28-015 (3) 198 SYLVESTER RD BP-2017-0800
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:28-015 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Penult: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-0800
Project# JS-2017-001329
Est. Cost:$67000.00
Fee: $435.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 112297.68 Owner: BASHISTA MARK
Zoning: Applicant: BASHISTA MARK
AT: 198 SYLVESTER RD
Applicant Address: Phone: Insurance:
198 SYLVESTER RD
FLORENCEMA01062 ISSUED ON:12/20/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATION OF 2ND FLOOR, NEW STAIRS,
NEW LR WINDOWS, SIDING, ROOF, ELECTRICITY TO BARN & GARGAE
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:
FeeTvpe: Date Paid: Amount:
Building 12/20/2016 0:00:00 $435.50
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0800
APPLICANT/CONTACT PERSON BASHISTA MARK
ADDRESS/PHONE 198 SYLVESTER RD FLORENCE
PROPERTY LOCATION 198 SYLVESTER RD
MAP 28 PARCEL 015 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid0
Building Permit Filled out 4436'46
Fee Paid
Typeof Construction: RENOVATION 0 NDf9SO(t,NEW STAIRS,NEW LR WINDOWS, SIDING,ROOF
ELECTRICITY TO BARN&GARGAE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR_ Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolitio el
Signature of Buildin fficia Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with a/I zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
it C• So AC-0/5
`$ r-- "2,y �..uUP ... �,'SII
City of Northampton ';F ,gr- ys, •i, - ""+ �`
__ - - Building Departments :'rrrA„ 8
__ _ -:� 212 Main Street d.,f" .4'"-,'« ,1I ate. '`
Room lOO 1`p-l:`°.a1°�6” 1��" II s
330 orthampton, MA 01060 q , + :i a i, te
phon 4 3-587-1240 Fax 413-587-1272
., .,n , V# & .ri,
f'• - TION 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
el ' P;:S\r P� Map Lot Unit.
T ogt_ 01310 Zone Overlay District
(NAElm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
null. rASk,S�P Ilii SylvtAt- A) _042,.(2,. ,x9 OIOL
Name(Print) ( / \ Current Mailing Address:
�
" Telephone I
Signature / Pfl(2/: MartAS114is}A (.) flUgprNc 1-w
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
903 — `lb — S T)S%
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
Dr0c0
2. Electrical I00 0 (b)Estimated Total Cost of
/ Construction from(6)
3. Plumbing 4 000 Building Permit Fee
4. Mechanical(HVAC) S 4=''>
5. Fire Protection / 7
6. Total= (1 +2+3+4+5) 000 Check Number al �
643S. SO
This Section For Official Use Only
Building Permit Number Date / 7 n_^/�
Issued: a 20
Signature: //////(//JJ''- Gk
CMnmissioner/Inspector of Buildings Date
DEC I9 - 1
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 tilled in by
Building Department
Lot Size I__. _. _. I -.. 1 __ _I
Frontage
_. - I -_4
Setbacks Front __..-.. r 1 r=_.
Side Li_..,,J Rt j L: _.,.I R:L C L..._- [----I
Rear [—_ 1 1 1
Building Height L. i L_.-,iC,_ ,
Bldg. Square Footage r i I L % r . C_l .I 1 "— 1
� _
Open Space Footage i _) .---
(Loi area minus bide&raved L____I L._ I L __.,I I -I f -
parking) ,
#of Parking Spaces -
1,-...1
�
Fill:
(i
(volume&Location) -- ...1_-__________- .__. -_-
A. Ha a Special Permit/Variance/Finding ever been issued forton the site?
NO �UDON'T KNOW 0 YES
IF YES, date issued:{ J
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW 0 YES O
IF YES: enter Book I Pagel ,._�\.,��yy 1 and/or Document el I
B. Does the site contain a brook, body of water or wetlands? NQ.6.1 DON'T KNOW C} YES O
IF YES, has a permit been or need to be obtained from the ConservationsCommission?
Needs to be obtained Obtained 0 , Date Issued: 1
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO ( T
WYES, describe size, type and location: ""^^"^.."'���
E. Will the construction activity disturb(clearing, grading,excavation,or Idling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Wafer Management Permit from the OPW is required,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) `—
New House n Addition ❑ Replacement Windows Alteration(s) Xsi Roofing VA
Or Doors J� """"'���11f
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks k Siding 04 Other[0] 1,r
runnrnj B.tic�j'' �eO�z
Brief Description of Proposed A Ifi nra N`
Work: R•rr ace\ro� ��wr new gigs APt> CR La�wf� $%k ort foe ' U ^ZS(9 a
Alteration of existing bedroom •N Yes No Adding new bedroom Yes )c No
Attached Narrative Renovating unfinished basement Yes _ No r;,d.11s
Plans Attached Roll -Sheet P
ca. 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?
E 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
I, CONTRACTORAPPLIES FOR BUILDING PERMIT
'4.0SdjR1I&
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner (� 11 Date
144a- (2
( 4S h•1k ,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,
(Talk Q4,{),x\1
Print Name
fjV
� �
Signature of Owner/Agent Date r.�rt\k
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: a
Ceei_ 11 Not Applicable 0
Name of License Holder: ffi iii.
License Number
Address Expiration Date
Signature Telephone
Em.r . .
S.Registered Horne Unprovement Contractor. . , , _ '; Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone_,,,,
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. -'t1ome-Owner-Eiemntion
The current exemption for"homeowners"was extended to include Owner-occupied Dwe0inEs 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 180, 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 building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,dmingand 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 nin Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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: \91 S1, At- 2� (Q,,e,u 14ci
The debris will be transported by: r'laik &Mk
The debris will be received by: VA>3 Ikec�AM,
Building permit number:
Name of Permit Applicant
l k5`IL (� k
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
�b -- Department of Industrial Accidents
I 1r_ i Office of Investigations
un [ 1 Congress Street,Suite 100
b
Boston,MA 02114-2017
,w�.: wwwmass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiowlndividual): p� ,.,�].
Address: -2Q. IAAl..
City/State/Zip: Phone#:
Are you an employer? Cheek the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 9 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 sore proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have X. ❑Demolition
workingf'or me in anycapacity. employees and have workers'
P tY 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.]f c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
'Any applicant than checks box lit must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc 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 subcontractors 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 a the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.II: 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 welt 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
Signature: Date' _ ....
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws 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,
express or implied,oral or written."
An employer is defined as"an individual,partnership,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 shall not because of such employment be deemed to be an employer"
MOL 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 the commonwealth 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
Please fill out the workers' compensation affidavit completely,by checking the boxes that 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 partners,are not required to carry workers' compensation insurance. 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 workers'
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"Job Site Address"the applicant should write"all locations in (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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 7-2013 www.masa.gov/dia
City of Northampton
; sem ,c . .
Massachusetts w =tt
A
i - DEPARTMENT OE BUILDING INSPECTIONS
, y ,a,
K. r 212 main Street • Municipal Building J C.
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 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
foundationlfootngs„{before backfill),sonotube hole •efore • . .r a r• . f bulletin. irmpection
(before work is concealed). insulation in ction ' _•ui ed n• . final e_ildin• i :pection.
The building department requires these inspections before the work is concealed, failure to secure
these insp=. tions ,r r-sult i .ilure to •• ain a cs s ificate 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
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 ma
Date
Address of work location
The Commonwealth of Massachusetts
P. h( Department of Industrial Accidents
_41- 71 I Congress Street,Suite 100
'SITim= a Boston,MA 02114-2017
wwwinass.gov/dia
o
yaWorkers'Compensationlnsurance Affidavit:Guiders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information ` Please Print Leatbly
'(tom
Name(BusinesslOrganizatiortiledividual): Y \4-QV_ SYir(y}Fr.n
Address: LI a t"c.3w.nrl. Neth Ye L. Qo0.C9
City1State/Zip:<,yta,„ ckc.r 4It,a O1e-ir3 Phone#: '41'73_ ate-- -4- }a
Are you an employer?Check appropriate Type of project(required):
I lam a employer with eamloyxs Melaaampasttwc).• 7. 0 New construction
2. I am a sole proprietor orpannenhip mdbave no employees working forma in B. ❑Remodeling
say capacity.(No wo trcra'comp.inswaaw meniadl
9. ❑Demolition
3.0 lam a homeowner doing ail wakpry$etf[No worker?comp.immix{required]t
4.0 lam ahomwsmcrand will behirimownmconductallworkon 1O, Building addition
hiring mygspray.IsvL
ensure dwell contractors either have workers'compensation insurance orate sok ILO Ele tricot repairs or additions
proprietor,with no employees.
12.EiPiumb]ng repairs or additions
TO lamwnmGnraadlhatelereddie wmwaclorslisted ante Matt shut tshet
13.QRoof repairs
Ttaesub outacmrshaveemployees and haveworkers'wmp.insurance
6.01 We are a caporatbdimer
nswl its s have exestsedthehden of exemption per MOL c. 14.0 Other
15;41(9),and wabaveno cmpbyees 0(0 workers'coop.insurance neared]
*Any applicant that check box#1 must also fill out the section below showing their weaken'compeontienpalcy information
t Homeowners who adrma Ws affidavit bdigdng they ale doing all work and then has outside mammon meat submit anew otfidavit'alkaline such
_ tconhactors that check this box mst attached an additional sheet show.iati the mmo o&the snh-connacbn and state whethvnrnot those entities have
emP-�Y�. IEthe mbaoMcbnbanemPkYeaa,they�stFari�tLe'v wurl¢rs'colaacymmber.
lam an employer that is providing workers'compensation insurance for my employees. Below Is thepoilcy and job site
information. /'
Insurance Company Name: ( EJ (-
PolicykorSelf-ins.Lic.# W C.C. S 00 SOH 93D C cAZzpiration Date: LA-1C—\La
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 MOL c. 152,@25A is a criminal violation punishable by a fine up to$1,500,00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido here-bye ttit�jaalia� Al des perjury that the information provided above is true and correct
Signature: � -I`� Date: 11-;d "J /D
Phone g: NI -<01-t.---
")'S�o7 7- R Si D
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Licenseit
Issuing Authority(circle one):
1.Board of Health 2.Miffing Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: - Phone#:
secncas-consTRucnoal SERVICES
3.1 Licensed Construction 5 oerriscr: Not Applicable E
'� icer!
Name or Cronsa Homer- ✓AsR,/i\ \ CS- 06-St-V51-1
P,,.,
k S 77" � eHamner
—`�-� - Y ,,., �2ar9ow "aacJ �— a8- ��
A ♦ f So r^`o^p ie, v6AD} -pa_aon bale
44/7 caress
13—s-a ---81
Signature relegise&
9.Registered Home Improvement Contractor: Not Applicable E
SU44b4Cl,,. dkl. r9e2S — - 3-989)9
Company Name CO Registration Number
LI f, \ (1
I Address Expiration Date
500 GWt \AI\sA oATelephone ‘413-S1-4-7817
1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(0l)
1 Ulorkers Compensation Insurance affidavit must be completed and su;anlit! d with this 2pplinchon-Far ore to provide this affidavit will result
in the denial of the issuance of the�[bu Idi,L permit,
Signed Affidavit Attached Yes-,y.-E No - F
11. -Home Owner Exemption
The current cteoption for"Iromeonner,'was ectended to include Owner-occupied DteellinEs°Cone(I) or two(2)families
and to allow such homeowner tee an individual whodoes al fur hirenot pox license provided that tine owner ads
as super.isor.CMR 730. Sixth Edition Section 1083.5.1.
Definition of Homeowner:l ton(s)who own .parcel ofLind .n ithichbench resides or intendstoen which there
._ is intended to beta one or two family ll .attached or detacheds c.Lime accessory to Fish use and or Ekon
structures.A person M he constructs more than one home in a two-year period shall mut be considered a homeowner.
Such"homeowner'shall submit to the Building Official,tin a form acceptable to the Building OlFcinl.that he/she shall be
responsible for all such work performed under the building permit
As anise Construction Supervisor sum'presence on the job site will io rceuircd L°:n tune m tcua during and upon
completion of the work for which this permit is issued.
also be advised that with Fenn-ellen to Chapter 4 oncea t.ompensation and Chapter 153 I.Liciiiiity of Employers io
Employees for injuries net r sunt iein Ds-ado oil the r areadu e ts Gemma Lew Antionded,VoleMai'be liable for per onisl
you idre
to perform work for you under this permit.
n lie undersigned homeowner certifies mid assignees responsibility for compliancewith the State Building Code.City of
isiortliammonOrdinances,Star and Local Eclipse_Letts and Ste inssiiciieseals Genes-al Lo-:; 4 routci.
Homeowner Signature
The Commonwealths of Massachusetts
-S/ Department oflndusfrialAccidents
—,ilii=
e StCibi= s 1 Congress Street,Suite 100
:_ �iiit=Sa Boston,M4 02114-2017
�':ti v,•� rowrmnrass.gov/dia
Workers'Compensation Insurance Affidavit:BultdersfContractors/Electriclans/Plumbers.
TO$E FILED WITH THE PERMITTING AUTHORITY.
anaRcant Information � Please Print Legibly
Name(UusinessIQrganizadon}ndivtdual): e ° \`offt V SAYE
Address: '-i . ,ow. rt `Ate. 'a ,. !...
CityfState/Zip: ya OW Phone/P: '- fl,-cal.--;-$ta
Arnim os employer?Clack the appropriate bar: Type of project(required):
1. tam a employer with -3 employees(full savor penttme).° 7. El New constmcllon
2- Isal amtepr Pietaror pxhemhipaadhave no employee%working f mein 8. Remodeling
any capacity.1Na maims'comp.iaseany.ueaaa.)
3.0 lams homeowner doing ell work payitICNoworker?comp.W =requlmd]t 9. ❑llomotition
4.0lane bemeoworradwill bzhamsaoonasmemeonMctaawork slimy pmparty. Iwrn IO, Building addition
mum matall coaeaetors tither kayo wmkm'campnmeiioo insurance oramlalo 11.0 Electrical repairs or additions •
p^'bion whits°employees
12.0 Plumbing repairs or additions
5.0 lama maeralcntechve hareldiMudemployees have waken comp.insuancet 13.DRoofrepairs
6.0 Wanescommadonaod es officershave exembed:bairn tofezemption per MGLC. 14.0Other
1St 41(4).and wa ban no employee,(Ho wallets'camp.]asmmarrqufre44
'Aessnal mattsr h-$zboz Amite also lilt out thasetliesbalowstoedeg heewatktre compemathapdicyiafomadst,
twaarowman who zubmitlab affidavillndiafiug they ramping en we&end dam hint outside coometen must submit a 04W affidavit mvaanae ma.
tCaetrmclun That check this bort must'Maeda the same oftheaubmstrat on and ale whethyaruut those ethic;lava
smp'Eytm.3froenbswlncMs hent __ .., __ _ .
emP1oY<tb meyamst Pnvh�ihe'n;MISrt'a�mo-lt^imYnumlvei.
Iam an employer that Is providingworkers'compensation l+raarrnweformy employees. Below is the policy tznd)ob site
hefWanettn. /'
Insurance Company Name: IC—L-
Policy#or Self-ins.L(c.ih W CC,.. rj Cb O\ l }�(3�O Ic!4Expiration Date: Lo-lc- L0
lob 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 noderMOL o.152,§25A is a criminal violation punishable by a fine up to 91400.00
and/ar oneyear imprisonment,as well as civilpenalties in the form of STOP WORK ORDER and a fine of up to 5250.0G a
day against the violator.A copy of this stueme t may be forwarded to the Office offnveatigations of the DIA for insurance
coverap vaiftcation. a�
Ido hereby ceel+ .'git pen ties perjuryamttha Information prnplded/above Is true and correct
Sienature `7
` 7 ( Date -a a-1 (1i
Phone A: '71 " Sc �-' �' S)
OJf tial ase only. Do not write In this area,to be completed by ely or town official.
City or Town: Permit/License#
Issuing Authority(eirele one):
1.Board of Health 2.Banding Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: - Phone
SECTION B-CONSTRUCTION SERVICES
8.1 Licensed Construction Sc_roiscr: I Not Applicable E
e
Bens, av 5✓}r i\\✓ CS— o34y
3
license Idumber
LI- $__
o v sSo.A-Lo.w.y 4¢.n (VAsi Us(§,A aplmrmncam
S ignalers Telephone
9.Registered Home Improvement Contractor: Not Applicable E
Company Namef(ti Regis
Number
1✓ `ail %weet..taN 1Mee atYrw `Q`7 UOS 9- 1-4- Itp
Address O -- i Expiration Dale
SCS Gw p ° 41 A 1:31\Co-41 Telephone t-113-Ca:1-7p� )
1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.152,§26C(6))
Workers Cornpensation Insurance affidavit most be completed and submitted with this appolcation.Fetters to provide Nis affidavit vvll result
in the denial of the issuance of thehf[building permit.
r Signed Andevr Attached Yes../SE
ll. - Home Owner Exemption
Inst current exemption for`bomemcneri's extended to include Owner-occupied Dwellings of one(ll or hw(2)families
and m allow Saw il0/11COWIler to - individual for hire 1 nut yusscss dowse.provided that tate owner acts
as spleen tsar.C\IR 780. Sixth Edition Section 10535.1.
Definition of Homeowner:nae :P on Cs)who on:parcel Of land 1111 V4iiich hctshc resides or intends treside.on which there •
B.or s intended to be.a one or two family dwelling attached or detached smaeres accesmr`to such ose and or farm
structures.A person who constructs more than one bonne in a two-year period shall not be considered a homeowner.
Such"homeowner'Sm hall submit the Building Oficial.on a Eosin m n acceptable the Budding Official,that Iie/cIte shall be
responsible for all such work performed under the building permit.
As active Construction Supervisor Wer prCSCIICC rn the job site ;coffint ern tiute.darn_and upon
completion of the work for which this permit is issued I
Also be ads ised dint with reference to Chapter 152 csgerlictf'r .. . Chino 153 tt.i t OfEmployersto
Elnnio) us for not resulting in penal; doe Ifaseachw General La•s Annotated.von nay be liable for personis)
Tho work hire to perform for you under this permit
e and d Incecertifies and aSSUIIICS re:1)011>lbiliLYf compliance with the Slate Blding Code.City of •
•
glorthamplon Ordimances.S t id inn Lowitc thaws endaffiblessechnffis(Dawn{Laws AacwmN.
Homeowner Signature ti
Other ams in this scope to include.
I.New 30 An circuit to garage.2"conduit already installed and inspected while septic and water lines were con to garage.
2 New 20 Amp circuit to ham z
J.New cedar clapboard siding on entire tome.
4 New 4"concrete floor existing basement under older section of home(kitchen) O Q
S.New bolted on Lally columns to replace okl wood posts supporting center girder under older FROM of home. _
Girder length•approx 28',columns spaced approx 5 apart If existing footers not 12'x1746"new footers to be poured O O
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New windows Arae largest double hung (n CO CC
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regnIy Makestha will fit in"'Sting Q CO 0
openings CO r ll
0 exiling openings approx 42 x40" _ _ -.. .
173 SF RENOVATION = z t
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Newdeck with re rings off front of home to extend 10 In 0- A-1 .1
front of house
h8 hand with 2xe joists I2"foot¢ Double 2x10 Fa n.
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