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17C-096 (9) 140 CHESTNUT ST BP-2019-1089 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :B : 17C-096 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Camgorv:ADDITION BUILDING PERMIT Permit BP-2019-1089 Proieet# JS-2019-001772 Est.Cost:$9000.00 Fec,$65, PERMISSION IS HEREBY GRANTED TO. Const,Class: Contractor. License: Use Group: STEPHEN YOSHEN 88490 Lot Sin(sp.R.1: 31842.36 Owner. ROLL JESSICA&MCNAMARA AMANDA Zoning:URA(I00VURB(0V Applicant: STEPHEN YOSHEN AT: 140 CHESTNUT ST A plicantAddress: Phone: Insarance: P O BOX 41 (413) 695-78010 CUMMI NGTONMA01028 ISSUED ON.41812019 0:00:00 TO PERFORM THE FOLLOWING WORK.-EXTEND FRONT PORCH 4 FEET TOWARD THE STREET 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: FeeType: Date Paid: Amount: Building 4/8/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File q BP-2019-1089 16 APPLICANT/CONTACT PERSON STEPHEN YOSHEN ADDRESSIPHONE P O BOX 41 CUMMINGTON (413)695-7801 () Oa. PROPERTY LOCATION 140 CHESTNUT ST 1 MAP 17C PARCEL 096 001 ZONE URA(IOOI/URB(OV THIS SECTION FOR OFFICIAL USE ONLY PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid I Building Permit Filled our Fee Paid Tvneof Construction: EXTEND FRONT PORCH 4 FEET TOWARD THE STREET New Construction Non Structural interior renovations Addition to Existina Accessory Structure Building Plans Included: Owner/Statement or License 88490 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INBOftMATION PRESENTED: I/ 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 Cm 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 EW Street Commission Permit DPW Storm Water Management Demolition Delay y-g-zo�g Sigfflnm of Building 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. Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street SewenSeptic Availabild ROOM 100 WateriWell Availability Northampton, MA 01060 Two Sets of Structural Plans 4P phone 413-587-1240 Fax 413-587-1272 Plot Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION ECEIVED 1.1 Property Address: This section to be completed by office )90 C 664-11)0451 MAR 29 201flap 7G Lot OClU Unit 0(6 / ( Zon Overlay District l0 DFPTO-ntlil;O.INOf.NI.HSPECTIONS tdCB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: �sslrn� f�dl� t4tl r es vt /D✓enul Ml� oln/. i Na (Print) Current M Ili Add s' T �( I 4I1- a o. 9-73U4T3-34'i0L88 Telephone SlgnaNre 2.2 Authorized Adam: e33 63 .,ati+ Rd. Name not Current Mailing Address: i//3 6 R5- 7�o Signature phone SECTION 3-ESTI ATED 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) ✓� 5. Fire Protection 6, Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued'. Signature: �- (�Pr-Za19 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Ber Replacement Windows Alterations) Roofing Or Doom ED Accessory Bldg. ❑ Demolition ❑ I New Signs [O] Decks [E] ylSidingl10] Other[[3] BnefDWork: es�cnption of Prgppse ( ± [�O CC.h � ' +gi Alteration of existing bedroom_Yes "I/ No Adding new bedroom Yes L-/ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 62. If New house and or addition to existing housing, complete the following: a. Use of building:One Family Two Family Other It. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage aftached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. 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 Sevver Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize 5 IOSYa9.� to act on my behalf, in all matteVelative to wohs authorized by this building permit application. l-) k 35 Signature/re ooJf (� _ V r ate / I, `JZ Q�+ /rSX�(V2, ,as Owner/Authorized Agent hereby clare that the statements and information on the foregoing application am true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print nature?Owmr/Ago?Ower/AgoDate SECTION S-CONSTRUCTION SERVICES 8.1 Licensed Construction//S''u��pervisor, 1y' Not Applicable/0 Name of License Holder;'71 7 A� e.-. I ('S 0 '% �Yg 0 HLicense 1 umB Ila Add s F)qhiration Dalg Signature Telephone 9.Re islemd Home Im v m n on ra tor. Not Applicable ❑ �� �s r / tCompium, me RegisMrN Kmbaer -3 / 6-EZ y Address Expiration Dale Telephone CTO 7Zj o1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.182,§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...... ❑ City of Northampton i Massachusetts �C S DEPARTMENT .e BUILDING al sui din, ff�p 212 Nein Bfreet • NuMA. 01l Building /C NocNamPten, Na 01060 le AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteretion, renovation, repair,modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered (^ 0 0 moo Type of Work: �orndr �avv`� DB (�f. Est.Cost I r� r� yea Address of Work: 14,0 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hatch apply for a building permit as the agent of the owner: 3 �a�1r4 �Yosl,�r Date ContraUtor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts 3 DEPABTAffi,T OF BUILDING INSPECTIONS 212 Nein Btreet •Municipal Building Noxtl�svpton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c40, 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. The debris from construction work being performed at: IQ) (' LI&--f s-t. (PI a e print house number and street name) Is too�be disposed of at: �� Vol11'J RfeU 6 ,25 (pleaserint name and cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Si re of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. 