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The Commonwealth of Massachusetts
Department of Industrial Accidents
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64 Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-201
wwx.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): "PA
Address: 0,eTH :5r,
City/State/Zip: Wog,—YIA M 0 Y DOPhone Q q,7 —&4161
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
IN 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 or me in an capacity. employees and have workers'
g Y P h'• t 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I i.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
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 indicatine thev are doine 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-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' 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 under the pains and penalties of perjury that the information provided above is true and correct.
Si natty • Date: ��~141—
Phone#: 916 . 7- 6 e10
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#:
City of Northampton
�5 s,
.sr Massachusetts
({y a G
A DEPARTMENT OF BUILDING INSPECTIONS
g 212 Main Street • Municipal BuildingJy ^b.
Northampton, MA 01060 sS't�t X�1 `
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
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- i
year period shall not be considered a home owner."
The building department for the City of Northartipton 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 backfiNl,wwftbe hoieg(before pour),a U=h build Inspawon
(before work Is concealed) insulation Inspection (if reap 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
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 DE the project until such time as the proper permits
and ins are made
pec
I, �9�/ / F"Yv�//-, understand the above.
(Home owner/resident's signature requesting Exert)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of worts location lL/ C�/`!�ti" �[/�
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: /// 5-rk&J l 4 1/6 rt,6i�-6,-,-V R4 d l 0(
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
zi
Date Signature of Permit Applicant
I SECTION 8-CONSTRUCTION SERVICES
r '
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
i
9.Registered Home Improvement Contractor: Not Applicable ❑
64 VID t-
Company Name Registration Number
T,>AC_O 0 ($i U S 7-0 n! 10 G rZ.i< -711&/x-617
Address Expiration Date
Telephone //6—`;?`0L6 VI
SECTION 10-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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-oceupied 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 Supervlsor 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,S to and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature )
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemengindows Alterations) ® Roofing E]Or Doors JJ��
Accessory Bldg. ❑ Demolition ❑ New Signs [L7] Decks [0 Siding[E:3] Other[CA
Brief: "CEti�fP� /�0lt� 19r✓t) GLb:�-T d'tr"� a A&x,
Work: N
Alteration of existing bedroom 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 foliowing:
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?
i
f. Method of heating? Fireplaces or Woodstoves Number of each 3
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? j
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
i
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
n
as Owner of the subject .
proper
hereby authorize �r `�u +�LL l AIS
to a my behalf,in all ers re],ptive t work authorized by this building permit application.
Sign of Owner i Ji Date 1
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.
Print Name
L9L
Signature of Owner/Agent Date
Section 4. ZONING Alt 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 & DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW Q YES Q
IF YES. has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
MIS 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
13-587-1240 Fax 413-587-1272 Plot/Site Plans
--" Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING t
SECTION 1-SITE INFORMATION
1.1 Property Address: This section to be completed by office
A V�6 Map Lot Unit
r j Zone Overlay District
i
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name( 'nt) Current Ma�l�ngAddress. 3 -7
Telephone%% 7
Signature
2.2 Authorized Agent:
DID V/6 e0 z'/VS 17//1//d QW arT I'Jip-IM1^14P/7X1 �'� L
Nam Print) Current Mailing Address:
dl-/7 �yd
j
ignature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit 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=(1 +2+3+4+5) 7 Check Number'
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
1 4
Building Commissioner/inspector of Buildings Date
File#BP-2016-0793
APPLICANT/CONTACT PERSON DAVID COLLINS
ADDRESS/PHONE 91 NORTH ST NORTHAMPTON01060(916)247-6401
PROPERTY LOCATION 111 STRAW AV
MAP 17D PARCEL 088 001 ZONE
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: CONSTRUCT NEW EGRESSS WINDOW&CLOSETS �I�'G /y V
New Construction — –/
Non Structural interior renovations ��OO
_ Addition to Existing
Accessory Structure
Buildiniz Plans Included:
Owner/Statement or License 176119 Upjell
3 sets of Plans/Plot Plan 1
THFpproved WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BAS�ON
INFON PRESENTED:
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
mo ay
Signature of Building 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.
I l I STRAW AV BP-2016-0793
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-088 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate.;ory: renovation BUILDING PERMIT
Permit# BP-2016-0793
Project# JS-2016-001336
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID COLLINS 176119
Lot Size(sq. ft.): 12632.40 Owner: GREEN FIELDS INC C/O DAVID FAYTELL
zoninc: Applicant. DAVID COLLINS
AT. 111 STRAW AV
Applicant Address: Phone: Insurance:
91 NORTH ST (916) 247-6401
NORTHAMPTONMA01060 ISSUED ON:1212112015 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT NEW EGRESSS WINDOW &
CLOSET TO CREATE BEDROOM - smoke & co detectors must be upgraded to current code
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 SiEnature:
FceTvpe: Date Paid: Amount:
Building 12/21/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner