16C-017 (4) I
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Information and Instructions
Massachusetts General Lairs chapter 152 requires all employers to provide workers! compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire~
ecpressorimplied,oral or written."
An employer is defined as"an individual,patratip,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shat I not because of such employment be deerned to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither theeornmonvvedth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Rease fill out the workerd compensation affidavit completely,by checking the boxesthat apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partner's,are not required to carry workers' compensation inairahce. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents Should you have any questions regarding the law or if you are required to obtain a wor kere
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under",bb SteAddrese the applicant should write"ail locatiortsin (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Conunonvvealth of'Massachusetts
Depaitynent of hidustrial Accidents
Office of Investigations
1 Congress Street. Suite 100
Boston, ILA 02114-2017
Tel. w 617-727-4900 ext 7406 or 1-877ALASSAFE
Revised 7-2013 Fax K 617-727-7749
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City of Northampton
' Massachusetts
a; 3
L' DEPAR71"T OF BUILDING INSPECTIONS m
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEME
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines"Homeowner"as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages,which include
foundation/footings(before backfill).sonotube holes(before pQuur), a rough building insertion
(before work is concealed). insulation inspection(of required)and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
Inspected,
If the homeowner hires other trades to perform work(electrical, plumbing &gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
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The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
(" ) I Congress Street,Suite 100
Boston,MA 02114-2017
" 4 wwlw massgov/dia
Workers' Compensation I nsuranceAffidavit: BuiI der slContractorslElectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:t t C.Ei 5YW V T AA%, J
City/State/Zip: 6613 Phone#: S-2-
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with Z 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, E]Demolition
working for me in any capacity. employees and have workers• 9. r-1 Building addition
[Noworkerd comp.insurance comp.insurance.
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions
myself. [No workerg comp. right of exemption per MGL 121,RrRoof repairs
insurance required.)t c. 152,§1(4),and we have no
employees [No workerd 13.❑Other
comp.insurance required.]
*Any appliarrtthatchedcsbox#1nitgalsofilloutthesectionlidam showing their workers corripmsetionpdicy 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-cwtractorshaveemployees,they mid providetheir workers'comp.policy number.
1 am an employer that isprouiding workerd compensation insurance for my employees Below is the policy andjob site
information. M
Insurance Company Name: ,/
Policy#or Self-ins.Lic.#:wC 5--315 —3026 0 S Expiration Date:
Job Site Address: 22& SP��AJrg cSf City/State/Zip:
Attach a copy of the workerl 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 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.
I do hereby certify unde a ins and pe ties of perjury that the information provided above is true and correct.
Si nature: Date: 3
Phone#: Q�2
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 Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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City of Northampton 212 Main Street,Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 220 Eerj� F-I&e- Q�
The debris will be transported by: ,TO-A1Es J FLJkAJEA
The debris will be received by: Zag" , C�/CLritJC
Building permit number:
Name of Permit Applicant ��1ES
Z
Date Si ature of 44Applicant
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �/ r�1�',' Not Ajpplica2ble//! 0 3
Name of License Holder: cJ,7r►�ICS f �`-'�F"'/v 1 16 J w1(p.1
License Number
14k 610f-3
Address
ExpiratioA DatA
a4- 652
S' ature Telephone
9.Registered Home Improvement Contractor: Not Applicable !
LTfi-ft&5 J. C a uc 7`�tsN I&151 Z
Company Name Registration Nu m er
So C#fSTNUT ry A wy�`r�� IHX- 61053 l�f2�t�l 7
Address Expiration Date
Telephonesoollo—Z,14 9662.
SECTION 10-WORKERS'CO PENSATION 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 builoag permit.
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 buildine 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all apolicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [Q Siding[C7] Other[CA
Brief Description of Propose /
Work:
Alteration of existing bedroom .J Yes -"'No Adding new bedroom Yes No
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 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
1, 4 k-nq as Owner of the subject
property
hereby authorize 3-49Yi E S J J44 t f S J
to ct ors my behalf in all matters relative t ork auth zed by this building permit application.
gn ture of owner Date !2 !
I, SAMF S J F4J1vNJ5A1 X*fV6-S T e44JcS7A'-VC 72Dti ,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.
�T&XC—_S 7. EL19WIV!/ A�
L Sig' Name
t re of r gent Date U.
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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 %
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 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
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,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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Department use only
�11 ty of Northampton Status of Permit:
Bu of
Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability.
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Spedfy
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
;ztf spn r s� Map Lot Unit
)�Jffe,,Ce /Lr (� 0 l ou 2- nt r 3 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/j5s1 r P%'I a /ze4x-r' 4ona s7- Porek[e, Aj* Ql Z
Name(Print) Current Mailin Address:
Telephone
-Signature
2.2 Authorized Anent:
arms �. �F S� L'Gc.Q�fn 3
Name(Print) Current Mailing Address:
56F -.Z�-1
Sign re Telephone
S ION 3-ESTIMATED COSTT UCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ! ?IJIJ.bo (a)Building Permit Fee
2. Electrical J lJV (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) 3 . 60 Check Number VE 4M
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/inspector of Buildings Date
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226 SPRING ST BP-2016-0778
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16C-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0778
Project# JS-2016-001320
Est. Cost: $9300.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES FLANNERY 103061
Lot Size(sq. ft.): 80324.64 Owner: KING PETER
Zoning: URA(100)/WSP(100)/ Applicant: JAMES FLANNERY
AT: 226 SPRING ST
Applicant Address: Phone: Insurance:
56 CLIESTNUT PLAIN RD (508) 294-4052 WC
WHATELYMA01093 ISSUED ON:12/11/2015 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 12/11/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner