31D-050 (6) r
The Commonwealth of Massachusetts
Department of Industrial Accidents
�,:� { `V' ` Office of Investigatio 4 '
" ~ ' -' 600 Washington Street •
=, ,. " Boston, MA 02111
y www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers
Applicant Information ' Please Print Legibly
Name ( Business /Organization/Individual): " _
Address: ' °, i
F
City /State /Zip: r Phone #: ,
Are you an employer? Check the appropriat ox: I Type of project (required):
1. ❑ I am a employer with 4. a am general contractor and I ,r`
❑ g 6. ❑ New construction
employees (full and/or part- time).* ha�re hired the sub-contractors/
liste•Qn the attached sheet. / 7. ❑ Remodeling
❑ I am a sole proprietor or partner- o
ship and have no employees These s contractors haves 8. ❑ Demolition
working for me in any capacity. employees and have workrs' 9 ❑ Building addition
jNo workers' comp. insurance comp. insura ye:$ /
required.] 5. ❑ We are a corpo : tion a Ad its 10. ❑ Electrical repairs or additions
officers have exer•seir 11. Plumbing re a
3. El I am a homeowner doing all work ffi h '-: their ❑ irs or additions � P.
myself. o workers' com right of exemption . MGL
y [N comp. 12.E Roof repairs
insurance required.] t c. 152, § 1(4), and e h.ve no
employees. [No + orkers' \ 13. ❑ Other
comp. insura I e required.] \
*Any applicant that checks box #1 must also fill out the section below showing eir workers' compensa - on policy information.
t Homeowners who submit this affidavit indicating they are doing all work • then hire outside contracts must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing e name of the sub - contractors *state whether or not those entities have
employees. If the sub - contractors have employees, they must provide thei • workers' comp. policy number.
I am an employer that is providing workers' compensa on insurance for my employees. low 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' compensati • . policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required unde 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 imp • onment, 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: 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
Contact Person: Phone #:
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
r
Independent Structural Engineering Structural Peer Review Required Yes No ` ° . 4
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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I,
A Z-0 7) 7 1 :4' . ... . . . , as Owner of the subject property
hereb authorize.. w l! ., to
act on my behalf, in all matters relative to work authorized by this building permit application,.
—42i Signature of Owner C3
1, _...__._ ..._._ . M._ „___..._ _ _: ___. _ ._._,__ . . _. .._; , 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 eiury � �_ ,. ,_ _ .
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 'tted 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
Versionl.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 EN SPACE)
9.1 Registered Architect:
NotApplicableD
Name (Registrant): _
Registration Number
Address
/ 7piration 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
—4\ X\
/ \
Signature j i Telephone » Expiration Date
Name Area of Responsibility
Address Registration Number
Signature TeleplIpne Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable 0
Company Name:
Responsible In Charge of Construction
Address ...„,
Signature Telephone
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•
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON; ZONING
Existing Proposed Required by Zoning
This column to filled in by
Building Department
Lot Size.__
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space % -•-
(Lot area minus bldg & paved
parking) w
# of Parking Spaces --
Fill:
( volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
- NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW elk
Sar YES
IF YES: enter Book ` Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO
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, ex avation, or 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
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 Us ,; Other ❑
Brief Description Enter a brief descripti9n here. I • — . • , ,'• , , 5
Of Proposed Work: ` 4 A5 541,0 t+/ ` ` ,__ II . • ,. "'
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 ❑ 1B ❑
B Business lit. 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C 0
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 0 R -2 ❑ R -3 0 5A ❑
S Storage ❑ S -1 0 S -2 ❑ 5B
U Utility ❑ Specify:
M Mixed Use n Specify:
u .
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
____. ...._.�.. _.....�.- ,_�.._..m..�- �_.._ ._..M_
Existing Use Group: . _ Proposed Use Group: _ l �._..
Existing Hazard Index 780 CMR 34): ..__...____ Proposed Hazard Index 780i1R 34):_ ___, _._, -_,
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PRO ED NEW CONSTRUCTIO OFFICE USE ONLY
R
Floor Area per Floor (sf)
1
s t
1 1
2 nd 2
3
3 3 '",
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 Ell
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Version1.7 Commercial Building Permit May 15, 2000
V .r Departmehit,use onky
City of Northampton sta of P�e r7y
! --- 2 —' 2 -7- 2 :- Building Department Curl�CrlR9,,reway Pemzit
z
212 Main Street Se
AUG 3 1 2012 1 Room 100 V{tate A talrabll ,,- &-
No' hampton, MA 01060 Two, Sets •ofIrcturar Plans
pE, - b uy . . Po 13 87 -1240 Fax 413- 587 -1272 PlotISk ns
te Fla
' N)RTHAMf IAA 01060 Other S eEl
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
G J -U �._ . _.. Map Lot Unit
3� QET Ft ,P 1 4 " ) .M Ps Zone Overlay District
CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record f9 • C 0.
.(/‘ Name (Print) v • I! Current ailing Address:
1� . 2 �., \� - 0 S & s- 5 ___.__ .. _ _ ._ _ .
Signature Ct ,
Telephone e ��, , • ti 7
2.2 Authoriz Agent
� a _ , S5 .0,7'_... ,le _ < ;' '? _..�._ '? _m . _ ...... � ._.
Name (Print) , ' / /, Curre t ailing dress
m / G` G'
TION 3'- ESTIMATED CONSTRUCTION COSTS
_. `�?
' ,-, ' -7/..-„, , -6( 44 ' ' '
Signature � , , � .�/ /�� A � _ i Telephone L,�� ' 7.5
•,�
D
/
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 ''
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- 2013 -0243
APPLICANT /CONTACT PERSON KESSLER LAURA & JUNE GAGNON
ADDRESS/PHONE 50 GREEN ST NORTHAMPTON (413) 527 -5005 0
PROPERTY LOCATION 50 GREEN ST -SALON 0
MAP 31D PARCEL 050 001 ZONE EU(100)/NB(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
Typeof Construction: USE AS SALON
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
INFORMATION 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
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.
50 GREEN ST -SALON O BP- 2013 -0243
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D - 050 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2013 -0243
Project # JS- 2013- 000235
Est. Cost:
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 7187.40 Owner: KESSLER LAURA & JUNE GAGNON
Zoning: EU(100)/NB(100)/ Applicant: KESSLER LAURA & JUNE GAGNON
AT: 50 GREEN ST -SALON 0
Applicant Address: Phone: Insurance:
50 GREEN ST (413) 527 -5005 0
NORTHAMPTONMA01060 ISSUED ON:8/31/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: USE AS SALON
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: 9. o - /2 ' Final: 9 J.?, 6? P'N Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: c9 (< 8131 I
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
QU
ANY OF ITS RULES AND RE ATIONS. / t lb (
Certificate of Occupanc� Signature:
FeeType: Date Paid: Amount:
Building 8/31/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner