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25C-251 (40) The Commonwealth of Massachusetts Department of Industrial Accidents h " Office of Investigations r:9 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): L au re y. j c " l L v 6 Y• Address: City/State/Zip: e - (1f J'C`° #: � �c��(' c Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t /equired.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. Other employees. [No workers' Sip comp. insurance required.] *Any 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: 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 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 pai and penalties of perjury that the information provided above is true and correct. Date: [lL Phone #: (it 3) 32o- 3b'•1 e 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 #: SECTION 8 - CONSTRUCTION SERVICES t r 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone ` me • isfererl , 1ome_lm . r•verner ontractor. =„+` " # a ..r . ;� � � A ��" ,. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION _ '10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L c x152, § 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 ❑ LE,4 o o uon The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 1083.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside; on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zo ' g Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) n Roofing i l Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [ j Other [DJ Brief Description of Proposed • Work: ► wl t j f\ p F vu N St. Alteration of existing bedroom Yes No Adding new f5edroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa ILN w,,house.ar d.or addition.to;existi.nq housrnq. comta eteAherfoihiwirii a. Use of building : One Family Y Two Family Other b. Number of rooms in each family unit: b Number of Bathrooms I c. Is there a garage attached? ICES d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? b'$ , A - / (.b f A ntL Fireplaces or Woodstoves YGS Number of each 1' g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction U ..a.cx i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? > Yes No . I. Septic Tank / City Sewer Private well City water Supply -SECTION 7a OWNER. AUTHORIZATION TO BECOMPLETED WHEN OWNERS AGENT OR CONTRACTORiAPPLIES FORBUILDING PERMIT I, , as Owner of the subject property hereby authorize to act on my behalf, in all matt s relative to work authorized by this building permit application. 9 - 2Z —J( Si nature 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 under the pains and penalties of perjury. Print Name Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Information a 4 b Existing Proposed Required by 'Loping ;: +.'" This column to be filldl in by Building Department I{ I i •, Lot Size ? i 1 p Frontage Setbacks Front j i Side L: R: L:i . i R:3 I 1 1 Rear 1 i d Building Height 3 a Bldg. Square Footage i 1 % f—" 1 1 Open Space Footage (Lot area minus bldg & paved 1 i r— I I = i 1 parking) i 1 i I i # of Parking Spaces Fill: __ _.___.___. _ __ _. __ . .___ __ (volume & Location) ' f A. Has a Special Permit /Variance /Finding ver been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page; and /or Document # B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW C YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO lr 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 IF YES, describe size, type and location: ' E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . RECEIVED Cit of Northampton S - tr i of P . Buildin Department City Cr ® ear . errn k �' sEp 2 3 all Room Main Street S. t.rA ep is atlat � � , Room 100 t►a er. e t y a'1 a bit 1 r a v �a , g te �s , � - ..2,- . Northampton, MA 0 4 1 1 0 3 6 -5 0 87- -,,tit!-, cr e _ Str` c al Patts� f4iEFT OF6UiLDIN P � 58"1 -1240 Fax 1272 F d i t $ P ' 3 NO ' `� i k® h et "peclfx , �t » b APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- " INFORMATION k Thrs sectr t o be completed lay office , 1.1 Property Address: a;'4 x � , � ( }'� � - N' t.^;`x}y -Pfeg A -« ' e 7 k 'fi ,,,, : .4i t ` g Z eY ` ` - 4* . n t L vx , 9 t+t . 4 hi rL ■ C L M �� OyerlarDistri c / � 'r w" g Y s:.. � ;^ :e°e. .' mt, A„„�, rr a 1 s . �' x �i � 3'Etm St District . . CB District SECTION 2 P R OP ERTY . OWNERSHIP /A AGENT 2.1 Owner of Record: r - A�)t'e..) �1���s011 1.Z cA,twAY pit. 9�Teoce, IA-v atoG2 Name (Print) C went Mailin Add ss: 61 Ca Te ephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 = ESTIMATED CO COSTS Item Estimated Cost ) to Official Use Only completed by permit (Dollars applicant be .. 1. Building °Q "(a) Building Pe :, . L' i miitFee x,36". 2. Electrical (b) Estim Total Cost of : , Constru fro (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: Issued: Signature: Building Commissioner /Inspector of Buildings Date a 22 FAIRWAY DR BP- 2012 -0294 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 44 - 047 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2012 -0294 Project # JS- 2012- 000477 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 17031.96 Owner: HICKSON LAUREN Zoning: SR(100) //WSP II Applicant: HICKSON LAUREN AT: 22 FAIRWAY DR Applicant Address: Phone: Insurance: 22 FAIRWAY DR (413) 718 -6162 0 FLORENCEMA01062 ISSUED ON:9/26/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE VINYL SIDING 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 9/26/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner dab X28 I ARADISE CITY ARTS ffjTIVAL I� x 15/ Li- 4 NORTRAMPTON, MA Gate 2 I OCT 8,9 10 2011 NORTHAMPTON'S FINEST RESTAURANTS ! ! ' Live Festival Dining Tent Jazz MORGAN BUILDING #2 4 Wine I e 1 ( 191319151 1 1 1 1 ( gp3 907 19091911 919 921 19231 192719291931 933 935 93919411 401 1403140514071409 1 413 141514171 1 419 421 901 943 12' — 9 00 904 906 19081910 912 916 19201 922 924 926 930 932 934 936 938 942 1 140014021 404 140614081410141214141 Museums 10 ( 805 80718091 811 813 817 18191 821 825 827 831 833 835 837 839 6' 8 00 804 1 808 810 812 816 818 18221 824 826 830 832 183418361838 842 3CU .PULE GARDEN — — 5 701 705 17071709 711 713 717 719172117231725 727 731 733173517371 739 743 1 6' 704 1 7061708 710 712 7161718 720 7241 726 730 732 734 17361738 130113031305130713091311131313151 317 1 319 11 601 605I 607 1 609 611 613 617 621 ( 1 623 825 631 633 635 637 639 643 12' 600 642 (1300130213041306130813101 312 1 314 13161 318 604 1606 608 610 612 618 618 620 1 624 1 626 630 63216341 636 6 ' 501 5051 507 509 511 513 517 519 5211 523 15251527 531 533 15351537 MORGAN BUILDING #1 5 0 0 1 I 50 I Silent Auction Tables 3 C li° �� l SHOW [ OFFICE 1 1 1 2011203120512071209121112131 215 1 217 721912211223 H2331235123712391 241 1 243 1245124712491 251 1253 202120412061 208 210 :121412161 218 220 232 1 236 240 2441 246 248 250 252 103 110511071109 111 115111711191121 123 Exhibitor 1311 133 1 137 139 143 1145 147_149 151 REGISTRATION 1-1 1001 102 1104 106 108 110 1 114 1116 1181 120 MAIN J 132 11341136113811401 142 11441146114811501 152 EXHIBITION TENT GATE t 10. Do any signs exist on the property? YES NO IF YES, describe size, type and location: Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: 11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan of development that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This colzrmn reserved for use by the Building De • a.rtment EXISTING PROPOSED Lot Size Frontage • Setbacks Front Side L R: L R: • Rear • Building Height • Building Square Footage % Open Space: (lot area minus building & paved = arkin.. s of Parking Spaces # of Loading Docks Fill: (volume & location) 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. _ /ate: z 4 ... 1 AppIicant's signature Li t, �..�: 4d . /i-o NOTE: Issuance of a zoning permit does not relieve an appli.:. is burden to comply with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Historic and Architectural Boards, Department of Public Works and other applicable permit granting authorities. w:\Docume unFORMs\ori6zures:::d in_- :-.-tt rzon. ^.2 P it- 4:?oii=on- passivcdoc 8 /4/2004 FEE$ 25, 00 /tent RECEIVED : SEP 2 6 2011 File No. T � Please type or print all information and return this form to the Building Inspector's Office - 'check or money order) payable to the City ofNor thampton / Name of Applicant: P!- g-ADtSE C t ri AR; rJ f ,S TI V P L ,Address: 30 - S"�LLSATP► 4 1 Ca / Telephone: 60 SI I -9 7 Z S ✓L. Owner of Property: 3 Co td'i ' oo rsvy x/vt Address: 0 FeA /'r.) O0 Telephone: J 1- 7 3. Status of Applicant: Owner l Contract Purchaser Lessee Other (explain) /4. Job Location: 3 C) \I ' 5 tl l r/ QtJY► ... f. �� Existing Use of Structure /Property: LIST EVENT p 1)15 ( C 1'1" 1 AIL f iS j VA l-- • 6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary): LIST DATES OF EVENT NO OF /SIZES OF TENTS • I SX 1 c 4'0 x 27-0 tp 0)C 3 WHEN TENTS READY FOR INSPECTION 111 J+(\ CPC-* 7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans 8. Has a Special Permit/Variance/Finding ever been issued for /on the site? NO DONT KNOW V YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document 9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , date issued: (Form Continues On Other Side) W:1130 ---..0 sF OFu iS,": arR rE .tr- ectorzoi i rse Penn+- ?*7pii=ion- pasive.doc 8/42004 FAIR ST - FAIRGROUNDS BP- 2012 -0298 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 251 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Tents BUILDING PERMIT Permit # BP- 2012 -0298 Project # JS- 2012 - 000485 Est. Cost: Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): Owner: HAMPSHIRE FRANKLIN & HAMPDEN AGRICULTURAL SOCIETY Zoning: Applicant: Paradise City Arts Festival AT: FAIR ST - FAIRGROUNDS Applicant Address: Phone: Insurance: 30 INDUSTRIAL DR EAST (413) 587 -0772 0 NORTHAMPTONMA01060 ISSUED ON:9/27/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: ERECT 15 X 15, 40 X 220 & 60 X 300 TENTS PARADISE CITY - 10/8 - 10/12/11 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 9/27/2011 0:00:00 $75.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner