24B-079 (40) 73 BARRETT ST UNIT 6197 BP-2019-0219
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:24B-079 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP-2019-0219
Proiect# JS-2019-000356
Est.Cost:$1600.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JONATHAN DEVINS 083221
Lot Size(so. ft.): 785822.40 Owner: HATHAWAY FARMS TOWNHOMES LIMITED PARTNERSHIP C/O SPEAR
MANAGEMENT
Zoning: URC(IOOVWP(7)/ Applicant: JONATHAN DEVINS
AT: 73 BARRETT ST UNIT 6197
ApplicantAddress: Phone. Insurance.
WC
NORTHAMPTONMA01060 ISSUED ON.8121/2018 0.00:00
TO PERFORM THE FOLLOWING WORK 12X15 DECK OFF OF BACK OF APARTMENT
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 Occuoancv Signature:
FeeType: Date Paid: Amount:
Building 821/20180:00:00 5100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File d BP-2019-0219
APPLICANT/CONTACT PERSON JONATHAN DEVINS
ADDRESSTHONE 73 BARRETT ST SUI'T'E 2000 NORTHAMPTON (413)586-1405 (5)
PROPERTY LOCATION 73 BARRETT ST TNIT 6197
MAP 24B PARCEL 079 001 ZONE URCi100)/WP(7)/
THIS SEC"'TON FOR OFFRILLL USE ONLY:
PERMIT APPLICATION CHECKLIST
E 'LOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin2 Permit Filled out
Fee Paid
T aof Construction: 12X15 DECK OFF OF CK O PARTMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 083221
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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:
Cub 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
D no)ition Delay
Building O Date
Note: Issuance of a Z.
i 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.
w Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
RECEIVED
Version].I Corrilmercial Building Permit 14ay 112000
��pp Department use only
City of Northamp n AUG 17 aTus o Pe R:
Building Departm nt Curb Cu Drive ay Permit
212 Main StreE t DEPT OF BUILDING)I SW&ffr60ep6C J k"ilabillity_
Room 100 NORTHAMPTON'1 04 1% suability
Northampton. MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloVSite Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
73 $cere+f S} lip+ 6147 Map Let 0 ;q Unit
Z
No/11T4MP}ON MP 01c Go one Overlay District
S.SL District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
H4.1{74w,q firms 'Fow, lru . es L.-? 73 &rre-d S4reef 5N,+F, 2000 /J-Xvfi ynPleaM4
Name(Print) Cumnt Mallin Address:
413 -S8G-1405
Signature Telephone
2.2 Authorized Aeem:
Z0w4//ru pe✓i ' Axs'4*•.fi 14Qr 4Je/ 73 Bcr/eff S{reef 5-4. POW Nor{lic.-pVaN MH
Name(Print) Current Mailing Addrese:
413 -586 —)vw
Signature Telephone
SE CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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) l(�
5.Fire Protection
6. Total=(1 +2+3+4+5) 1 1 Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissionempspeetor of Buildings Date
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs,[I Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signa❑ Roofing[I Change of Use❑ Other
Brief Description Enter a brief description here. &A,(; ,3 c P r 15 o(«k off cf T1,e b.c k of
Of Proposed Work: il," rp..rrM<-++ fcr Hae
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A AssemblyElAA ❑ A-2 ❑ A-3 El IA El
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C 101H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
5 Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 8 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sl)
e
1.1
2n°
2n°
3. 3m
04u
Total Area(sp Total Proposed New Construction(sf)
Total Height(fl)
Total Height If
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Venionl.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column m M Llkd in b,
Building Upenmcni
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(W eea in.bldg&pared
In 1
4 o Parking Spaces
Fill:
(volume&Loca iun
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES O
IF YES: enter Book Page and/or Document*
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES ® NO O
IF YES, describe size, type and location: {„r, e, jra .S;3,5 nn 3e.rr.it Si ide.wV; lintti<�.y
0. Are there any proposed changes to or additions of signs intended for the property 7 YES O NO if
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,goading, excavation, or filling)over 1 acre or is it pan of a common plan
that vall disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit horn the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Regisbalion Number
Address
Expiration Dale
Signature Telephone
9.2 Registered Professional Enginear(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expinuft n Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Data
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Dale
9.3 General Contactor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ����pp��``
I, GE'e>gR > 4&6W5y pu'y'VC /MAN 'f �4f #0 �l I z'zr'Ss'Owrier of the subject property
herebyauthonze (�4r/14N ✓i NS to
act on my ben n all matte relative to work authorized by this building permit application. c
Signature of Omer tf.t.
1, oN4�ici✓ �e✓i.�LT ,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
��unnd�der th��e//pains and penalties of perjury.
Print Name
� i7 /
MS' ure of Owner/Agent Date
CTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Summisor. Not Applicable ❑
Name of Llceme!older
License Number
73 -8&,rrett- S1fee} S }e a000 '/ a_ '901 r
Address Exp! n ate
- y_iJ-S__86 -/ya_ serf S
S' re Telephone
SECTION 13-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 0
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: 73 ' orref/ c5;trcef-
The debris will be transported by: /25 hl;c �SPrr,'«s
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date 69/nature of Permit Applicant
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 ajoint 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."
MGL chapter 152, §25C(6)also states that"every slate 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 your insurance company's name,address and phone number along with a certificate 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. Alco be sure to sign and date the affidavit. The affidavit should be remmed 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 1111 in the permitnicense 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). 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 bum leaves eta)said person is NOT required to complete this
affidavit
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
ALN The Commonwealth of Massach melts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass govIdia
WWorkers'Compensation Insurance Affidavit: Builders/ConlraelorsiElectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Learlyly
Name (Business/Organization/Individuap: 114,/AIcaiax /M6 OcJN�1oM Cs L �
i
Address: 73j'�, vre+} .54rce't
City/State/Zip: Noritia ow 11A ol0 o Phone#: V/,7 -j"b, OS
Are you an employer?Cheek the appropriate box: Type of project(required):
L❑l am a employer with employees Moll and/or par-ling).• 7. ❑New construction
2 I am a sole proprietor or partnership and have no employees working for use in
any capacity.Mo workers comp.insumncc required.] g. ❑ Remodeling
3❑I am a homeowner doing all work myself(No workers'comp.insurance required.] 9. ❑Demolition
4 I not a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
propriemrs with no employees.
12.E]Plumbing repairs or additions
5.r7 lama general comactorI have hired the subcontractors listed on the attached sheet
These subcontractors have
employees and have workers'comp.insurance? 13 ❑Roof repairs
6E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
*Ary appl want that checks box 41 must also fill out the section below showing their workers'compensation polity information.
t Homeowners who submit this untruth indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
lConterea rs that check this box most coached m additional sheet showing the name of the sub-contrac ars and state whether or not those entities have
employees. If the sub-con asucas have employes,they most 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: A T-Me(,.;s4 I
Policy#or Self-ins.Lia#: WNZ.- 400- &ooalb;a- dol s'A Expiration Date: 7LG 19ol9
Job Site Address: 73 &� rtc(t 54- City/State/Zip: IUo,6ui,,9&w MA olorgo
Attach a copy ofthe workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL 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 a STOP WORK ORDER and a fine of up to$250.00 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.
I do hereby certify under the tins and penalties of perjury that the information provided above is true and correct.
Signature, Date: 'Fl /
Phone .
Officio/use only. Do not write in this area,to be completed by city or town of whirl
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#:
'qfl� a CERTIFICATE OF LIABILITY INSURANCE o8/16 20 1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this Certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRooucsa CONTACT HAMSMichael Bonac_or_so
: _ _
eonacoreo Ineurmce Agency, Inc. PANE (]81)93]-3200
DRESS � Na. nen 99T-B2m
10 Cedar Street 'MAIL michaelabonacorsoins.com
AD :
Unit If 32 INSURE S)AFFORDING COVERAGE NAIL/
Woburn MA 01801 INSURERAAIM Mutual
INSURED
INSURER B: _
Hathaway Farms Townhomea, LP INSURER
c/o Spear Management Group INSURER D: _
575 Southbridge Street DISORERE:
Auburn MA 01501 INSURER F:
COVERAGES CERTIFICATE NUMBER:2018 Master REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
U0. TYPE OF INSURANCE ADOL SUMMIT POLICY EFF POLICY ERP
PoLICY NUMBER MMmUYYYYT LIMITS
COMMERCIAL GENERAL UANUTY EACH OCCURRENCE E
CLAIMSNAOE1:1 OCCURPREMISE$[ER.,umMe b
MED EXP("p g or) S
PERSO.A AOV INJURY S
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
FCUCy[ JE� LOC PRODUCTS.COMP,UP AGO E
OTHER: S
AUTOMOBILE UABILRY COMBINED L LI $
'Afa P EI nl
ANY AUTO _ BODILYIWURY(Per person) $
ALL OWNED SCHEDULED BODILY IWVRY(Per acnEem) $
AUTO$
HIRED AUTOS AMUIC PeOraxl wYAGE
AUTOS _E
$
UMBRELLA UPS OCCUR EACH OCCURRENCE _ E _ __
EXCESS UAB C_WMSANOE AGGREGATE _ $
CED I I RETE-101 E
WORNEIIS COMPERWTION X
AND EMPLOYERS'LIABILITY YIN — A. TE ER
MY PROPRIETIXH`MONEWF%ECUTIYE —] N/A EL EACHACCIOEM $ $00,000
A OW�ERAIE^N E%CLUDEOi NMe-BOO-BOO6102_201BA T/26/2016 ]/26/2019
ff tlerY 1 aL DISEASE-EAEWLOrE $ soa,oDD
0 S meonee OF O --
OESCRI WION OF OPEMTIONS EBbw EL DISEASE-POLICY LIMB I$ 500,000
DESCflIPNOH OF OPEM110H5/LOCATONSIVEHICLES(ACORD tot,Adesond Remnlu SMMuM,MW Be MUIOIE N m FPce hma'"'s
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Coverage. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATVE
®198&2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025(XI401)
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,and 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 ajoint 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."
MGL chapter 152, §25C(6)also stales 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 thew 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 Www.mass.gov/dia
ilm
athaway Farm
IOW NHOMES+, V0RIHAMV101
Commissioner Hasbrouck
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the
Entryway roof at Hathaway Farms Townhomes 73 Barrett Street, Building 8, in Northampton because
the work is of a minor nature, will not affect health,accessibility, life and fire safety,or structural
requirements and is impractical in that the cost of control construction is considerable when compared
to the cost of the proposed work.All work will be completed within the prescriptive requirements of
780 CMR.Thank you for your consideration.
"Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
Jonathan Devins
Operations Manager
Hathaway Farms Townhomes
73 Barrett Street
Mass CSL CS-083221
73 Barmt Street,a21xx1,Northampton.MA 1111160 t Tel 413.586.14(15 Fax 413586.&138 TRS WMA37.0183 f Emad hathaaaNvnu nnpearmt ntxoen Q
Jonathan Devins
From: vztpositivenotification@verizon.com
Sent: Thursday,August 09, 2018 10:14 AM
To: Jonathan Devins
Subject: 20183210337
Dear Excavator,
Your request to locate Verizon facilities for the ticket identified above has been reviewed. The extent of work
described in the request noted above has been compared with our facility records. Verizon has determined that the
excavation location and scope of work you have identified does not conflict with our underground facilities. If you have
questions or have additional information where you feel Verizon's underground facilities are in the excavation area,do
not hesitate to contact our National Facility Locate Call Center at 800-492-3100.
Thank you and remember to dig safely!
Please do not reply to this email as the account is not monitored.
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