18D-004 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
.
- tea r Office of Investigations
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/Individua1): R01/ Ytv' lap Isj
Address: 1 L pkc S 1-he; OT
City /State /Zip: i Phone #: 0
Are you an employer? Check the appropriate box: Type of project (required):
0 4. I am a general contractor and I
1C-Er I am a employer with ❑
employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
Y P h'• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.
3. ❑ I am a homeowner doing all work ffi h d h
❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' li. ❑ Other
comp. insurance required.]
*Any 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. -(� (��
Insurance Company Name: T kk 1 ��1
Policy # or Self -ins. Lic. #: 65 6 GU 6 - 9-1 , 0 r ) g6 ` 'O� Expiration Date: 06 16 C)
Job Site Address: F O N pc) City /State /Zip: ['icg `'1 MiptoI / 11p
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expitation 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 pains and penalties of perjury that the information provided above is tr and correct.
Signature: Date:
Phone #:
Official use only. Du nut 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 #:
- 1
, -. �
e
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CN1R110.11)
Independent Stru �� �� c�una|EnQineeringStruntuoa|PeerRevimwRoquined Yes \~� No v_/
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
("\r). - -
��
|. __-_el �/ ____ Owner of the subject property
.
hereby authohze� to
act behaff, in aU matters relative to work authorized by this building permit appflcation.
-`���r�. / . ��
-~ '/
s/^'am� mowno, \�/ Date
|.-___v .
Agent hereby declare that the statements and nform the and mo��� knowledge 6 ,
and belief.
Signed under the pains arid penallies of perjury. ,
R13 to-cl r'4 JA4.uo N\ . .. .. -
SliglsoP) _ _ , _ ,....,......, _ _ „
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Constru Su Not Applicable []
Name v, License Holder : _ / \ 0515147 License Numb
___ ___
�_-___[[ - /_/(-� __-______'--�
Address a / Exp�auvnoa� - fp -��
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION uRANCE (M.G.L. c.
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 buiWingpormit.
_ �I'd �_�-- �_�
G�nodAffidavhA�ached Yes No v_/
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Versionl.7 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:
Not Applicable
Name (Registrant): .w,
Registration Number
Address _ ..... ..:.... .. _
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration
g p Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
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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 . . _
Frontage
Setbacks Front '
Side L L :'
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 CO DONT KNOW 0 YES 0
IF YES, date issued: '
IF YES: Was the permit recorded at the Registry of Deeds?
NO (s.,,,) DONT KNOW Q YES C
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 Q Obtained Date Issued:
C. Do any signs exist on the property? YES Q NO 39
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 9
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t v. r
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition ❑ Repairs ❑ Additions Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. - g
f , 1
Of Proposed Work: IN\ AU U t y 5 tc t w G\
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 0 A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B I ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 0 R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify::.
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group: '
Existing Hazard Index 780 CMR 34): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P r o p o s e d Hazard Index 780 CMR 34): _.m_.__.__ __________ ._
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1 st
1 st
2 nd
2 „d
3rd 3rd
_..._.._ . 4t
4'
Total Area (sf) Total Proposed New Construction (sf),____
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone _„ , Outside Flood Zone Municipal 0 On site disposal system E]
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Versionl.7 Commercial Building Permit May 15, 2000
3 Departmept use only
City of Northampton Status of ger. rlit
1
Building Department Ciirb"CutUDi veway P
_ __ _ 212 Main Street seterlSeptic9fluailal5tlity
Room 100 WaterlllleltAvallabillty
AUG 1 9 2009 Northampton, MA 01060 Two Se of S tructu r al , Plan ,:'
phone 413;- 587 -;1240 Fax 413- 587 -1272 Plot/Sit Plan
.
Othe Specify
APPLICATION TO CONSTR&CTTREPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION'
This section to be completed by office
1.1 Property Address:
1 C)% Map Lot Unit
r .,) ('‘(Y)101.\) R /�,i\l) Zone Overlay District
_.._..__ q - `�.,._. _ I Q 0 \ ROT1U, • i Elm. St District CB District
N
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
001 u m mK : tall: �.m.:C ( - __. ________,A,,,,, �� ? - . .
Name (Print) Ai Current Mails Address:
N - � . . . C?.
IV Signatu e d',... 2. _ Telephone 1' �o75
2.2 Aut • rized A. ent
" 4 ' itk Al
Name (Print) Current Mailing Address
, 1- .. .� „c),,\5, '41,,,._,. _ ..
Signature � I i �d Telephone q I3 531 'u 6`4 k
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
- completed hypermit applicant
1. Building �� " ( a ) Buildin Permit Fee
2. Electrical ;b) Estimated' Total Cost of
Construction from (6) ._.._,,..„ .....
3. Plumbing 'wilding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) ,eckNumber —
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
) :
BP- 2010 -0194
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- 2010 -0194
Project # JS- 2010 - 000237
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT ARDIZZONI 051547
Lot Size(sq. ft.): 87120.00 Owner: MOCK WILLIAM D & EVELYN F
Zoning: GB(100) /GI/ Applicant: ROBERT ARDIZZONI
AT: 108 DAMON RD
Applicant Address: Phone: Insurance:
7 LAKESHORE DR (413) 531 -4841 WC
HOLLANDMA01521 ISSUED ON:8/19/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 8/19/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo