24D-242BP-2011-0447
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0447
Proiect # JS- 2011- 000728
Est. Cost: $200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHARLES J FLORIO 35712
Lot Size(sq. ft.): 17990.28 Owner: LAFLAMME ROBERT G
Zoning: URC(100)// Applicant: CHARLES J FLORIO
AT. 83 CRESCENT ST
Applicant Address: Phone: Insurance:
3 STRAITS RD (413 247 -5152
HATFIELDMA01038 ISSUED ON :11/16/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPAIR PORCH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
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 11/16/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
BP-2011-0447
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0447
Proiect # JS- 2011- 000728
Est. Cost: $200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHARLES J FLORIO 35712
Lot Size(sq. ft.): 17990.28 Owner: LAFLAMME ROBERT G
Zoning: URC(100)// Applicant: CHARLES J FLORIO
AT. 83 CRESCENT ST
Applicant Address: Phone: Insurance:
3 STRAITS RD (413 247 -5152
HATFIELDMA01038 ISSUED ON :11/16/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPAIR PORCH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
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 11/16/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0447
APPLICANT /CONTACT PERSON CHARLES J FLORIO
ADDRESS/PHONE 3 STRAITS RD HATFIELD (413) 247 -5152
PROPERTY LOCATION 83 CRESCENT ST
MAP 24D PARCEL 242 001 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvneof Construction: REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 35712
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I ATION 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
Septic Approval Board of Health
Water Availability Sewer Availability
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
De 'o a
afore of Building Officia
&-d-M
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.
File # BP- 2011 -0447
APPLICANT /CONTACT PERSON CHARLES J FLORIO
ADDRESS/PHONE 3 STRAITS RD HATFIELD (413) 247 -5152
PROPERTY LOCATION 83 CRESCENT ST
MAP 24D PARCEL 242 001 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvneof Construction: REPAIR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 35712
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I ATION 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
Septic Approval Board of Health
Water Availability Sewer Availability
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
De 'o a
afore of Building Officia
&-d-M
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.
Versionl.7 Commercial Building Permit May 15, 2000
I 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
3 _ Map
Zone
...._ ., _ _ v .._ -, a..__.. �... wm �, ! Elm St. Distric
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
Signature
2.2 Authorized Agent:
Name (Print)
Signature
This section to be completed by office
Lot Unit
Overlay District
District CB District
.�_...�.�. D.Q.. p.�� ...__... � - �../�..,�..�... .
Current Mailing Address:
t 1 A-Ti- - 7 Ci AA n i nlh
Current Mailing Address
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit 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 = 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number I _ Date
Signature:
Issued
Commissioner /Inspector of Buildings I Date
City of Northampton
Staw� fpm(
Building Department
ct�r LVD�ru uvay P�
212 Main Street
Sei�rerSepticRrartal.
Room 100
iNateretuitb�ftf
�\ n,r
IS48 �lampton, MA 01060
Tv o Sets of aura
phone 413 -587 -1240 Fax 413 - 587 -1272
PlatiSrte Ptans .-
I 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
3 _ Map
Zone
...._ ., _ _ v .._ -, a..__.. �... wm �, ! Elm St. Distric
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
Signature
2.2 Authorized Agent:
Name (Print)
Signature
This section to be completed by office
Lot Unit
Overlay District
District CB District
.�_...�.�. D.Q.. p.�� ...__... � - �../�..,�..�... .
Current Mailing Address:
t 1 A-Ti- - 7 Ci AA n i nlh
Current Mailing Address
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit 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 = 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number I _ Date
Signature:
Issued
Commissioner /Inspector of Buildings I Date
Versionl.7 Commercial Building Permit May 15, 2000
I 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
3 _ Map
Zone
...._ ., _ _ v .._ -, a..__.. �... wm �, ! Elm St. Distric
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
Signature
2.2 Authorized Agent:
Name (Print)
Signature
This section to be completed by office
Lot Unit
Overlay District
District CB District
.�_...�.�. D.Q.. p.�� ...__... � - �../�..,�..�... .
Current Mailing Address:
t 1 A-Ti- - 7 Ci AA n i nlh
Current Mailing Address
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit 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 = 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number I _ Date
Signature:
Issued
Commissioner /Inspector of Buildings I Date
City of Northampton
Staw� fpm(
Building Department
ct�r LVD�ru uvay P�
212 Main Street
Sei�rerSepticRrartal.
Room 100
iNateretuitb�ftf
�\ n,r
IS48 �lampton, MA 01060
Tv o Sets of aura
phone 413 -587 -1240 Fax 413 - 587 -1272
PlatiSrte Ptans .-
I 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
3 _ Map
Zone
...._ ., _ _ v .._ -, a..__.. �... wm �, ! Elm St. Distric
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
Name (Print)
Signature
2.2 Authorized Agent:
Name (Print)
Signature
This section to be completed by office
Lot Unit
Overlay District
District CB District
.�_...�.�. D.Q.. p.�� ...__... � - �../�..,�..�... .
Current Mailing Address:
t 1 A-Ti- - 7 Ci AA n i nlh
Current Mailing Address
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit 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 = 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number I _ Date
Signature:
Issued
Commissioner /Inspector of Buildings I Date
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
a
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
1
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑
A -1
A -4
❑ A -2
❑ A -5
❑ A -3 ❑
❑
1A
113
❑
❑
B Business ❑
2A
2B _
2C
❑
❑
❑
E Educational ❑
F Factory ❑
F -1 ❑ F -2 ❑
H High Hazard ❑
3A
3B
❑
❑
I Institutional ❑
1-1 ❑ 1 -2 ❑ 1 -3 ❑
M Mercantile ❑
4
❑
R Residential ❑
R -1
❑ R -2
❑ R -3 ❑
5A
5B
❑
❑
S Storage ❑
S -1 ❑ S -2 ❑
U Utility ❑
Specify:
Specify:
M Mixed Use ❑
S Special Use ❑
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _,.....
Existing Hazard Index 780 CMR 34):
m _ ,., ,......_ __ _
_ ., ...,, ..._,._ , __:..N
. _.__
Proposed Use Group:
Proposed Hazard Index 780 CMR 34):
; _. .,__. ..
_........_.
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
Floor Area per Floor (sf)
PROPOSED NEW CONSTRUCTION
OFFICE USE ONLY
f
1 sc
2 nd
3 'd
4` h
Total Area (sf)
Total Height (ft)
1 St
4
Total Proposed New Construction (sf)
Total Height ft
7. Water Supply (M.G.L. c, 40, § 54) 7.1 Flood _Zone Information: 7.3 Sewage Disposal System:
Public n Private ❑ Zone „ „ , Outside Flood Zone❑ Muni ❑ On site disposal sys
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
a
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
1
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑
A -1
A -4
❑ A -2
❑ A -5
❑ A -3 ❑
❑
1A
113
❑
❑
B Business ❑
2A
2B _
2C
❑
❑
❑
E Educational ❑
F Factory ❑
F -1 ❑ F -2 ❑
H High Hazard ❑
3A
3B
❑
❑
I Institutional ❑
1-1 ❑ 1 -2 ❑ 1 -3 ❑
M Mercantile ❑
4
❑
R Residential ❑
R -1
❑ R -2
❑ R -3 ❑
5A
5B
❑
❑
S Storage ❑
S -1 ❑ S -2 ❑
U Utility ❑
Specify:
Specify:
M Mixed Use ❑
S Special Use ❑
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _,.....
Existing Hazard Index 780 CMR 34):
m _ ,., ,......_ __ _
_ ., ...,, ..._,._ , __:..N
. _.__
Proposed Use Group:
Proposed Hazard Index 780 CMR 34):
; _. .,__. ..
_........_.
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
Floor Area per Floor (sf)
PROPOSED NEW CONSTRUCTION
OFFICE USE ONLY
f
1 sc
2 nd
3 'd
4` h
Total Area (sf)
Total Height (ft)
1 St
4
Total Proposed New Construction (sf)
Total Height ft
7. Water Supply (M.G.L. c, 40, § 54) 7.1 Flood _Zone Information: 7.3 Sewage Disposal System:
Public n Private ❑ Zone „ „ , Outside Flood Zone❑ Muni ❑ On site disposal sys
t
Versionl.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
_._.._._ ._ _..
...,_ .............
,,._. _.
Fron
.. ,., .,.
,.
.._., .,, .. ....._. _ _ .. ........ .....
.. ......
Setbacks Front
Side
L. '., __,
R. ..__.. _
L. .. ..... .. R: '..__.._
Rear
Building Height
Bldg. Square Footage
_ _�
.,
- %
Open Space Footage
_, _ %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill:
(volume & Location)
�_ ........... .... ....... .
._..r._,�.,_..,. ,_. _...., ___
. __.,.... ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW 0 m YES w rn µ
IF YES: enter Book ; Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t
Versionl.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
_._.._._ ._ _..
...,_ .............
,,._. _.
Fron
.. ,., .,.
,.
.._., .,, .. ....._. _ _ .. ........ .....
.. ......
Setbacks Front
Side
L. '., __,
R. ..__.. _
L. .. ..... .. R: '..__.._
Rear
Building Height
Bldg. Square Footage
_ _�
.,
- %
Open Space Footage
_, _ %
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill:
(volume & Location)
�_ ........... .... ....... .
._..r._,�.,_..,. ,_. _...., ___
. __.,.... ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW 0 m YES w rn µ
IF YES: enter Book ; Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version L7 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:
Name (Registr
Address
Signature
9.2 Registered Professional Engi
Telephone
Not Applicable ❑
Registration Number
Expiration Date
Date
Name
Address
Address
9.3 General Contractor
Company Name:
Responsible In Charge of Construction
Address
Not Applicable ❑
Version L7 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:
Name (Registr
Address
Signature
9.2 Registered Professional Engi
Telephone
Not Applicable ❑
Registration Number
Expiration Date
Date
Name
Address
Address
9.3 General Contractor
Company Name:
Responsible In Charge of Construction
Address
Not Applicable ❑
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10 STRUCTURAL, PEER REVIEW (780 CMR 110.11)
Inde pendent Structural Engineering Structural Peer Review Required Yes 0 No 0
r SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
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
Print Name - - -•
of
SECTION 12 - CONSTRUCTION SERVICES
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.
Affidavit Attached Yes LJ No
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10 STRUCTURAL, PEER REVIEW (780 CMR 110.11)
Inde pendent Structural Engineering Structural Peer Review Required Yes 0 No 0
r SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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
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
Print Name - - -•
of
SECTION 12 - CONSTRUCTION SERVICES
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.
Affidavit Attached Yes LJ No
- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information � _ Please Print Legibly
Name ( Business /Organization/Individual): wetgf/? -
Address: /t � (Z
/Stat
Phone #: r14' L)
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
4. ❑ I am a general contractor and I
Department of Industrial Accidents
s
„ -=
Office of Investigations
d � , ",
600 Washington Street
These sub - contractors have
Boston, MA 02111
- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information � _ Please Print Legibly
Name ( Business /Organization/Individual): wetgf/? -
Address: /t � (Z
/Stat
Phone #: r14' L)
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
mployees (full and/or part- time).*
have hired the sub - contractors
2. am a sole proprietor or partner-
listed on the attached sheet.
s hip and have no employees
These sub - contractors have
working for me in any capacity.
employees and have workers'
comp. insurance.:
[No workers' comp. insurance
quired.]
5. ❑ We are a corporation and its
3, am a homeowner doing all work
officers have exercised their
[No workers' comp.
right of exemption per MGL
,myself.
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.X Other ��j ",({ /�"—
*An} applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
' 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.
7 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. Lic. #:
Job Site Address:
Expiration Date:
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 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 hereby certify under the painland p aloes o�erjury that the information: provided above is true and
X
Of 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 #:
- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information � _ Please Print Legibly
Name ( Business /Organization/Individual): wetgf/? -
Address: /t � (Z
/Stat
Phone #: r14' L)
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
4. ❑ I am a general contractor and I
Department of Industrial Accidents
s
„ -=
Office of Investigations
d � , ",
600 Washington Street
These sub - contractors have
Boston, MA 02111
- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information � _ Please Print Legibly
Name ( Business /Organization/Individual): wetgf/? -
Address: /t � (Z
/Stat
Phone #: r14' L)
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
mployees (full and/or part- time).*
have hired the sub - contractors
2. am a sole proprietor or partner-
listed on the attached sheet.
s hip and have no employees
These sub - contractors have
working for me in any capacity.
employees and have workers'
comp. insurance.:
[No workers' comp. insurance
quired.]
5. ❑ We are a corporation and its
3, am a homeowner doing all work
officers have exercised their
[No workers' comp.
right of exemption per MGL
,myself.
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.X Other ��j ",({ /�"—
*An} applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
' 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.
7 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. Lic. #:
Job Site Address:
Expiration Date:
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 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 hereby certify under the painland p aloes o�erjury that the information: provided above is true and
X
Of 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 #: