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25C-125 (8) 14 ELIZABETH ST BP-2020-0164 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-Block:25C- 125 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:Porch Enclosure BUILDING PERMIT Permit# BP-2020-0164 Proiect# JS-2020-000275 Est.Cost: $11000.00 Fee: $72.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BRIAN WORGESS 106973 Lot Size(sa.ft.): 3354.12 Owner: RUSSELL ALEX Zoning URB(101)/ Applicant: BRIAN WORGESS AT. 14 ELIZABETH ST Applicant Address: Phone: Insurance: 680 BAY RD (508) 680-6271 AMHERSTMA01002 ISSUED ON.8/9/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-CLOSE IN AN EXISTING PORCH 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: FeeTvpe: Date Paid: Amount: Building 8/9/2019 0:00:00 $72.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0164 APPLICANT/CONTACT PERSON BRIAN WORGESS ADDRESS/PHONE 680 BAY RD AMHERST (508)680-6271 v PROPERTY LOCATION 14 ELIZABETH ST MAP 25C PARCEL 125 001 ZONE URBO 01) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: CLOSE IN AN EXISTING PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106973 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9KAATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project:_____Site Plan AND/OR Special Permit With Site Plan Major Project: site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: 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 94001? 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. Department use only City of Northampton Status of Permit: r .>> Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability �4 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,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completedbyoffice F I tom`J, �4 Map OZLot a `' Unit l/ jf Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ilk" !q ,,Si,11 f3,-i;,,-j1 Na �(PrintrentCy(rM�il�g Add�ess: ((. t�J IvA Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building f� (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 ;IL on 49 0j 6. Total = 0 +2+3+4+5) K Check Number f This Section For Official Use Only Building Permit Number: DateIssued: Signature: g q'ZDIQ Building Commissioner/Inspector of Buildings Date @ �� 6(1111113 EMAIL ADDRESS (RE UIRED; EITHER HOMEOWNER OR CONTRACTOR) 1 .'_K�r'-, ? .'i";'Er ;C� ., 1.. �,� yF� �,. +.:�J.�'��Ti� }^trd�h ..ie' ..�+1 . •',� •v��,�J�v,S.�s.•�.'+ ♦r.,.., ..!•2JYh.sr t'-.•aM�WMy a ve, K•aY,aalnu.p�.ahM:MM.Ma: �A r.. _w.1NlMaf:-1. :a{,y,:.n •Y4•�rr.�_ +� a !• �,,:x .r. •JM�Y:: .11[.�Ky'IM1r�v.,'�K'". .r.V�YM/ro4ir!V:rc1�,.-,.a <1 +:.._... .,.....M. .-.,„.. :.,. . .:.,-mne- -..:,.. ..+a,w.«.e*.m --,ww..:.:,"«+a.w,....,M,-..tr...*+N-s.v _.,,....».:.»..:: ,c.«:^ .,:..,we_,,.n.,.•.:.a,-n�c..rw ,>. ,.._..o:sr.ww;a*r.w,+:*s•., ,e<. , .. ..... r i + i a 4 i 4 t j iF'` ut-•'',{'. ;r,A;.j ifs" ' 2 a . .. •`' -. � Yat,. F t �S"`. i 'AW 5.;i1 i,rttiQW. .i . - - :�(.., °,. a rT;• ';T . 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 Height Bldg.Square Footage % 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 © DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NODONT KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained © , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: 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 0 NO g IF YES,then a Northampton Storm Water Management Permit from the DPW is required. t ., ... ;'EC:E.�t!'2 - 3�. , 4 �4.�_!-��..�,f• ,i ..�i �#.C�+Lt(. '•N', -,t:i4:.;. - �''c- .. ;: z,S•:a,a.�R yr �4 t, ,:A �ial�±;iy C�»T"i.",sr..r. ., �!:iti,': ,� .... 's i• :�` •i)3i-.f - +',. _. `'t,i + .f. ,ii•F.t� .i� .:1. ;(±�r'� � ..i; 'r •'d;3� .. �'+f;U� .� i ._, . :�' tic. .`'. •, , M1r_ • r,; }� i )e; . r.;� }-�' ,rj..'r_.. � .Mi. ,I�LY':t j(s �rG- �'iJ..:`o ,�.•i: . .,l#F.: ;�;,-; t�A;��,�, ,. '1,,. . Ey• , ,' .'i. L' !�' i'✓: •.•ti:rrt �'i. dJ+• i#^; ,,r') � •^ cT.. l i P. .. y°"r. S,,`. '?. �. ±t,, '!l'':�,• I ?'t�_r cif �T',, !•","4,+i i ',•(aE; ;� , <!? 6, 3 i , i i ± �.yt, 4 � i, rt 'r'''} t t:,(' t :1 i•.. ±...` L '�• r ,a'r'�r' .:; .� y):., L14:V:' `H. £_.� rJ.11.F,1r4'?. SjS,i+i, (•4� �s�-1" ��+ .. � tt.". a.... 'S'NS�. r• i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition m Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [[] Siding [0] Other[CIJ Brief Description of Proposed p Work: r-451,-Jj ..J ,�nl cx�S��N� p�n�� W/ f_£rJ•` h mVi1 rz Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: [ Number of Bathrooms if c. Is there a garage attached? D d. Proposed Square footage of new construction. Ex�S�''`�'3 �:5 NJ W IZL Dimensions I t � e. Number of stories? -- 11 f. Method of heating? t4c; h+-r4 L•vIe55 fe��,('> 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 X 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, /1.-1 0V 5 t'- ` as Owner of the subject property hereby authorize _13 ) (J� to ct onbeh f ' all matters relative to work authorized by this building permit application. Signatur of wner Date 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. 1 0 r\J Ts, Print Namen Signature of O ner/Agent Date . i s - .. �t ��� � 1''{.,a;.a+dY,� iC� 'i.{s"�:.,,E •.{,. ..4t 4i "d ntks ..id i.e(:'.:r•�%t'..'�r- .. .. :.c�,. � fi. ; . ;'�'. .:'. t i r r ff' r•air i { ` ;J� p R_ i . t x [[d do VeM �. -. .:1! �1' •.J.. {7 .1. d�t`� ! .... � •y.t iii. ... ... >r •.. 7 • - - .. ,. ..„fit ..d "rni. ..._..... _. __ _. :i,t„Y.r:. , l.a.�%1'. +.1:” ... s..! .�.»�..'�.;A a„_.__.� ._.. .. �. .. .. :�'.: .�.+`. •`!Kyr• �r' .. 1_. ,. . •. . .,... .., -4w ...n.-<•v{•,w rv.. ......•.w> ...♦.a _�Wr•. ..,ww{.w.r.... •s. ....:1V M�•+...a�a.N... ... "�'ils .... . .. .._r- .. .•..ai...-i,• r , -C; .� �:�, P1•�:: j...:.� �, �. r^�. l i'i; ,i'�'if{1J` .. �.�`•��`r ..... ,,I• '� ._ :,"•dry' _.. t('i.*6 a't' :} `;isti7.:r..° ?✓'' �J4 '4 > .. .. ' t t t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: j� a, 1 M of C�- I o f09- 3 License Number 6� 9r7 1 c, AJ. rrn � 1( 3 3( z I Address Expiration Date go-40 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 8a, tylnl J WQP,6£SS /gto7z0-7- Comp ny Name Registration Number &,tom ID/)l i zo Addressn Expiratio Dat l3Av Pi- fr`l�aal D(Wra- Telephone 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...... ❑ ---:_� v� of v� r�v� •.r�wr►jr vv�r S S . Massachusetts DEPARTMENT OF BUILDING INSPECTIONS a x 212 Main Street • Municipal Building xvti a � Northampton, MA 01060 s o 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 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 he registered Type of Work: Rc-moiQ-IEst. Cost: (�jPoo Address of Work: Iq E Za @e- j�`►{,1��i�P�pr�J A ��D�c� Date of Permit Application: Pui uS' I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Cont—raclofName HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature 1 . ., .., ,-.,.«.. ...... +..,.....ur........w-.....,+,�...,... .,. ..w..r.�.,,.._...-aw+..+r.,-.,•...... .«,...r,. .. ..wwv:r •w..., .,..-...«..mow.,.... o....-.:......,,... .... . �'(1`. . j°. 'l,.. %ya ��.f.,a ::�t7. .. ��1 � .u•'+'�(ti .. :,:1: i.;. ,p� -�,f.�' ,,:.. .�, ;,fes . . ....,........ .»...,.Sw-.w......-,o.,..-.,.: -w.......::...,,..+r.. +r.... .>.,._.-�.w... ,._.,.-.,a....:. >s..»,...,......,....:,r,sa. ....:r.....w r.;w,.........w,-.- r. :' i` 'R: { .. ...t tAr''f{4f� ',P. r.!t,. - .,.E .9i. .l.f'. .ft. .. �%i"$ .... `i' `a�•�- � ;f : ?,,., »,. .-+i 4: ti 'i( ]- .i' f, 4t a' �.•t"yi r. •,1t - e-'r,� •-a . .. Y.l� F., 'Rt*l: ._l i. . !t't �.i�`f ,�r}}�� ..s• �:- 6 t�� {: .. 3Wt . t:.... 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F "Iwo .:,r:Aiiq ( {y;4 v� vj Massachusetts �`��S•s .. scf``c t - DEPARTMENT OF BUILDING INSPECTIONS z `yam 212 Main Street •Municipal Building yJti a y Northampton, MA 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: L-1 t- 1 t z<< te-"I, 54, (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) - (.,I )tr' Signatu a of Permit pplicant 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. �j ... - . .. .�•�:+ !r �� f.l- './4S.,.F�i .r3�iJ�FI _:( ,'jP"+' �;+ il' t (i Jt'1�1' , r ,.� y... i• a i ay OKtk:ty tJa .' 1,'. sii. .t 1J:. .r } ...-7i, _ !!•, tl, r A +, ..�i✓i`.'i:i'. t�. 3i� _ '.d�Ail�-�,�ar. ,f� 'ti�t?:ta ri iG.,y�;• (• t ' 'e S?:�5 ;.i'_it [:..y..•t• Cj`j ..:.71.^�'i' :!jf-.�i;1.' y • i :;F`-?,. i•: �. "t''i'. ,�'tf ,. . '+. i;. P;n;'a(1;4,k�C;y `'i. .. 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M• .... • , fu, i• 'YY�?S"•"v.+h• P� S`f i .a Additional hooks/ Winterize storage at entry porch entry EPI \ -D 28"FRIDGE I Galley Kitchen w Seating I v NOTE: 28" counter-depth sw refrigerator 18"Rubbish Mu I � / DW I � 36" Li � 30" 14^9 45 — — — — — Additional hooks/ I y Susan storage at entry I Add steps on front of porch - - - - - - - NOTE: Nf — — 4'MudroomCubby change F — Add architecturally appropriate — — — -� Cubby/storage open up — _ — at main entry Mathews Brothers Proud Supplier of Customer rdArMEWS QUOTATION Tel: BWYM RS ---------- ' AMERIC/i 5 OLDEST W INOOW MANUFACTURER Fax: Email: BILL TO: SHIP TO: QUOTE# STATUS CUSTOMER PO# DATE QUOTED 461142 None 8/7/2019 1:46:34 PM QUOTED BY TERMS 11140.IECT NANIE QUOTE NAME Chris Skiathitis Brian Worgess Elizabeth St.Mulled window LINE # DESCRIPTION QTY LIST PRICE NET PRICE EXTD.PRICE 100-1 1 $1,065.25 $705.39 $705.39 Walcott Ne onstruction 1/2"Aluminum Reinforced Structural Vertic Mull POSITION 1:Dou Hung DH2642,White,Insul Low-E& o 0 Argon,20.62 X 15.25 Opening,2.18 SQFT,Single u u Lock,wBalance Covers, 'te Window Opening Control ' Device,Insert White Full Sc Applied POSITION 2:Direct Glaze Pic W4042,White, ul Low-E&Argon POSITION 3:Double Hung DH2642, 'te, ul Low-E& Argon,20.62 X 15.25 Clear Opening,2.18 FT,Single Lock,wBalance Covers,White Windo Control Device,Insert White Full Screen A ied w/Nailing Flange,w/J Channel, Exterior Casing Unit 1:UFactor:0.27,SHG: ,VLT:0.55,CR: 60 Energy Star Qualified((No ern) Unit 2:UFactor:0.27,S G:0.32,VLT:0.57,CR:63 Energy Star Qualified(Northern) Unit 3:UFactor:0.27,SHG:0.3,VLT:0.55,CR:60 Energy Star Qualified(Northern) Opening: 92"X 42" O.S.M.: 91.5"X 41.5" Tag: None Assigned LINE# DESCRIPTION QTY LIST PRICE NET PRICE EXTD PRICE 200-1 1 $789.00 $522.46 $522.46 Walcott New Construction 3 Lite Horizontal Slider 92 X 41.5 Unit Size,Operating 1/4- 1/2- 1/4,White,Insul Low-E&Argon,20.25 X 36.5 Clear Opening,5.13 SQFT, Dual Lock,White Retrofit Window Opening Control Device,White Screen Applied w/Nailing Flange,w/J Channel,No Exterior Casing Unit 1:UFactor:0.27,SHG:0.3,VLT:0.55,CR:62 Energy Star Qualified(Northern) Opening: 92.5"X 42" O.S.M.: 92" X 41.5" Tag: None Assigned Page 1 Of 2 , i i ..,;�.. 2' '13 Aw , w•,..raw . ...,_., .rw,....iww�....nw-�... ,...,....�n....ae.r....w.�rra.+rw....,�. .�, .XV9S«..'.^,x.tlrn:ilk^:.Sti4W".:.SY.YI�.I"-:rlC:t�«Jf}'yr�[ ...w... _ ....•... .. ..,.. .. ..,.,r., t .... ..«....y w•r..Nrwa.....r. ,., �....�. ..v•.,.-....w«..,.,... .�...,.c...m.w..w.w. .w :.tw..,...rr...... .�+..»w+.1,.w«.rYr.-...... ,,.v w.r.4......,,y..w,. .w..w....- ....w.r+cd.IF:>.' • 1•<f�i�: i ..ill:, � i Y ��1�:!"` "�+ �._..« r ._,.., .� ,,.., QUOTE# STATUS CUSTOMER PO# DATE QUOTED • 461142 None 8/7/2019 1:46:34 PM QUOTED BY TERMS PROJECT NAME QUOTE NAME Chris Skiathitis Brian Worgess Elizabeth St.Mulled window All Prices are net. Quote is good for thirty days. Please review all quantities, specifications, SUB-TOTAL: $1,227.85 and information for accuracy. Special orders can not be returned for credit. Signature implies LABOR: $0.0 acceptance of these specifications. Your order will not be processed without authorized FREIGHT: $0.00 signature. SALES TAX: $0.00 Thank you for all of your efforts! TOTAL: $1,227.85 CUSTOMER SIGNATURE DATE We appreciate the opportunity to provide you with this quote! Page 2 Of 2 �%R 6'Fr� A W co A o i woP�� Worgess Woodworking Brian Worgess 680 Bay Rd,Amherst, MA 01002 Cell: 508-680-6271 MACSL: CS-106973 Exp. 3/31/21 HIC Lic#: 186207 Exp. 10/11/20 Project: 14 Elizabeth St. Northampton, MA 01060 Scope: The goal is to create a mudroom entrance, by framing in the existing porch roof off of the driveway. The existing deck would be removed, keeping the roof intact. 2 new helical posts would be installed for footings and a new floor deck would be installed out of pressure treated 2x10's. Next, I would frame in new walls from the new floor deck to the existing roof structure. The driveway-facing wall would have one large window. The road-facing wall would have a new door installed. The exterior would be finished to match the house,with cedar shingles and identical casings. Questions for the Town: The homeowners are hoping to not have to heat the space.And leave it unconditioned. Consequently,that raises a few questions on how far up to code we need to bring this existing structure. 1. Do we have to heat the space? 2. How far do we have to go with insulation? 3. Is a 2x4 wall,insulated to R-15 ok? 4. Does a 2x10 floor, insulated to R-38 suffice? 5. For the door going into the mudroom,the homeowners would like just a storm door. Does that fly? `, _.,. j�.. �'�� art'�3°` .. il;! '� .Li{.:iii f.!4i ��taljj4-;"i'hi''• :' ,'ry�'. ;`jii• ti�j .. 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L'.i:)! 0, `> ,.I 1 VVL .%g z :'.Ir ,:'. .J &UTuu' i,:/., ' ul.gLi i•=1 •."U) boo" on; r.. tit F•IfE � ' ..... f,.k�• \f,.T .k�i � r t a , The Commonwealth of Massachusetts Department of Industrial Accidents 1 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. Aimlicant Information Please Print Legibly Name (Business/OOrganization/Individual): S e Sri oo �4,J ri wocqcvc Address: X080 13e:y City/State/Zip: D 100Z Phone#: (56�6FO _ Are you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with employees(full and/or part-time)." 7. []New construction 2.211 am a sole proprietor or partnership and have no employees working for me in $. Wemodeling any capacity.[No workers'comp.insurance required.] 3.n I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 1.❑Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5.rJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]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.] 'My applicant that checks box#1 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: rq Policy#or Self-ins.Lic.#: 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 verification. I do hereby cerafr under he pains and penalties of perjury that the information provided above is true and correct. Signature: Date: ZGl hone#: 504 Official use only. 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