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32C-260 (36) The Commonwealth of Massathusetts • Department of Industrial Accidents 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/Individual): _ Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. Q I am a employer with 4. Q I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. ['Remodeling ship and have no employees These sub contractors have 8. Q Demolition working for me in aci employees and have workers' g any capacity. n 9. ❑ Building addition [No workers' comp. insurance p. insurance. required.] 5. We are a corporation and its 10.E Electrical repairs or additions 3. Q I am a homeowner doing all work officers have exercised their 11.Q 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.] *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 nder the pains and penalties of perjury that the information provided above is true and correct. Sisnature• , � �� Date: ,� l Phone #: SL:/(75 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 #: r . 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 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /—/A11.,Z ___ / 1 . ... ...... __ .._ .__ __... _ as Owner of the subject property hereby authorize ✓g j.. .1 ._. to act on my behalf, in all matters re tive to work authorized by this building permit application. 7_, — -- - - -- __+ /// ..-"e Signature of Owner y Date 1, i , ey,..___...Fe: ! ..._ ._.._.,__ ._.___..___...._._.,._,___.. .__....__ , as 5iiviwar /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 perdu A / Y . ' , 't_ . 0 .. _ ... ..s.. Print Na • - / ignature -r/Agent Date SECTIO 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: dge4 ' 7 r, ,.L . T / . /... Wirer.- •.,.. __. . ;./. 7 .& License Number / Address Expirati 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 . 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 Not Applicable ❑ Company Name: Responsible In Charge of Construction / / f ... % Address - Telephone Version1.7 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 m Frontage Setbacks Front Side L. ____._. R:— ... L., __.... R. _ Rear ._ _____ Building Height Bldg. Square Footage Open Space Footage ___. __,. % µ,_ __ . __ (Lot area minus bldg & paved m _.,. parking) # of Parking Spaces _____ (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regist of Deeds? NO DONT KNOW YES 0 IF YES: enter Book ° Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 0 NO G---- IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO IF YES, describe size, type and Location: E. Will the construction activity disturb (clearing, grading, excavatio r 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. , Version1.7 Commercial Building Permit May 15, 2000 • • SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 I 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 ❑ Othert] t ". Brief Description Enter a brief description here. 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 1 ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 1 2B i ❑ F Factory ❑ F -1 ❑ F -2 ❑ 1 2C ❑ H High Hazard ❑ 3A ❑ 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 ❑ J 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: ,...W S Special Use ❑ Specify� COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: _ _ ,, . _. ..__._ Proposed Use Group ,_m._.. 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 1st st 2 2nd nd rd.. _.. 3 4th 4tn Total Area (sf) Total Proposed New Constructionisf)_ 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 Zoneo Municipal ❑ On site disposal system • f • • RECEIVED Version1.7 Commercial Buildin& Permit May 15, 2000 � � De Eaten #use vnl City of Northampton S #atG►af er,�� 111/11 I 52011 am' o� 212 Main Street Building Department curb Cgt4rtufrw�I Pertf e,er�5ep #acrar a itlttj Room 100 vlia #erltilt/ U A all�r ttit l �tI A 1�� Kamm' nonntnu PTON.w►otaeo Northampton, MA 01060 Teo Sets o Structural PJans phone 413 - 587 -1240 Fax 413 - 587 -1272 PiaUSrte 1?lans Othet Spef�r '� 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 Map Lot Unit Zone Overlay District — .A. �. ., �_ , a. , 'EImSt.`District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Signature �"'- -- ' Telephone 2.2 Authorized Agent: Name (Print) Current Mailing Address Signature 6 . y - Telephone /4//)7 .� ` y7-' SECTION 3 - ES f ED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed 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 c ) 1 30 6. Total = 1 +2 +3 +4 +5 Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 1 dune 6, 2011 Louis Hasbrouck, Building Commissioner Office of the Building Commissioner Puchalski Municipal Building 212 Main Street Northampton, MA 01060 41.3 587 -1240 RED:: PC)MI ROY I IANCOCK CONDOMINIUMS, 90 Pomeroy Terrace Change of General Contractors - 1_'nit #5 Dear Mt. Hasbrouck, This letter serves to notify you of a change in status pertaining to construction on Unit #5 at Pomeroy Hancock Condominiums, 90 Pomeroy Terrace, Northarnpton MA 01060. General Contractor Al Martinbeault currently holds the building permit for improvements to this unit. Due to changes in his personal circumstances he is now unavailable to perform the work. A new general contractor, Harry Nett of BSI' Construction, has been hired to complete the work and with this letter will be submitting an application requesting this change to the building permit. Please on't hesitate to call if you have any questions regarding this matter. Sine ely, / titifi / Linda S. Muerle File it BP- 2011 -1052 APPLICANT /CONTACT PERSON BSF CONSTRUCTION INC ADDRESS/PHONE 18 GLENDALE VIEW DR HAMPDEN (413) 530 -9055 PROPERTY LOCATION 90 POMEROY TER MAP 32C PARCEL 260 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out l Fee Paid /��'� ✓vgJ� Typeof Construction: RENOVATE 3RD FLR UNIT 5 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 70668 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO$MATION PRESENTED: pproved 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 / Signature of Building 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. 90 POMEROY TER BP- 2011 -1052 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 260 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -1052 Project # JS- 2011- 001696 Est. Cost: Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BSF CONSTRUCTION INC 70668 Lot Size(sq. ft.): 23304.60 Owner: MUERLE LINDA & BURT EWART Zoning: URC(100)/ Applicant: BSF CONSTRUCTION INC AT: 90 POMEROY TER Applicant Address: Phone: Insurance: 18 GLENDALE VIEW DR (413) 530 -9055 HAMPDENMA01036 ISSUED ON:6/30/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE 3RD FLR UNIT 5 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 6/30/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner