode 2 (©� �-._?�!`(P Ai�dr ;x � ;tti�tinn Crate -Y/3-56Y-75; et�pl�tlr#� �,. SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(WG. L_c. 162,§25C{6}) Workers Compensation tnsurance affidavit must be,complfaled and submitted wah this applicat=fin failure to provide this affidavit will result 1 in the denial of the issuance of the building permit_ Signed Affidavit Attached Yes. Na...., � Home Owner Exemption t.. c k°z rrtt3i cti nil ti�i# lkzr`"€cAr3 z+* 7�vr " c ttr.lrs?T= ira (u f f3��r rt- tcu�3aeil [)r>Ilan<_= t f t�tst{€} or t%%ot'#i'ar ifies and to allm �ual hollick)44;1i:r tv ctie rix an individual dal tOr°Iris dt)cs r#eit posseNs a liccnsc.provitletl that then a li r:acts su Viers Isar.(AIR"tilt, Sixth Edition :�erflota Drfinition of Ilia ewik tier. 1'en;on i F ,Oii 0.M a ly i :k, .:d.1 o �§tltS: " . ,i r?flat a,or intended to bv-:3-nc art"%S o iani.Es ..,:,#Hint,.-,ILin._s.,'J c}° ��;lalc,frs'�..i .s..s.aia.�,td:c.'L:�.�tr ..� :I`G:i;#�1u ,.,.,,,, A gerson wbo cow truct more than one hcsnte itt t�cr e`c�r rrir3�a B aal curt hr c�antilcl�retl�I�t>tatetr����cr. Such"tt trY:c sncr hall #u}n.it tr1 the 33u=! #ir;z t i'ii i (,4,11j l ir7l acc°c°l;t Pt.l4 iza:ire tfarils3lr- Official,that Ie sltr h alb rea,Elonsi€it for aII Mach wor t Tt-t —ic A� actiEEt #t ttnstraactlrrtt t Iael l tra your pl-c st<3ce on the joh"itc skill he rc r,uircd lr"m tinrc tie orlic dilrWQ and upon c�3jrip 1cuon t f the work tt`:w 3h i ii d �,pSv3"wt is Also l,c:..i:.3ll ej that t.*har,iw. :'. { t.-,r.-,ey 153 l:.Tet?•a,gt�. tdca"it114,&si(:s no! ,v�:rltiny i8'8'9�c,it#'t,d thd. ;b'I.iS.`^tiix_§.it i�=.^.w(AE„i3C"9">i.{ i :�1.4 `ail Ytt ulte:°lp_t"t,_ lnay bt liable t ol,,,,von!±;.6 you hire to Ivrfonri ewrk t6r N ou under this permit I'h tttl ii:r,.i racd"honicco'++ne~r"e:cni ie anti<f wont"res[Vil,iNlic" t'ir COnlj3liar3i:c\,irll tlac`;tWIC Ilk"'iitiF C`i3 ic, ('it. c= cirtl3arrlt3tij:3 t}#x};#1;3.tri;£' .,;^sC�itt" :sf1ti I.i.Tc<fl"otline t ?-w' ilti 5iiiti.4.t %lassac.hw ,cw (4-ticral Lw:C ,s Anna;%itc'cl.. Ilosueowner 1+ionalture __ ` F�S-E-QTION --D--ESCRIPTION—QFPR0--P-0' SEO WORK icheck Roofing Or Doors Accessory Bldg Demolition El New Signs 101 Decks 10 Siding[01] 0 er V171 I Work, rn) iroorn Yes No Adding new bedroom Yes No Alteration of existing be,, --- —X—, Attached Narrative Renovating unfinished basement —Yes No Plans Attached Roll Sheet 6a,If New house and ot addition to existing housing, complete the followina. a Use of building one Family__ Two Family-- Other b Number of rooms in each farniry unit____ Number of Bathrooms--- c Is there a garage attached,,-' d, Proposed Square fontage of new con 5truction_--Dimensions f, Method of healing? Fireplaces or Woodstoves Number of each Energy Conservation Compliance Masscheck Energy Compliance form attached? h, Type of construction i is construction within I DIV ft of wetlands? Yes No, Is construction within ID-)yT floodplain Yes No j, Depth of basement or cellar floor below finished grade k Will building conform to the Butiding and Zoning regulations? —Yes--.No I Septic Tank_ City Sewer FInvate well____ City water SuP#Y SECTION?a-OWNER AUTHORIZATION-TO BIE COMPLETED WHEN i OWNERS AGENT Ok CONTRACTOR APPLIES FOR BUILDING PERMIT as Own"of the subject 1 propeny j to act on my behad, Nal—"ers relative towo auttiorized D ihi�-buzlding perma app4zation Signature of Dwner 7)� as 0wner!AuthorrzPd and bliel Jawr"— - Section 4, ZONING At! klfoE't4latkotl MkAt tic=C04110i,,,' Pf>rtrrat Ce,,f,e�.*::r s€° Mw 7u lnoorst,atpte Mforrtat nr �— ��...� �......irtira .._ � 715�cyttiresi by x'i)tt€rt te,,,Y fdl(tj in h, I,ol Size site R Ar Building Iicight Mdg Squxr I(X)taK_°C tTtwn`� sc�c I e°tat _: fi!'I lark ir���y } 11TI:i .. A. Hasa Special Permit/V arianc tf i €ding e�rer been iss red fctr ion the site? N DO NT KNOW � YES IF YES, clue issued: IF YES: Was the permit recorded at the Registry of Steeds?' NO 0 DOWT KNOW YES IF YES: enter Boob Page ,r d rc,r Docurnent r contain r ,,->"' W Yx:5 . :boes The site a brooi&, "p-- y� of w ate- ��3 KNOW �> IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 gate Issued: C. Do any signs exist on ',litf lopertys? YES i1 � IF YES, describe size, type and tocation: Ct. Are there any proposed changes to or additions of suns intended for the property? YES N 1F r'ES. describe„xc�, type avid U)catiOrl: E loll the r=,,);:r clmn acl+tty d!sto t)(dea l's !:�ald=r q e "'ali s: n-1'M r39,�r,:,r�.:r" a£"S£it is it part L"Ft c2�-�)sTa2'YFChP4�.?IaP"s tt,ry'�vs @k disturb c���er � acre-/ YES� tit--y .f Y'L-S then a rt3„rmanta"3'on ,tom" -vV-,1*e, � i§i'1�3„�a_i..,,?.#.�: i's.;tr?ttt$roar".;t:.«:- i � � �If188MCIj1I8PIt8 ^; z �r, DEPARTMENT OF' BUILDING INSPECTIONS 212 Main Street . Municipal Building Northampton, MA 01060 LOUIS)HASBROUCK 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 I"floor .30 2nd floor .20 YA 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 $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. II NO CASH -CHECKS OR MONEY ORDERS ONLY II *Filing deadline is 12:00 pm(noon)on Wednesday. zmu z--IT� Department use only ity of Northampton Status of Permit. SE P g ilding Department Curb Cut/Driveway.Permit- �_�_� ��� 12 Main Street Sewer/Septic Availability Room 100 WateMell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site'Pians- Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property,Address: ,)4 Ct eSTV Yew D'r- Map Lot Unit FLOfence) MAA ©tO&A Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 13c)-sal ce Name(Print) Current Mailing A dress: !Vt3 � /- 131 9 a Telephone Signature 2.2 Authorized Agent: , 0v ( one Ued Nam (FA t) Current Mailing Address: 4/13 --mac l Sig re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building da (a)Building Permit Fee 2. Electrical UW (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3 1 sop. QQ Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0338 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 24 CRESTVIEW DR MAP 29 PARCEL 450 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid c Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC 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 INFORMATION PRESENTED: 4expproved 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 Demolition Delay dV r-Is S of Building ida'] 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. 24 CRESTVIEW DR BP-2016-0338 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-450 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-2016-0338 Project# JS-2016-000547 Est. Cost: $2800.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 108772 Lot Size(sq.ft.): 10018.80 Owner: ROSA GILMA&FREDY Zoning: Applicant: VALLEY HOME IMPROVEMENT INC AT. 24 CRESTVIEW DR 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 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 Sianature: 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