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/Contr•dors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/OrgmimtioMndividual): O Address: City/State/Zip: Phone#: Are rem••n employert Cheek the•ppropd•m balic J , Type of project(required): Ln{am a employer vital employees(full mallow pan-time).• 7. n bFew construction 2 lama solepropritterorpam¢nhipand haven employees working farmers g. Lrn/Remodeling any capacity.[No workers'comp.insomnee required.) 3.M I an a homeowner doing all work ,.If [No workers'comp,insurance required.I' 10 Demolition 4.❑Iama bomeowner and will ba hiring contractors to ma ndeall work ala my mopert, Iwill 10 Building addition we that all comm nts either have workers compensation insurance or are win 11.�Electrical repairs or additions p rprietors with no employee" 12. Plumbing repairs or additions 5.❑l am a general connactorvtd l have hued the rub-contactors listed on the attached sham. 13.�Roofrepairs Theme subcwxmwwrs have employees and have workers'comp.insurance: 6 We are a calculation and in offices have examined their fight f exemption per MGL a 14.❑Other 153,§I(4),and we bave no employees.Mo workers comp.insurance rx,mradl •Arty applicant vin checks box#1 mast also fill out the sec tion belowshowing their sawma compensation policy iNormation. t Homeowners who submit this atidavit indicating Nay are doing all work and than him maside contactors..at submit a new affidavit indicating such. ZContractors that check this box must attached an additional sheet showing the name addle subcontractors and state whether or not those entities have employeeslittle subcontractors have employees,thry most provide their workers'comppol try number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lia It: 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 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 verificati n. I do hereby cerci rain ndp aides of perjury that the information provided a ve is tr e and correct. Si attire: Date: c3 Phone#: Official use only. Do not write in this area,to be completed by city or town oJjicial. 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 Conrad Person: Phone#: 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 Depanment Lot Size Frontage (0 O (O O Setbacks Front 90 e0 -"3"7 Side L. 30 R Y�' L: I;1n0 R Rear Building HeightaCC Bldg.Square Footage r' % I n Aff Open Space Footage _pn O a gUl 4........ Parking) fibm arkin ) min sbld8ffi paNved l h QV , _. erkin rJ 2 ofParking SacesJ volume@Location -------- A. Has a Special Permit/Variance/Fmc ever been issued for/on the site? NO O DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'TKNOW O YES O IF YES: enter Book '.. Page and/or Document#'.. '. B. Does the site contain a brook, body of water or wetlands? NO IV DONT 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 g IF YES, describe size, type and location: F... D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: _ _1 E. Will the construction activity disturb(Gearing,grading,(exs�pJv ation, or filling)over 1 acre or is it part ore common plan —x that will disturb over 1 acre? YES Q NO V IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Massachusetts nSFANTNENT OF BUILDING ZNSPBCTFONS 010 [Yin Street • NNn 010 0uiltlinq Neq. 010 Noru�pton, 60 Massachusetts Residential Building Code Section I IO.R5.1.2 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. Section I IO.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall act as supervisor. 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. -NOTE- THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED 100.04't BOOK 9092, PAGE 261 n o 0 b b h � 00 W 10o.00't _ CHESTNUT STREET TO: FLORENCE SAVINGS BANK AND FIRST AMERICAN TITLE INSURANCE COMPANY TO THE BEST OF MY !NFORMATION, KNOW!EDGE AND RFI IFF 1 HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY #250167 -NOTE- SURVENID�.RRC- ] APP'F. I THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY iNy -MORTGAGE LOAN INSPECTION PLAT- NORTHAMPTON, MASSACHUSETTS PREPARED FOR ,IF = JESSICA T. ROLL SCALE: 1'=40' DECEMBER 1, 2012 HAROLD L EATON AND ASSOCIATES, INC. REGISTERED PROFESSIONAL LAND SURVEYORS 235 RUSSELL STREET - HADLEY - MASSACHUSETTS 2013 111100001871ii Bk: 11197Pg: 101 Page: 1 ol2 RecorO : 01123/201302:47 PM MASSACHUSETTS EXCISE TAX Hampshhe DIWGI ROD#13 001 Date: 01123/2013 02:47 PM ctrl#029013 22952 Doc# 00001871 Fee: $1.247.18 Cone:$273.300.00 AFFECTED PREMISES: 140 Chestnut Street,Northampton(Florence), MA WE,ROBERT D. WHITMAN and CHRISTINE R. WHITMAN,Trustees of the Robert and Christine Whitman Living Trust dated April 6,2007, in consideration of Two Hundred Seventy-Three Thousand Three Hundred and 00/100 ($273,300.00)Dollars grant to JOSHUA L. OWSLEY and JESSICA T. ROLL,husband and wife as tenants by the entirety,of 24 Northern Avenue,Northampton,MA 01060 with QUITCLAIM COVENANTS A certain tract of land,with the buildings thereon,situated on the westerly side of Chestnut Street,in the Village of Florence,Northampton,Hampshire County, Massachusetts, known as 140 Chestnut Street, further bounded and described as follows: Beginning at a stone bound on the westerly side of Chestnut Street at the northeasterly comer of the premises herein described,the same being the southeasterly corner of land formerly of Charles A. Sheffield,now or formerly of one Sonderegger,thence N. 66'44' 30"W. along land now or formerly of said Sonderegger and land now or formerly of A. W.Borawski and land now or formerly of J. H. F.Longpre' to a point marked by an iron pin a distance of four hundred seventy-six and sixty-eight one-hundredths(476.68).feet;thence S. 250 14' W. along land now or formerly of Francis Cole,Jr. to land formerly of A. W. Borowski,which point is marked by an iron pin,a distance of one hundred and four one- hundredths(100.04)feet; thence S. 66°44' 30"E. along land now or formerly of said Borawski, land now or formerly of Louis J. Montgomery et ux.,and land now or formerly of Wilbur Peterson to said Chestnut Street,which point is marked by an iron pin,a distance of four hundred eighty-one and eighty-seven one- hundredths(481.87);thence N.220 15' 30"W. along said Chestnut Street to the place of beginning,a distance of one hundred(100)feet. Being that tract of land shown on plan entitled,"Plan of Land in Northampton,Mass. Belonging to John Dalton, Scale I"= 80', April l8, 1955, W.W. Forbush,Reg. C.E."to which reference may be had for a more particular description of the premises described herein. Being the same premises described in deed of Robert D. Whitman and Christine R. Whitman to Robert D. Whitman and Christine R. Whitman,trustees or successor trustees,of the Robert and Christine Whitman Living Trust dated April 6,2007, dated April 6, 2007 and recorded in the Hampshire County Registry of Deeds in Book 9092,Page 261. Robert D. Whitman and Christine R. Whitman execute this deed for the purpose of releasing the life estates reserved in the deed recorded in the Hampshire County Registry of Deeds in Book 9092,Page 261. Executed as a sealed instrument this 23rD day of January, 2013. Robert D. Whitman,Trustee Christine R. Whitman,Trustee Robert D. Whitman l . Christine R. Wl tman THE COMMONWEALTH OF MASSACHUSETTS Hampshire, ss. On this 2P day of January, 2013,before me,the undersigned notary public,personally appeared Robert D. Whitman and Christine R. Whitman,who are personally known to me, and acknowledged to me that they signed this document voluntarily for its stated purpose. M'..Ga.,wy� Thomas M. Ovowhoski,Notary Public ��cPynr� y My commission expires: Jan.23,2015 $ •;, �o�r,\ny� bq sa U$ ATTEST: HAMPSHME, • REGMA MARY LBERD 0 ' G ° o� ryf4 0 6 � c �4 �e 1ec a` �1Mg�8e K 'tl� hAt�«are h I Nof 4 21VO, V11 "7t OW 11 e4 4,� V11 'WZA. ou( ale i I tik O:aw a�.d tkc rode t D P-7r To+a( � 22s &Qss � ;� 20oo TA( we,14 ©� `LO 16 ;t (oad yk7 `b 8a 6 d (; re taxa �`oocJ" 70 (6 foal 17 t -3-g�2s0 �l � ' t� d(4Men d glees �r ap e�r c�. ref Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an¢mploym 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 ofthe foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of m 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 t Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contructor(s)name(s),addresses)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 palmers,are not required to carry workers'compensation insurance. If an LLC or LLP does have employces,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 retuned 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 ifyou 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 ofthe affidavit for you to fill out in the event the Office of investigations has m 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 ofthe 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.When a home owner or citizen is obtaining a license or permit not related many 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 Al 617-727-7749 Revised 02-23-15 wWw.mass.gov/dia f•T Diamond Pier Foundations mond Pier Foundations ** 98flfICNt(6) Rate or review to earn-Dec§Pe[ke.polatFi d Pier Foudertaos offer both com actors and DIY homeowners a tionary new way to install stable,solid footings for any dark or other backyard without the traditional mess,este work and frustration.Traditionally,instnllidg a foundation or footing required excavating a hole below the host line,Pouring the g and then waiting for the concrete to set With the new Diamond Pier a0on,all that is in the push This new footing system features a concrete head that ins pre-made holes.Simply set the head in place and drive the included steel- g pins through it deep into the ground with simple hand tools The pin pile tion quickly delivers a secure dark footing below the host line,all without ing washing landscaping.Attach a standard port bracket and you're ready to in your deck immediately!Tip:Order 4 or owner for best shipping value. mple Installation animal Digging bad Lifetime Warranty H e in the USA cepts 4x4&6x6 Posts R Code Approved E$3-l89� MOREwtws Cock,Cpm.l h f D' d d f ■■■®®I M n Wisconsin 8u Idng Product Evaluatde on-CoAoprpv_al View mareore product details •Deck Pier Size Choose an Option... •04m and No Length Choose an Option... $158.99 i 110 TO CART r aneonn war a r rewu r<escnnc o,iLk a—aaT Freight Shipping Required Thi:ahi&ut equihsmaght mippirg. 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