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31A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov1dia Workers' Compensation I nsu r anceAff i davit: Builder s/Contr actor s(Electr icianstPl umbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I icyve c'Q_(T-K Address: Mey City/State/Zip: Phone Are you an employer? Check the appropriate box: Type of project(required): 1.[2!R am a employer with 4. 7 1 am a general contractor and 1 6. 7 New construction employees (full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. 7. 7 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. $ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑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 131� Other employees. [N o workers comp. insurance required.] Any apps icwt that checks box#1 must also fill out the rection 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 providetheir 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: h illi Mirf kAl Policy 9 or Self-ins. Lic. #: to Expiration Date: 10 Job Site Address: 00_e_ City/State/Zip: o mv\PV0 o ti D Attach a copy of theworkers' 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 hereh c rtify der the pain alties of perjury that the information provided above is true and correct Sianaturel 7 ___41 Date: IN Phone#: i3 5 3 2 -5T-113 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 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: .�\ a-� The debris will be transported by: P�-Qo L- kc- The debris will be received by: Building permit number: Name of Permit Applicant pa t b my)LJZ'N Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: l Not Applicable ! Name of License Holder: ,{�� 0-s- Licensee Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractors NotApplicable ! R`l St PrT ST CA--r'�- L?.K..) o A-� Company Name Registration Number Lcr k I \^6 � 2C7 Aress Expiration Date Telephone G lQ 53 �1� 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-occupied 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 building permit. As acting Construction Supervisor 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,State 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 ❑ Replacement Windows Alteration(s) 57Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [❑ Siding Other[QJ Brief Des�,gr'iption of Proposed _ n Work: {"�rn�t►_ c�R riles lCc��t.�b ,,l74( �7AmA � 3I{J�3 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 8a. if New house and or addition to!existinca 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? f. 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 APPLIES FOR BUILDING PERMIT l .�c`F F 12Z—it4-4\SmE 3> as Owner of the subject property hereby authorize 0)P"ZA to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, Mom MtaY 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. gned under the pais penalties of perjury. V t Name M hie 1-0 ft} Signature of Owner/Agent Date Section 4. ZONING All 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 Heights Nµ Bldg. Square Footage % ...,.,. _ Open Space Footage _, % (Lot area minus bldg&paved parking) #of Parking Spaces -- rv- Fill: F (volume&Location) A. Has a Sp ial Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW a YES 0 IF YES, daa issued- IF YES: Was the permit recorded at the Registry of Deeds? NO r-10 DON'T KNOW 0 YES 0 IF YES: enter Book .uA „~µ .„._.,.... Pagew. .. and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 Date Issued: _. w C. Do any signs exist on the property? YES 0 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 NOO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excmvation,or filling)over 1 acre or is it part of a common pian that will disturb over 1 acre? YES 0 NO -(;�r IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use.t7nly City of Northampton F,, ,,-. s.,of'Pen.nit:, Building Department Cut/Driueway Permit212 Main Streetr/SePtlb, Vailabilily> Room 100Watt?r/1Ielllluairability Northampton,.MA 01060 Two;Setsof'Structura►Plans1` phone 413-587-1240 Fax 413-587-1272 ProtLSite Plans er S cifj! APPLICATION TO CONSTRUCT,ALTER, REPAIR, ENOVATE OR DE OLIS H A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION NOV 2 8 2018 1.1 Prooertv Address: This sectio to be completed by office. DEPT.OF BUILDING INSPECTIONS i 15~ / Q_-c) NORTHAMPTOIM!l1�41060 Lot: Unit I )1)1zafi Iq M PTbrj MR Zone Overlay District Elm St.District- CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: F 1`Q c�/ G Lrv1 sTE 7�'\ YYl>A'itl� 2� �N per, v 11'►q Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: M W3 MA&)Lt cok 6NGPEsc < �ct� � � �to�3 Name(Print Current Mailing Address: Signature _T Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by permit applicant 1. Building tl7 Z SU (a) Building Permit Fee I 2. Electrical (b) Estimated Total Cost of 3. Plumbing Construction from 6 Building Permit Fee 4. Mechanical(HVAC) 5 Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2019-0638 APPLICANT/CONTACT PERSON BAYSTATE RESTORATION GROUP ADDRESS/PHONE 69 GAGNE ST CHICOPEE (413)532-3473 PROPERTY LOCATION 31 MAYNARD RD MAP 3 IA PARCEL 151 001 LONE URB(100 THIS SECTION FOR OFFICUL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fge Paid Building Pprmit Filled out Fee Paid T)mNf Construction: FIRE REPAIR ON GARAGE ROOF AND SIDING,REPLACE DAMAGED STUDS New Construction Non StWctural interior reaQvLtions Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 056785 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) le� PLANNING BOARD PERMIT REQUIRED UNDERI 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 D=oliti2n Dcla* Sightle-o'fBuil dmg(5fflcial 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. 31MAYNARDRD BP-2019-0638 GIS#: COMMONWEALTH OF MASSACHUSETTS —Map�Rlmk;31A- 151 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) CategM: REPAIR BUILDING PERMIT Rgrut# BP-2019-0638 Project# JS-2019-001040 Est.Cost:$10250.09 Fee:S§6.OQ PERMISSION IS HEREBY GRANTED TO Cqnst,CWs: Contractor, License. Use fir,mR: BAYSTATE RESTORATION GROUP 056785 Lot size(sg.ft.): 7927.92 Qwner., OLMSIE&2 MFEREY S&JULIE G Zoning:URB000V Applicant: BAYSTATE RESTORATION GROUP AT: 31 MAYNARD RQ Applicant Address: Phone: Insurance: 69 GAGNE ST (413) 532-3473 WC CHICOPEEMA01013 ISSUED ON.-1211012018 0.-00:00 TO PERFORM THE FOLLOWING WORK.-FIRE REPAIR ON GARAGE ROOF AND SIDING, REPLACE DAMAGED STUDS 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 Nl!aLtm0j Fireplace/Chimney: Rough: ot 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 Occugangy Signature: FeCIERe: Date Paid: Amount: Building 12/10/20180:00:00 $66.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner