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steel door I � 1 : [:
Y
1 4 & frame walls
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#, i s 'i 1/2" /2" drywall ` �
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■ :/ 1 common brick walls . _ - 1
6 t1
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r ' 11 Changes salon 157 Main St Northampton
li 1 ; proposed work on existing basement room
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? existing wall . 1 -�G v e S ` C('(''q cf, r.L(
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•
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
I request that you grant a modification to waive the requirement for control construction for the
project at 157 Main Street in Northampton because the work is of a minor nature, will not affect health,
accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control
construction is considerable when compared to the cost of the proposed work. Thank you for your
consideration.
Respectfully,
..‹------ 4 .., - P/
)07=1/ (. /
ry Avery r
Avery Renovations
40 Aldrich St.
Belchertown Ma. 01007
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800) 876 -2765 NCCI NO 26158
POLICY NO. AWC 7016282012011
PRIOR NO. AWC 7016282012010
ITEM
1. The insured Avery Renovations Inc
Mail Address: 40 Aldrich Road Belchertown MA 01007
Street No. Town or City County State Zip Code
FEIN 65- 1211856
❑individual [Partnership IDCorporation ['Joint Venture ['Association ❑Other
Other workplaces not shown above:
2. The policy period is from 01/02/2011 to 01/02/2012 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per $100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 338760
SEE EKTENSION OF INFORMATICN PAGE
Minimum premium $ 500.00 Total Estimated Annual Premium $ 500.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 500.00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA Assessment Chg.
$291.00 x 6.8000% $0.00
This policy, including all endorsements, is hereby countersigned by 12/23/2010
Authorized Signature Date
GOV GOV KIND PLACING CLAIM NAME SAFETY J Raymond Lussier Insurance
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Agency Inc
MA 5403 2 707 P 0 Box 499
West Springfield, MA 01090
WC 00 00 01 A (11 -88)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
The Commonwealth of Massachusetts
Department of Industrial Accidents
= „+ t� Office of Investigations
I
= •
60 Washington Street
Boston, MA 02111
., www. mass. gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Nalne ( Business /Organization/Individual): A vec y c o a ti G vi i S --l-- I, I l :
• Address: 1 AI (,(f r C S''f .
City /State /Zip: fl t % (t it t i^ /0,„)v1 Ak,, 0 & f Phone. #: 1 i l 7- 3 Z 3 -id / O
•
Are you an employer? Check the appropriate box: Type of project (required):
1.V] I am a employer with / 4. D I am a general contractor and I 6. ❑New construction
• employees (full and/or part-time).* have hired the sub-contractors
2. ❑ I am a 'sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition .
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions
3. [l 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 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
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.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. /
Insurance Company Name: i o LI
Policy # or Self-ins. Lic. #: _Ai 4 t..✓ C. 701 6 4 Expiration Date: I 4z //L
Job Site Address: ($ 7 ,N 1 c, t n 5 r City /State/Zip: 4 44 4 h <p,e/r i l /�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratIt n 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 ag. inst 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.
1 do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct
Signature: -0 (5 Date: /2/1 U/ /
Phone #: )4 i S ' 3Z 3- / 6f d
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 CIerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person: Phone #:
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 5 euf ^- St G it ( , as Owner of the subject property
hereby authorize Te )/ 1 (1 (,)(77 to
act on my behalf, i all m ers r- . . to work authorize8 by this building permit application.
Signature of Owner Date
I, / "Z f r y
Ave( j/ , 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.
7 Z r r y
Print Name /
L(Zcr/ t
Signature of Owner/ Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
f
Name of License Holder : f r r y v fib' y C I 021
License Number
o A Sfi e fcti tc -4,41 c tool )/2 ? be_
Address Expiration Date
14 13 -37 2376
Signature V Telephone
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.
Signed Affidavit Attached Yes No
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 ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. 1 'rK,,, 4 . G tr i GA. ✓1/41 5 L f (.1,-,L k 3 'v" /15
Of Proposed Work: (`11 tt. Vi rV6 Tlnl�1 / 64re Cn'( rev vii
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A-4 ❑ A -5 0 1B ❑
B Business 5 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B l ❑
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): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
151 1si
2nd 2 nd
3rd 3 rd
4th
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 ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
E EIVED
City of Northampton ,
Building Department
tit '2. I 2 011 212 Main Street
Room 100
WILDING INSPECTIONS ampton, MA 01060
DE FroN mA
413-587-1240 Fax 413-587-1272 „ r v: 3,
r
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOUSH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELUNG
SECTION 1 -SITEINFORNATIC*1
IhisseCtilotito becoll~bY office,
1.1 Property Adcbess:
Unit
5.- ill Map t
,tIo r1hrP1l zone averfavasbict
SECTION 2 -PROPERTY OWNERSHIPIAUTHORIZED AGEPIT
• _
S oose)&0/ be_
Name (Print) Current Mailing Address: ..g/24,7„,, -; -
414 ■itil
Snake __ TephoneL/)777d
4111
2.2 Authorized f Age _.. ijA. Tit e ,
'Jr ry a „tic.
Name (Print)
Signature Teeone Hf3-37' 1 - Z7 7 C
'd I a 127 C ;:k ,••.13-40 els!. TS
Item Estimated Cost (Dollars) to be Official Use only
completed by permit applicant
1. Building (a)Bulding Permil Fee
2. Electrical • (b) Estimated Total Cost of 4
Consttuctionfroni (6)
3. Plumbing Buliding permit Fee
,
4. Mechanical (HVAC)
5. Fire Protection .
6. Total=(1+2+3+4+5)
ch N um b er di? 55 5
This Section For Official Use Otdy
-
Building Poiret Number Data
Issued
Signature:
Building Commissioner/Inspector oft3u1kdings Date
File # BP- 2012 -0593
APPLICANT /CONTACT PERSON TERRY AVERY
35X K ro
ADDRESS/PHONE 40 ALDRICH RD BELCHERTOWN (413) 323 -1010
1 5 5 /15 7
PROPERTY LOCATION 157 MAIN ST NI'pt4
MAP 31D PARCEL 144 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out n j
Fee Paid 0 /
Tvpeof Construction: FRAME OUT & SHEETROCK 3 WALLS IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 59029
3 sets of Plans / Plot Plan
THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F 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 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
. i r pri b el - ,.-.... .._
fi r, l ,� L /' 2
.! . 1 e ofuilding 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.
157 MAIN ST BP- 2012 -0593
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D - 144 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0593
Project # JS- 2012- 001021
Est. Cost: $5500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TERRY AVERY 59029
Lot Size(sq. ft.): Owner: SICLARI STEVEN
Zoning: Applicant: TERRY AVERY
AT: 157 MAIN ST
Applicant Address: Phone: Insurance:
40 ALDRICH RD (413) 323 -1010 WC
BELCHERTOWNMA01007 ISSUED ON:1/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: FRAME OUT & SHEETROCK 3 WALLS IN
BASEMENT
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 1/3/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner