24A-001 (2) Z,_\ i tie c omr� ortweairn, �f 1�2assC c�� sG S
,_-:�---- Department of Industrial Accidents
Office of Investigations
j 600 Washington Street
Roston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): a�Ifk_k (w ' �V`�(L�Oi�CJ`v 1(�`]e,
Address: f
(`�02-
City/State/Zip: � ,(�I{?�(1(� [ � Phone##:
Are you an employer? Check the appropriate box: Type of project(required):
LM I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in.any capacity. employees and have workers' 9 0 Building addition
[No workers' comp.insurance comp.insurance.#
required.] 5. r_1 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 t
employees. [No workers' 13 Other J�3U�17(
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 whetber or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing woa leers'compensadon insurance for my employees. Below is the policy and job site
information.
insurance Company Name: tfE'�ic, C. iS
Policy#or Self-ins. Lie.#: 00 C055 0?5 02— Expiration Date: t �'
Job Site Address: '13 �e:t-�'T��y' ST City/State/Zip: ,/4+of&a
Attach a copy of the workers' cortni pensadon policy declaration page(show»g the poUcy number %Du 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 DU for insurance.coverage verification.
1 do hereby certl :E d the pains a id penalti perjPry that the inf ornnation provided above is trze and co.sect
/'��;�``�
Signature: Date:
Official use only. loo not write in this area,to be completed by city or town of ciaL
i!
City oz T mwn: Permit/Llf cemFe
fg-gufng AUtlrorlty (e;reie one):
I.Board of Health 2.BuRdIng Department 39.City/Tawn Cperiz 4,_7lecte-cal S.Minmba g inspector
i
6. Other l�
Contact Person: Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS jo,3 77A 7/d I
'}
John . meo L � License Number Expiration Date
Name of CSL Holder
3To 8 IVUI'Si G1e N List CSL Type(see below)
No.and Street Type Description
Owe` MA O` U Unrestricted(Buildings u to 35,000 cu.ft.)
City/Town,State ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofmg Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q/,3-,58q I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HI
\/a I I , `� vernen i' /o S S�f.3 17
C Registration Number Expiration Date
TC CConany Nam or IDC Registrant Name
Nc.GS�I E �•
N and Street
r\o(-e m6 r y,��a� Email address
City/Town, State,ZIP Telephone
SECTION 6: 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 .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize_an to(
to act on my behalf,in all matters relative to work authorized by this building permit application.
VBy 's Name(El tr i Signature) �z Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
my name below,I here by attest under the pains and penalties of perjury that all of the information
n thi application is e and accurate to the best of my knowledge and understanding.
Print Owner's o Authorized A ent' Name(Electronic Signature) bate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
` V Th C monwealth of Massachusetts
Board f B ilding Regulations and Standards FOR
MUNICIPALITY s State Building Code, 780 CMR
r USE
B i`i ' '' '� it Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.3 rope lr���ldlres n 'x-Mff 0)I, ^n pl 1.2 Assessors Map&Parcel Numbers
1.1a Is��ttheits'fan accepted street?yes!L( no �1�T Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flo d =? Municipo(On site disposal system ❑
Check if ye
SECTION 2: PROPERTY OWNERST P''
2. Owner'of Record:
t�r,LnlQf 6002a..le7- J or4hampft HA vw(eo
Name(Print) City,State,ZIP
q3 i 1444edd cat. y13-361-4/9'0
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)"❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: Iy�SU(tGylt c l
Brief Description of Proposed Work2: L ln,5 n er V
v 1 r-1 r) ev R 9 r 3 U!1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building $ dd 1. Building Permit Fee:$ Indicate how fee is determined:
11 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $dgOO,C).O ❑paid in Full ❑ Outstanding Balance Due:
File# BP-2016-0789
APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P O BOX 60627 FLORENCE01062 (413)584-7522
PROPERTY LOCATION 43 HATFIELD ST
MAP 24A PARCEL 001 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT y
Fee Paid
Buildino,Permit Filled out
Fce Paid
Typeof Construction: INSTALL ATTIC & BASEMENT 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 RMATION PRESENTED:
proved 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—
Sign re o uilding Official 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.
43 HATFIELD ST BP-2016-0789
GIS w: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cate,ory: INSULATION BUILDING PERMIT
hermit# BP-2016-0789
Project# JS-2016-001331
Est. Cost: $2400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME IMPROVEMENT INC 108772
Lot Size(sq. ft.): 14418.36 Owner: GONZALEZ DANIEL
Zonin,,: URB(100)/ Applicant: VALLEY HOME IMPROVEMENT INC
AT. 43 HATFIELD ST
Applicant Address: Phone: Insurance:
P O BOX 60627 (413) 584-7522 Workers Compensation
FLORENCEMA01062 ISSUED ON:1211412015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC & BASEMENT 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:
Buildin(! 12/14/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner