18D-059 •
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New non - bearing walls
199 Industrial Dr,
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self- insured companies should enter their
self - insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit /license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Fax # 617- 727 -7749
Revised 4 -24 -07
www.mass.gov /dia
,
The Commonwealth of Massachusetts
i- Department of Industrial Accidents
B -,?x
' i '''''' \-' — 1 :''' 4' ' ' -17'! Office of Investigations
600 Washington Street
s Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization /Individual): 7/si y G ,fit Jv(1 q Co r.>fT, ueT, J
Address: v ' ✓0o,j>N L L 'PA .
City /State /Zip: ,t6;.4.,,..'c e, , ,M ✓A 0104 L Phone #: 9/ 5' - 34 " 3 - 9e' y z
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 1
employees (full and /or part- time).* have hired the sub - contractors 6. Ill New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working ca employees and have workers'
g for me in any capacity. Y . 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3 . ❑ I am a homeowner doing all work officers have exercised their 1 1 . 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 ,,,i7 +Y Au s
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.
il 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 pains and penalties of perjury that the information provided above is true and correct.
Signature: 2 ' .rte Date: 3/i 7/ /o
Phone #: 1/ 3- 30 3 — ?o 9 Z
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 #:
•
Version I.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
Edward Dzenis , as Owner of the subject property
hereby authorize Barry R. Cohen to
act on my behalf, in all matters rela ive to work authorized by this building permit application.
fie—` c 03/17/2010
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 under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder Barry R. Cohen 5639
License Number
40 O'Donnell Dr Florence, MA 01062 07/09/2011
Address Expiration Date
(413) 303 -9092
Signature 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 0 No 0
Version I.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):
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 Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15. 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be tilled in by
Building Department
Lot Size 87120 sq/ft N/A
Frontage 246' N/A
Setbacks Front N/A
Side L N/A R N/A E: R:
Rear N/A
Building Height N/A
Bldg. Square Footage N/A N /A %
Open Space Footage
(Lot area minus bldg & paved N/A N/A
parking)
# of Parking Spaces N/A
Fill: N/A
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T 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 Date Issued:
C. Do any signs exist on the property? YES (3 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.
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 ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 0
Brief Description Erect interior non - structural walls.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1 B ❑
B Business 0 2A ❑
E Educational ❑ 2B I 0
—
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R -1 ❑ 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): 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)
1 24,600 15,
2 nd 2
3rd 3rd
4th 4th
Total Area (sf) 24,600 Total Proposed New Construction (sf)
Total Height (ft) 20
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 151 On site disposal system ❑
i }
Version 1.7 Commercial Building Permit May 15. 2000
Department use only
City of Northampton Status of Permit:
i°' Building Department Curb Cut/Driveway Permit
\ 1 X 212 Main Street Sewer /Septic Availability
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, 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: This section to be completed by office
195 industrial Dr Map Lot Unit
Northampton, MA 01060
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Yankee Wood Inds., INC. 195 Industrial Dr. Northampton, MA 01060
Name (Print) Current Mailing Address:
(413) 584-4124
Signature � -- — Telephone
2.2 Authorized Agent:
Edward Dzenis 131 Cape St Goshen, MA 01032
Name (Print) Current Mailing Address:
(413) 268 -0231
Signature _ _. n/ — • _ Telephone
SECTION 3 - ESTIMATED CONSTR CTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $10,000.00 (a) Building Permit Fee
2. Electrical $5,000.00, (b) Estimated Total Cost of
Construction from (6)
3. Plumbing $0.00 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection $2,500.00
6. Total = (1 + 2 + 3 + 4 + 5) # 17 5S o.va Check Number 6.(1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0809
APPLICANT /CONTACT PERSON BARRY R COHEN
ADDRESS/PHONE 40 O'DONNELL DRIVE FLORENCE (413) 303 -9092 Q
PROPERTY LOCATION 195 INDUSTRIAL DR
MAP 18D PARCEL 059 001 ZONE GI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,
Fee Paid off /f 116—
Typeof Construction: ERECT INTERIOR WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 005639 r •
3 sets of Plans / Plot Plan P 126 'DOT i f;1Jc F F f? Q ptoo R p, f 1.ov,.
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFpRMATION 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
A14'"A--'/1" / 17 /10
Signature of Building Official Date
g g
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.
t �J � 0✓ (7_41-44;G4043
195 INDUSTRIAL DR BP- 2010 -0809
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 059 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-2010-0809
Project # JS- 2010 - 001191
Est. Cost: $17500.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BARRY R COHEN 005639
Lot Size(sq. ft.): 87120.00 Owner: YANKEE WOOD INDUSTRIES INC
Zoning: GI(100)/ Applicant: BARRY R COHEN
AT: 195 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
40 O'DONNELL DRIVE (413) 303 -9092 0
FLORE NCEMA01062 -3525 ISSUED ON:3/18/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT INTERIOR WALLS
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: 7; - 1 G House # Foundation:
P Driveway Final:
Final: Final: `� 0
( P-M' Rough Frame: dK 31 Cocq, s
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Ot< 03 J rQ its
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO , ION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancys73 /ia f Signature: -
FeeType: Date Paid: Antcal
Building 3/18/2010 0:00:00 $105.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo