39-041 (4) The Commonwealth of Massachusetts
• Department of Industrial Accidents
Iv) 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. ❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. [1] 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
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 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.] l
*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 co py 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 ofperjury that the information provided above is true and correct.
Signature: Date:
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
11 Contact Person: Phone #:
•
•
Versionl.7 Commercial Building Permit May 15, 2000
J
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required • Yes 0 No J
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,_, . .a, .�__. _ d._.., _ _., as Owner of the subject property
hereby authorize A.. . .._ ..
act on my behalf, in all matters relative to work authorized by this building permit application_
Signature of Owner ''/ 7i Date i `�
'ms / (J
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 andpenalties_of per._ _
Print Name _ ____ .._______ ,_.., ._..
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
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
Version1.7 Commercial Building Permit May 15, 2000
J
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 ENSLOSED SPACE)
9.1 Registered Architect:
___..... _.__._...._.__ _..._._,...._._... Not Applicable ❑
Name (Registrant): . ._._.... __ ___________.._...__..____...
. .
....._ - _µ w_m_�
Registration Number
Address
Expiration Date
Signature Telephone
9:2 Registered Professional Engineer(s):
.... _.._.. F ___, -. .... _ _....
4
Name Area of Responsibility
q r/ cl TJ C3'.F7) ." e C.... 2 c _.. f C k._ .... :.. _
Address _ Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address . Registration Number ______ _
Signature Telephone Expiration Date
Name Area of Responsibility w .
i
Address Registration Number
w
Signature Telephone Expiration Date
_,. .. _ _ _..___ . _m
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
._ ..__ _,._ . _. .__.__ _.__= Not Applicable ❑
Company Name:
_►�? ___o ` _.. ______ ._.___._
Responsible In Charge of Construction (I' (C HC L 4....0
Address
4i _ - 7 $'" 7 3 9 7
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON. ZONING
Existing Proposed Required by Zoning
This column to .e filled in by
Building Department
Lot Size
Frontage
Setbacks Front
• Side L : ._._.. R: L: K._' R: ' •
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area m bldg & paved
parking) ...,�...a.. .m,., � ,.. .. ., ..._....�... ��_....w,
r
# of Parking Spaces
Fill: _ ,w.w_._____.. .....�._....
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW Q YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
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 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 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
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ( 3 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 ti
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.
Of Proposed Work eG i,.: e 4.4 ---4_ c "—A4...;› z7 , 1� e -? Lt,v i f
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE`
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ t 11` We, A -2 ❑ A -3 ❑ 1A 1 ❑
,.,/ A-4 - ❑ A -5 ❑ 1B ❑
B Business L'7 2A ❑
E Educational ❑ 26 ❑
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 I ❑
U Utility ❑ Specify: _ _
m _
M Mixed Use ❑ Specify: ._ _ __
__�
_ __ _
S Special Use ❑ Specify: _.�.,... _ __. _ �__ s.�.m..m _ ..w.. ..
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
_
Existing Use Group: ___ _ i _ __ 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)
z .
1st- - .m_.., 1 st
2nd 2 nd
3rd M�. 3`�
__...__. .____ . _ _._.w.. 4 th
4 __..__.
Total Area (sf) Total Proposed New Construction s
Total Height (ft) ________ _. ,.. _...._
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood ZoneInformation: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone ,__. _, Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version1.7 Commercial Building Permit May 15, 2000
����r Pepartmel t�trse ` '' :g A
City of Northampton Sta ts rf e t ' "
Building Department C��%r D. wa pe tt u �
212 Main Street Sa , pti G briny . ' e - ` . r
Room 100 �a #e� �e� Aitat abti t : . ,�, !, ' a 4
Northampton, MA 01060 Tr+Sets , a� '
rtcur �
phone 413 -587 -1240 Fax 413 -587 -1272 Plot/Srte Pla
Ot S pecify
s.;�� r,
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY r+ - ' EMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELL G �': .,,
SECTION 1 - SITE INFORMATION
1.1 Property Address: This s • ctio to o ZeJ* y o ice
I 0.0, �' . ... pi_. . Map 39 ., O Zi tkops , L r C._ ', nit
! V' j Al" Zone Overlay Distric
.Elm St.` District
°- -..__ __ A .1� District cB Dii
... ct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
lh f#,1- A . .3C7a� -
Name (Print) r /Ar v , �( f Current Mailing Address: __ µw mm
Signature Telephone 'S � T T- ------- _ . . _.
2.2 Author A ent:
C °L n2 4-c l Nom % - 2. r : i . _ `e3 c e x x.; i / G — 3 /-�- ? - Fz, �u..�_.N _Kr -
Name (Print) Current Mailin Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building , 14 e1 L (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
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1130
APPLICANT /CONTACT PERSON Armand Roy Concrete
ADDRESS /PHONE 16 Suzanne St SPRINGFIELD (413) 788 -9397
PROPERTY LOCATION 1 ATWOOD DR
MAP 39 PARCEL 041 001 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 ?S5 ,OCR # 3 �j
0 5 1
Typeof Construction: Energy Recovery System
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFilORMATION PRESENTED:
Approved Additional penults 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
C. / /// 8//2.,
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.
1 ATWOOD DR BP- 2012 -1130
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39 - 041 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: HVAC BUILDING PERMIT
Permit # BP- 2012 -1130
Project # JS- 2012 - 001933
Est. Cost: $1400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Armand Roy Concrete
Lot Size(sq. ft.): 217800.00 Owner: Hampshire Hospitality Group
Zoning: Applicant: Armand Roy Concrete
AT: 1 ATWOOD DR
Applicant Address: Phone: Insurance:
16 Suzanne St (413) 788 -9397
SPRINGFIELDMA01104 ISSUED ON:6/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: Energy Recovery System
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 Signatu
IES Smart EnerG Systems, LLC
FeeType: Date Paid: Amount: Craig Maclntyre
Principal
Building 6/18/2012 0:00:00 $55.00
703 Ocean Blvd
Suite C -3
Hampton, NH 03842 - =
212 Main Street, Phone (413) 587 12� 802.579.1317 office Smart EnerG Systems'""
603.381.4510 cell
Louis Hasbrouck — Building craigm @SmartEnerG.com
www.SmartEnerG.com