43-035 (2) 95 AUTUMN DR BP-2019-1432
G1sa: COMMONWEALTH OF MASSACHUSETTS
Mam Block:43-035 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Buildino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categop indow replaced BUILDING PERMIT
Permit 9 BP-2019-1432
Protect 4 JS-2019-002315
Est.Cost: $5250.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group NORTHEAST SPECIALTY CORP 110285
Lot Size(sa I T 12806.64 Owner: BROWN STEPHEN A
zo_ nine: Applicant: NORTH EAST SPECIALTY CORP
AT: 95 AUTUMN DR
Applicant Address: Phone: Insurance:
148 DOTY CIRCLE (413) 739-4333 WC
WEST SPRINGFIELDMA01089 ISSUED ON.611912019 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 5 REPLACEMENT WINDOWS
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 4 Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Denartmen[ 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:
FeeTvoe: Date Paid: Amount:
Building 6/19/20190:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of E I V E D tus of Permit:
BuildingDep C Cut/Driveway Permit
212 K lain treet S r/Septic Availability
Rom 1 0 II''11NN 7 2019 W ter/WellAvailability
Northamp on, A i7iQ60 Tv D Sets of Structural Plans
phone 413-587-1 40 ax 413-587-1272 Ph t/Site Plans
DrPT Or nuuDINr,INSPecnouS Of ier Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6 P If
1.1 Property Address: qb Jwfun 'Trly_ This section to be completed by officey�� i pp��mh �J Map Lot /J 35— Unit
IV 1 G�Ce t I t �IV� A Zone Overlay District
Elm St.Distinct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5kenhnr I�arloyr r�lU ti\I�. q5 kk�WMO Ty F recce mA �,ao
Name(P int) Current Mailin Address:
w3 baa -A
Telephone
Signature
2.2 Authorized Agent:
the imh llpevin (w8 rimy u�s1 Ma oma
No ( int) Current Mailing cess'.
Dim"- WS-1"Z�4u333
LTignatirre Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building + C a� (a)Building Permit Fee
2. Electrical J (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee 1/
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) S , `�}�l7 Check Number
This Section For Official Use Onl
Date
Building Permit Numb Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled m by
n,ilding Dcpnrtmem
Lot Size
Frontage
Setbacks Front
Side i.: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage
(Lot are,minus bldg&pi
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findi ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO O DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW d 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 O NO (�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the Construction activity disturb(clearing,grading, ex9dvation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemenl Yyindows Alleration(s) ❑ Roofing E]Or Doors S�
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[[3] Other(i
Brief De cription cf Proposetl
Work: QYy Te nv r� r? (A Le 5 601X) hur1G W)rdOU � dr\ 2n5�;n� �rQy lgty ,k
Alteration of existing bedroom_Yes ✓ No Adding new bedroom Yes
Attached Narrative Renovating unfinished bament Yes No
sev No
Plans Attached Roll -Sheet
ea. If New house and or addition to existina housing. complete the following:
a. Use of building '.One Fari Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
J. 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?
In. Type of construction
i. Is construction within 100 fi. 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
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, �Q j'''`/1 \1�Y\ D�� �t�r as OwnerlAuthofized
Agent hereby declare that the statements and information on the foregomg application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print g
Signaure of OwnerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable
❑
Name of License Holder VC DewIn � pf S
\,-� I,I9 ( -aoao
Adm Expiration Date
'Sighature Telephone
8 Registered Home Improvement Contractor: Not Applicable ❑
t�x+heasr Sp�KN Cor4 103-W�
Company Name T Registration Number
tux a ,,rCl C l,'AA ooB Q �I i 3l a0
Adtlress , I Expi fiAte
Telephonegl3l)�9 "l3
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(15))
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
� .�. Massachusetts
® c
DEPARTMENT OF BUILDING INSPECTIONS 9
212 Main Street • Municipal Building w Cm
MorNampton, !A 01060
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, alteration, 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 mon:than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Lfthe homeowner has contracted with a corporation or LLC, that entity must he registered.
Type of Work: VJ�660.yJ V�K���(�(Yr (�-t' Est Cost: St aJ()
Address of Work: "15 Pw,�)�ffn ,jX . Eoce.'nu_ m� Q«�-
Date of Permit Application: LD I C t(c(
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law (explain):
Jab 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 hereby apply for a building permit as the agent gf the owner:
0,7(-��*5tS aA� CblP (0A�)
p�PwC,Y �— 103713
Date Contractor 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
�" s
DEPARTMENT OF BUILDING INSPECTIONS i m
212 Main Street Municipal Building CD
Nortra ton, M 01060
Debris 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.
The debris from construction work being performed at:
alb flu WMI') brtye E1or2nce ,MR olocDa
(Please print house number and street name)
Is, t'oCbee�disposed
'of/at:-� A �' rt} q-
�W F'6 r \l` `-1- ``J t"�V�.F`tr' �, . ErCOCL �y OtoWo�
(Please print na and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Namea Address)
i
`Sign ure of Permit Applicant r 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.
NORTHEAST SPECIALTY CORPORATION dlb/a NESCOR All home improvement contractors and subcontractors
MA License #103713 engaged in home improvement contracting, unless specifi-
148 Doty Circle • WEST SPRINGFIELD, MA 01089 cally exempt from registration by Provisions of Chapter 142A
1-888-NESCOR-1 1-888-637-2671 of the general laws, must be registered with the
413-739-4333 Commonwealth of Massachusetts. Inquiries about registra-
nescornow.com tion and status should be made to the Director of Consumer
Affairs and Business Regulation, Ten Park Plaza, Suite 5170
Submitted -.{ Boston, MA 02116-Phone(617)973-8700
To: � OIC-_0 yv_Y1
JOB NAME IJI/ !I k. Y�
a_ 7 Q oma .0 J� JOB LOCATION // U!�'l^ C e-
PILN^ S_ _ �9 DATF. I ESTIMATOR
We hereby submitpspecifications and estimates for work to be performed and materials to be use)
/1/z' A7 / 1 .Il remjiE. c,,, C
l ✓/ ,.� x t e w12h
Do nor do: construction related permits:
WORKHE LE
er 4
1 gin Me work or offer the materials before Me Mid day hollowing Me signing of this Agreamanl un ksa s is ntuddar will begin Me and on or most
(date).Baring delay cial ed by cimark ekes beyond Conbador's control,the work M Da '.V
by dabt1he Owner hereby acknowledges
an agrees at the scheduling dates are appmeimab and That such delays Mal are not avoidable by the Contractor induding,bat t li d b sdkes.Acts of God,morasses of meter-
als.modents,and all other needy,layout its contml.shall not be considered as vblatbns of this Agreement.
WARRANTY &L
Tile, de,Contractor warrants Mal the work fumismal hereunder mall be free hmm dlects In metenals and workmanship for a period ds-• ` / 5 6dbvnrg comp eton and slWl cwnply
with Merequirementsd Mas AgramanteIle eventany Wd inworkmanshipmmdehals,ardamagecausedbytheconvector,bsubcontractors,employeesoragems.lsdx ked
after wmplatbn deny job,Indudso,cleanup,the Lontredorshell,at its own eapenae,forthwith remedy repair,correct,replace,or cause to he rssuaded,repaired or replaced,such dam-
0 e or such defect In materials and workman .The fore cantles shall smarke an Magadan performed In comle tion with the a entr n work.
We rO OSe he!r /by to furnish m erialane ratio wco�eta' accord ce with above s ecifications,fa me sum of:
p !!d:JUS -� - / d,..p �at,d`� r,ra,� nA�"/�P— �, dollars(5
Pay am
am to I»Made as follows:
1 ` %(5 /?s;s J )upon signing contract; K-1 NORTHEAST SPECIALTY CORPORATION d/b/a NESCOR
A; /-7 5 PA I,e Name of Conlracboff1mignated Registrant
%(5 t upon compietbn of / ''Z 148 DOTY CIRCLE
Street Address
upon completion of WEST SPRINGFIELD, MA01089 413-739-4333
ClrylStata Phone
stall Ire made forthwith upon 103713
completion of work,under this contact. Registration No. ,(/j/
Notice: No agreement far home improvementquire contracting work shall rea down Name of Salesman / ' 0
payment(aMance deposit)of more than one-trod of the Audit corned price or the Authorized SgnaAre _
mull amount m all deposits or payments which the contractor M
ctor must make,in eerca,
to order ami otherwise obtain delivery of special order materials and equipment
whlMever amount is Greater.
Acceptance of Proposal: I have read both sides of this document and accept the prices, specifications and conditions stated.
I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified.
Payment will be made as outlined above.You may cancel this agreement if it has been signed by a party thereto at a place other
than an address of the Seller,which may be his main office or branch thereof, provided you notify the Seller in writing at his main
office branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following
the signing of this agrafement lease refer o the Notice of Cancellati
HIS CONTRACLIF�TF�EIt` ARE ANY BLANK SPACES.
DO NOT SIC�tIT
Signatures J Signature Data
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.m cergov/dia
«brkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organivmtion/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1 7. [] New construction
2.❑1 am a sole proprietor or parnership and have no employees working for me in g. ❑Remodeling
any capacity.INo workerscompinsurance required.]
9. El Demolition
3.❑1 am a homeowner doing all work myself,[No workers com,insurance required.]
4 l am a homeowner and will be hiringtractors to conduct all work on m Iwill 10❑ Building addition
can my
ensure that all contractors either have workers'compensation insurance or am colo 11.0 Electrical repairs or additions
propncmrs with no employers.
12.E]Plumbing repairs or additions
5.rl I am agvacrid mmmmcterand l have hired thcsubcwtractrs lewd on the mtwficdsbeet 13. Roof repairs
These subconlmetors have employees and have workers'comp_insurance.t
6-❑We arc a corporation and its officers have exercised their right of exemption per MG L e 14.❑Other
152,§I(4),and we have no employees.IN.workers'comp_insumuce,,a...d.I
'Any applicant that chinks box 61 must also fill out the section below showing their wod ars'compensation Fmu,,information.
`Homeowners no s.limit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such,
Contractors that check this box must attached an additional sheet alm,mo the name of the subconaamors and state whether or net those entities here
emplotb s- If the subcontractors have employees,they most provide their workers com,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob.site
information. (�
Insurance Company Name: F-`tI 11 `/� (�
Policy#or Self-ins
�Lia #: V UJl y� J'1[d/t` Ot��O Expiration Date: q 141 I`I n
Job Site Address: `'1JJ O11�«mn � City/State/Zip:�kof-e c2 _�`� 010(0')
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, p25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c y under the pains and penalties of perjury that the information provided above is true and correct.
S , .t Date "s
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACt? NESCC-1
DATE(MMDWh
1. . f _ CERTIFICATE CF LIABILITY,INSURANCE 03112/2019
THIS CERTIFICATE IS ISSUED AS A MAfli-Ht OF 4NFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, TM$CEftYIFICATE OF INSURANGB DOM NOT CONSTITUTE A CONTRACT BETWEEN THE 16SU(NO INSURER{8), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT; If the cefORoateholder Is ah ADDITIONAL INSURED,the pcSMiss)must have ADDITIONAL INSURED provistans or be endorsed..'
if SUEROGAMON 18 WAiVBO,an act to the terms and condRlcns of the policy,certain pollales may require an endorsemad. A etatemeN on
this co"11100e does not cahler ry to thecertlRcete h der In Ilsu of such endorse s t s.
PPOOUCERR mon U887erin8Inc
RnvnLusMerirta Ailey Inc
181 Paryc A' Suite 8 :413-73 - $ .418-iS2-2 e�7
PO Box 4" It USS r suranCe,com
Wsst Spri�go�d,MA SIO W0498
J Raymond-WastarinsADcylrm LUNY INSURANCE CO
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specially Coro 3948
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nn 91I.MASINS O- .-
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COVERAGES CERTIFICATE NUMBERt REVISION
F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER1o0
*MATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY OONLRAOT OR OTHER DOCUMENT WITH RESPECT TO WHICH TMS
CERTIFICATE MAY OE ISSUED ORMqY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES OESCRISED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SIMSH POLICIRLIMITS SHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS.
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1056.2045"C ORD CORPORATION. All d9hre!?,,rued.
ACORD 25(2D16m3) Th.ACORD name and logo are molab"od men,of ACORD
�� " olg&w6ac
Office of Consumer Affairs and Business Regulation
One Ashburton Place- Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Cwpwabw
Regishaaon: 103713
NORTH EAST SPECIALTY CORPORATION Expimbw: 07/13/2020
148 DOTY CIRCLE
WEST SPRWGFIELD,MA 01089
Update AkI.aM RMum Cad.
$CA1 E $IN4y1)
'..woAwaa//L �(avo�4.W/a
Ofaw FIMIwRar Mayas CONTRACTOR
HOME IYPTYPE.C HT COHI'RIICTOR Re1a:lr a valid lrc individual Yea aelY
ttPid pPW18Etl1 helve Ne aaphatbn dMe. R bund rotum b:
3f�11t4p 2
103713 D711V0M OpfeficAeashhC m Ple-Su p1301
Rpulatbn
NORTH FAST SPECIALTY CORPORATION iJpsk^MA 02109
SHARON M.TARIFF
148 DOW CIRCLE -ate-- i
WEST SPRNGFIE�D,MA moos Ulwrlsecrrcrnry Not valid without signan
a l o luv otta Ocped,nent lnf Vuhu, oun�!y
Hoard f Building Regulotinnv and Standardo
oen9o:cs-11028,
We
onstmctloo Suporm
KEITH W DEVIN
01M MOUNTAIN ROAD
WEST SUFFIELD CT O9b90
011091PCY0
DEBRIS DISPOSAL AFFIDAVIT
In accordance with the provisions of M.G.L. c. 40,a. 54,Building Permit
# was issued with the condition that all debris resuldne
from this work shall be disposed of in a Properly licensed solid waste
disposal facility as defined by M.G.L c. Ill,a. 150A.
The debris will be disposed of in:
US\A
Name of Waste FaoiAty
4,x\`ejr\ iA . �w U -Joo&Z
Address of Waste Facility
111.5 Dellis: As a Wlxglion of ending a padit Ge IIs tlemdiMlg terovatwn,
eelubJrtniw oe.,W eltaalun of a ENdbg oe a nohh ,M.0.4 u b a 54 onel.
dsa the dela molting diesefind,sM111 disposed of in a pdpcly Ikeaad wind was¢
dispo®I!wilily a defend by M.G.L.c.I I I s.1511 A.Si®rime oftM lin ilw thhern,
UM.h.W.fthe Idildi,point toInd issued tall MiMllatntona food,provided
by IM BMdng Depmooag ell mhrheel d trs olBm ropy a she hoildiog gnat
notd by the Balding Deyatonent.if IM deed will not do disposed of in indicant,
IM Mldes of IM Moot sMll nonly the building off in,in venting on W the loadon
where the debns will l disposal.
780 CMR-6°Ed&n
SignaWrc pplic®t
1kLTOP �
Department of Industrial Accidents
Office of fitvesligations
-'� 600 Washington Street
Boston, MA 02111
`.fin www.ntass.gov/dier
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Monte Print Legibly
t
Name(BoninesslOrgnnnatioNhMividual):__
Address'_ /\�r --
City/State'Ztp: � �,N. 1 R'1C r)VOS9 Phone#: q "—P-,q'
Ore younn employed Check the appropriate box: Type of pseject(required).
❑'I;nn a employer With -2_Z)__ 4, E] I am a general contractor and 1
employees(full andior part-lime).• have hired the sub-contractors 6. []N0/construction
❑ I am a sole proprietor or partner- listed on the attached sheet. 7, [] Remodeling
ship and have no employees These sub-contractors have g, [] Denc01ition 'I
workingfor me in any capacity employees and have workers'
Y P ty 9. []Building addition
[No workers'comp.insurance comp.i a corporal
required.] - 5. ❑ We aro a corporation and its I0.❑EleeVical repairs or additions
❑ 1 am a homeowner doing all work officer have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12❑Roof repair
insurance required.]t c. 152,¢I(4),and we have an
employes. [No workers' 13.[�Other_
comp.insurance required.]
my sawicent that checks hox al must alae all can the action below Showing Heir woken'mmpamaien policy inaxaatim,
iomeownen who submit this eRidivit itdicating they am&,as ell work end then h,,,..aide contnetms mm su eek.ossa arrw.va mdwfmg such.
'ontnclon that check Chia box mwt aaacMA en additional sheet ahow'asg the
phey r nemc.lthasealon aha ahm wheshw:p col dove entities hove
iployeu. If the aub<onnacmry kava employea,taey matt psovida Char wokari wsnp.polity numhm '
am an employer that is providing workers'compensation Insurance for my employees. Below is thepoliry and Jab site
formation.
isurance Company Name: �T, Vn
Any#or Self-ins.Lie.0: VExpiration Date: -I hcilkG
,b Site Address: City/SrtclZip'.
trach a copy of the workers'companwtion policy declaration page(showing the policy number and expiration date).
ailuro to acture coverage as required under Section 25A of MGL c. 152 can lead in the imposition 4f criminal penalties of a
ne up to$1,500.00 and/or one-year imprisonment,ss well u civil penalties in the form of a STOP WORK ORDER and a Me
f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA For treatments coverage verification.
do hereby certify under ge paains� era ury that the information provideed above is t and eorrecc
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Offfclai use only. Do not write in this area,to be completed by city or town official.
City or Town: Permitucense#
Issuing Authority(circle one):
1.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5. loathing Inspector
6.Other
Contact Person: Phone#: