24B-075 (3) 344 KING ST-BURGER KING BP-2019-0276
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24B-075 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2019-0276
Project# JS-2019-000460
Est. Cost: $365000.00
Fee: $2555.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AMARAL ASSOCIATES 086199
Lot Size(sg. ft.): 53491.68 Owner: CASTLE PINES LLC
ZoningHB(100)/ Applicant: AMARAL ASSOCIATES
AT. 344 KING ST - BURGER KING
Applicant Address: Phone: Insurance:
148 West River St (401) 641-8014 O WC
PROVIDENCER102904 ISSUED ON:9/13/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.EXTERIOR RENOVATIONS, RELOCATE
RESTROOMS, RENO DINING AREA -DOES NOT INCLUDE SIGNS-
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 Siiznature:
FeeType: Date Paid: Amount:
Building 9/13/2018 0:00:00 $2555.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0276
APPLICANT/CONTACT PERSON AMAR L ASSOCIAT'
ADDRESS/PHONE 148 West River St P OVIDENCE ( d)641-8014 Q
PROPERTY LOCATION 344 KING ST-E 'RGER KING
MAP 35 PARCEL 040 ZONE SR/WSPI
THIS SEC 'ION I_'-'R OFFIC I„L �i ONLY:
PERb I' CA N CH . KL IS F
r'Iv .LOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
T eof Construction: RENOVATIONS tO T XTERIOR OF BUILDING RELOCATE RESTROOMS
RENO DINING AREA — POC-197 /VOT (NCUAPE Si (j-W S
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 086199
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFqRMATION PRESENTED:
_VApproved 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: § f ;
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
%113li 8
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.
516-S PIAN`
Versionl.7 Commercial Building Permit May 15,2000 _
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 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 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
344 King Street Map yj5 Lot 07,5 Unit
Northampton, MA
Zone Overlay District
- Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Castle Pines LLC PO Box 313, West Springfield, MA 01090
Name(Print) � ] Current Mailing Address:
Signature Telephone
2.2 Authorized A-gent:
Jeff Benevides 148 west river street Providence, 8102904
Name(Print) Current Mailing Address:
(401) 641-8014
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $305,000.00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
{ $42,000.00 Construction from 6
3. PlumbingBuilding Permit Fee
$14,500.00
4. Mechanical(HVAC)
5. Fire Protection $3,500.00' __..
6. Total=(1 +2+3+4+5) ~:E 610 t) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
�T
- R
Versionl.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❑ Additions ❑ Accessory Building❑
Exterior Alteration Q Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Renovations to the exterior of the building. Relocation of restrooms. Dining room remodel and
Of Proposed Work: new decor.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 1:1A-2 El A-3 El1A El A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 26 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B El
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: A2 Proposed Use Group: A2
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1St 3,125 1st __ ..._.. 321251
2nd 2nd
3rd 3rd
4th 4th !
Total Area(sf) 3,125 Total Proposed New Construction(sf)
3,125
Total Height(ft) 18
Total Height ft 20
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone_Information: 7.3 Sewage Disposal System:
Public [D Private ❑ I Zone Outside Flood Zone[:] Municipal 1] On site disposal system[]
s
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 1.228 1.228
Frontage
Setbacks Front exisij
Side L: _ R:= L: . _, RT--7-
Rear
T--7Rear
Building Height 18 20 7
Bldg. Square Footage 3125 % 3125''
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 Q DON'T KNOW Q YES Q
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 E) DON'T KNOW ® 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 O NO 0
IF YES, describe size, type and location: 1 pylon sign and 1 set of channel letters
D. Are there any proposed changes to or additions of signs intended for the property? YES e NO
IF YES, describe size, type and location: under separate permit
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Y ' /1
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:
148 West River St. Suite 5 Providence, RI 02904 Not Applicable 011
Name(Registrant): 8973
148 West River St. Suite 5 Providence, RI 02904 Registration Number
Address 08/19/2018
(401)454-6867 Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Amaral Revite Not Applicable ❑
Company Name:
Jeff Benevides
Responsible In Charge of Construction
148 West River Street, Suite 5, Providence RI 02904
Address
(401) 641-8014
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 No 4
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
Jeff Benevides, Amaral Revite
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
09/04/2018
Signature of Owner Date
'Jeff Benevides 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.
Jeff Benevides
Print Name
09/04/2018
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jeff Benevides 086199
License Number
25 Maries Way, East Freetown, MA 02717 02/21/2019
Address Expiration Date
(401) 641-8014
Signature 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 O No 4
Versionl.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 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 PlottSite 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
344 King Street Map Lot Unit
Northampton, MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Castle Pines LLC PO Box 313,West SpringfieK MA 01090
Name(Print) Current Mailing Address:
1 _
Signature # Telephone q 1 3 -7 P t C)
2.2 Authorized Agent:
Jeff Benevides 148 west river street Providence. RI 02904
Name(Print) Current Mailing Address:
(401) 641-8014
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building $345,000.00 (a)Building Permit Fee
2 Electrical $42,000 00 (b)Estimated Total Cost of
Construction from 6
3 Plumbing $14,500.00 Building Permit Fee
4. Mechanical(HVAC) $3,$00.00
5 Fire Protection _....
6. Total=0 +2 +3+4+ 5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
r
Building Commissionerllnspector of Buildings Date
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 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
S ` �' , rL ___.ff✓ 5/ '�- ..,...__. , as Owner of the subject property,
Jeff Benevides, Amaral Revite
hereby authorize _ _____...- to
act on my alf, in all atte rel to work authorized by this building permit application
09:,0412018
Signature er Date
1 `Jeff Benevides
Jeff 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 penury,
Jeff Benevides
Print Name
09/04/2018
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
Teff Benevides 086199
License Number
25 Manes Way, .Bast Freetown,MSA 02717 � � 02,21 X2019
Address Expiration Dale
(401)641-8014
Signature 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 G No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW{780 CMR 110.11}
Independent Structural Engineering Structural Peer Review Required Yes 0 No e
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�� gig,. � I,,
I. I - .. .'.__�tl�� t fitr� r 1�1 , rr.L� as Owner of the subject prooerty
Jeff Benevides,Amaral Revite
hereby authorize
act on tallf,in all atte Arel to work authorized by this building permit application
09.'0412018
Signature er Date
.......... .
Jcff'Benevides 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.
,Jeff Benevides
Print Name
09,/04x'201 S
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor. Not Applicable ❑
Teff Benevides 086199
Name of License Holder -... _._.
License Number
25 Mari es Way, East Freetown,MA 02717 02,21/2019
Address Expiration Date
401)641-8014
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
t
Workers Compensation Insurance affidavit must be completed and submitted with this application Faiure to provide this affidavit will result
in the denial of the issuance of the building permit
Sigred Affidavit Attached Yes 0 No C)
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
Uf
for work per the ninth edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Burger King, Northampton, MA September 4, 2018
Property Address:
344 King Street, Northampton, MA 01060
Project: Check (x) one or both as applicable: New construction Ok Existing Construction
Project description:
I MA Registration Number: Expiration date: ,am a registered design professional, and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee) shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports (see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a r �? on Control Document'.
Enter in the space to the right a"wet" or
electronic signature and seal:
:.a
� �'�_ 3 gin="Cni l�;
fir_- =p•
Phone number: G(45 Email: to C96S ( A t
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an'x' project design plans,computations and specifications that you prepared or directly supervised. If'other' is
chosen,provide a description.
Version 01 01 2018
r � �o} w '�',.'�.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Annlicant Information Please Print Leeibly
Name (Business/Organization/Individual):Amaral Revite
Address: 148 West River Street
City/State/Zip:Providence, RI 02904 Phone#:401..454.6867
Are you an employer?Check the appropriate box: Type of project(required):
1.[✓ I am a employer with 15 employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ✓❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.M I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10❑Building addition
4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.[:]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑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.]
*Any applicant that checks box#I 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 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:Am Guard Insurance Company
Policy#or Self-ins.Lic.#:AMWC 817548 Expiration Date: 10/1/2018
Job Site Address:344 King Street City/State/Zip:Northampton, MA
Attach a copy of the 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 un t ns and p ties of perjury that the information provided above is true and correct
Signature: Date: s'
Phone#:401.4 .6867
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#:
i
. A
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."
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 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 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
r
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."
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 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. 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). 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 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
♦ r
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:
The debris will be transported by: V5A44UL-44�,
The debris will be received by:
Building permit number:
Name of Permit Applicant -A"T �*l�v�rS
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Date S' nature of Permit Applicant