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T I Ott P . 07198 .,�• •�•,.u�.., 14.1U +aoJooYuut 4131200ft i-mtsE 07/09 The Commonwealth othlessaelracsetts Department oflnd Jn j4JAccidents Office ofInvesfigetj.as 600 WeskiagroR Street Beam, 2'S/I 02111 ' 1 warn utes.govldia Workers' Compensation Insnraiace Affidavit: Build err/ Contractors /Electrjciaasll'Iu, ers App can' Infarmstloe Please Print L.eaIv Name euroIyeeiaaowisdiviikon: 1/ 1a it. !a .Address:_eQ Ci /State/'' • _ , s 1! ' 1 / Phone #: .-. , 3 &C) Arejou an employer? Cleat the appropriate box: Type of project (required): I. ( 1 am a employer with. 4* 4 . 0 I am a general contractor and 6. ❑ New coortn crion es'rrployxs (Pall and/or pate - tone).* have hired the nub -maes n 2. ❑ I am a sole peopdetor or pastier listed on the attached sheet, 7. [ e�e000deliag ship and have no employees These sub - contractors have S. Q Demolition working far rat in any capacity ettelltrYees sad have workers' 9. f)tti addition [No wnsl:is' comp_ insoranee comp insurances 10.0 Electrical repairs 05 widow , l 5. 0 We m a corporation and its officers have easseiscd their 11, 3. ❑ [ am a hotncowoer dam all work officers Plambhag moir6 or additions • myself: ;No workers' comp. rigid of exertrion pet )401.. 12. J Roof repairs mum= required) ' c. 152. j3(4), and we have ao 13.0 Oehar employees. ("No ' c insolence requQed•] 'Amy appeiwel dot chats boa in rwust am fit oat en widen Wow sawn tsar maws' oaruanastion polity ivvarnneoe. • tiomoaween who saber: aril i davit adastag day we deist aU week sid tea bite aoeide soetraoess must admit s Crow d5dawt *dead,'5 sent. :Cayman Mast otter// *is as vane wsaod ao adaritro a menu/ stowiaa t bo sae eta tab.eaattsears ad wale *War at see eat atlas have m1400)mea. Yale nt•eeeeuwrs bun capsoye+ts, dray must pavrids d c* vo+kas' coma policy matte. I era an ash ok}nt' gloat ispirialbig WIrkere crapensatian brsarraaee fir my a pleyees Selma is the pd icy aa/Jo8 she btferraedeet 1Y'psf Firms 'f�5.Iw1t 0 Insurance Connally Name fee , self-trns. I.;c. tk-Me Ge 1Ji2 A Ole? cot E p aaan Dale' 01 1$109 l o b Site Address... ,1 - ._t ►, r . s � r . atylStabw'zip:FiffeA t , mLj Amuck a copy of the workers' compeasatioo policy dedaretion pave (slowing the policy number and esplration date). Failure to secure coverage as requited under Section 2SA. Mt c. 152 can Iced to the imposition of crW aal penalties of a tine up to $1,500.DO and/or one-year immiscathenr. as well as civil penalties in the form of a STOP WORK ORDER and a fine oI up to 1250,00 a gay against the violator. Be advised that a copy of this statement may be forwarded to the Office of leurarriptioncriftheDIA torte I to keaeby aaip wader the s4 u1►p...jury /lent At belo wales prarril4d ebrsrt is teat and correct Pulls ft ` Official war oat,.. Do nor prone is Skis are to be complied by dry cent,* official 1 City or Toter _ . Permit/License lulling Authority (circle one): 1. Board of Health 2, Ending Department 3, Cityrfown Clerk 4. Electrical Inspector 3. Plumbing Inspector 6. Other ---- Contact Perm., Phone di 1 of 1 10/5/2009 11:36 AM https://www2.ny.accessline.com/tw2fteleweb?uifwa=converUpeg& Fax page • Page: 2 - paint fa ROT= 1 non so! wig liFt .j - Tv P OCT-01-2e09 10:37 SPLOOret CONSTRUCTION )JAL*. 06/08 oliouArro *t.1.01, ULU V1111111131.7 Consectcia1 Staten Piro* May 15, 2000 8E471041W STIttICTIJML 116;11) trvittOendentStructovel • • Pt Reek* Yes 110 sio SE '47" T 5 OWNERS AGESITaket*MUCTOR APPUES TOR itteXifflainniar a _ -- – . es Owner of das subject propert my tentis. In al matters - to . authorised by this butting permit aoptcation. _ 4 , . (%) - - taS Ovmen'Autrarted Agent hereby retr.iare at the ramerterms and information OP the Weeding eopactaion are eve and accura°41. to the UM Of my laneweelge and beee. • 5 itffild.W0f-tIn *If NItztervatig_9!-PeAgri.:,-. %an Pere --,--.— Sonatas cd Orineineent pea 11‘011014 12 •CCIN51101C110,1 8R'I stmessam • Not Aecticablet D mey Name of Llama *Vs - 41 - It.. Za t i a q: 40==.1.....catuant. ; ; Unfat Numbs( p . Expiration Ws it/ hit NO/ 04 sons: I SE '41 **cgirceijimusA 103;r0Aitkatiki.'%*1 • • . • .- _L.tr r""!.: mows Comore; Gen trourance efadeve must be completed and sobnatted tms asdatation. Patiam to provide line affidavit MO . Stoned Madera Pat ched Yes 10/5/2009 11:35 AM 1 Of 1 Fax page ~t ~ - v ~~------------'- ' - .. . Prirr ' pmoe: 1 -�m� ��z s wLoc»ns/ CONSTRUCT ION 4....0147.10,42 p.m�«� rAut. tow too -' ` v*rsion1Jcoamanauaill &Aida* Parma May o5, 2000 SECTION S- 9- RIN/NSlied Architect MAIMS ._ ~ __~~__..____- _~~_ - j . Nsoir Arse et Nezoonetiley �- -- � � � _~--_ � _-- __ __� mows ' - �� / ----- �� F -' - ---'-��_ � � e=matlonmmw -- ____ 1 . _ ..... ' ' - --_ Woo . -- _-'-___ �~_�___-~_.__�-_� '_ _-__-. .._~_~ �=_� ' . ---'___ --_- Aftela - ~~~ ' / _t f ___~___~-'_-.__ — '- ' =- '' Dow - ' ___ , -__ _ Ana or ReeestioNse Norm -_~~___-- . ~�-��— ration Hoene - ' 1 _- _-_~_____~� mu of Plesowsibalv • -- -_- _- - __- ^ L - Nerve —~ -----._~-� � ____ _ � ._.~_J • mw�r� . . km~~_~-� ~ ' Noi»gyiltaiii ti ' --- _ , _ i '. ____ `� `' �� — �� °�� . / w • 10/5/2009 11:34 AM The Commonwealth of Massachusetts Department of Industrial Accidents — Office of Investigations �, 600 Washington Street w • • Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. 111 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 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. 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. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r 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.theDIA 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: Dtit%: Phone #: 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 #: tib Versionl.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 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 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 :_W _ .M_y_. - . License Number Address Expiration Date 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 • Version1.7 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 _. __ ...._ ..__r_,._ ...._..._._ Not Applicable ❑ Company Name: p Res onsible 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 filled in by Building Department Lot Size Frontage Setbacks Front Side 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 (3 DONT KNOW (0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 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 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 cornr)1011 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. - , , 4 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 0 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: rr SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 0 A -2 ❑ A -3 ❑ 1A I ❑ 0/' A -4 ❑ A -5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ 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 0 R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Spec M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE 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 1 st St 2nd 2 nd .... .. 3rd 3rd . .... _ ..... 4 th Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water S ply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage D' posal System: Public Private 0 Zone Outside Flood Zon Municipal On site disposal system le- Version1.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton ' ' -- - , , ,. „ , , , ., status of Permit r Building Department curb cut/Dmreway P - � 212 Main Street S e w er Sep Av arlabrlrtiy NO[tha ton , 100 W A n _, / - � Roorr� p AM Two Vets of ell S truc ailabili Plans ° " p hone 413- 587 -1240 ax A 01060 413- 587 -1272 Piot/Site Plans . O tper Specif 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 /e, /6 q Ac [- Map Lot Unit Zone Overlay District -.... ..n.... Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address clip . , Q 1 r 71,E 1, r.�. it4P i Telephone 7 c.c'-5---S C1' U(� Signature i1. i eti.' d tlJ�i�t' it. p m/ � _/ 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only corn eted by permit 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 = (1 + 2 + 3 + 4 + 5) Check Number /f 2/ t1,5 — This Section. For Official Use Only Building Permit Number Date Issued Signature- Date Building Commissioner /Inspector of Buildings File # BP- 2010 -0377 APPLICANT /CONTACT PERSON SALOOMEY CONSTRUCTION ADDRESS /PHONE P 0 BOX 1203 WESTFIELD (413) 269 -4360 PROPERTY LOCATION 267 LOCUST ST MAP 23B PARCEL 008 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid /a/ A, Typeof Construction: RENOVATE REST ROOM SUITE R6C New Construction Non Structural interior renovations Add ition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 018780 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: p proved 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 - iV/ -;P./ _.'*' ___//-C,C1 i Signature of Bui ing 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. 267 LOCUST ST BP- 2010 -0377 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 008 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0377 Project # JS- 2010 - 000500 Est. Cost: $4400.00 5 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: :,Contractor: License: Use Group t `SALOOMEY CONSTRUCTION 018780 Lot Size(sq. ft.): Owner: CAHILLANE STEPHEN & W WOOD Zoning: Applicant: SALOOMEY CONSTRUCTION 471- 267 i OCt IST ST Applicant Address: Phone: Insurance: P 0 BOX 1203 (413) 269 -4360 Workers Compensation WESTFIELDMA01086 ISSUED ON ::10/7/2009 0:00:00 TO PERFORM THE FOLLOWING WORK :RENOVATE REST ROOM SUITE R6C 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 .1(� $ ou • h: /Ql� 1 C1 House # Foundation: v 6 Driveway Final: Final :1 Final: i �� / /i,a3/ q Rough Frameer 10 .o C' "0 ` - -t 7 Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 0K 1(1/to ,.o145 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. -tea" „ Certificate of Occupan� Signature: FeeType: Date Paid: Amount: Building 10/7/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo