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�,-`�_ The Co»unonwealth of Massachusetts
=.� Department of Lzdustrial.4ccideltts
�. Office OfInvestigations
- F: =_ ' =' 600 Ifashiiz ton Street
- Boston, IVL4 02111
11'ww. mass.; oi/dia
«Yorkers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
GERRY SHATTUCK
Nlp1e j Puniness /Organlzationilndividual) : _ 53 CIarI Avenue #11
Northampton, Massachusetts 01060
Address: (413) 584 -6265
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
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.$
required.] 5 ❑ We are a corporation and its 10.0 Electrical repairs or additions
q ]
officers have exercised their 11. Plumbing repairs or additions re a
3. El I am a homeowner doing all work � P.
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.E Other
comp. insurance required.]
`Any applicant that checks box # I 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 c1 copy of tiff lyllrlici - N' s'Prnp nsition Tolley de tgrptjgu (lase (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 pettaitie§ 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 certi Juxderhe pains and penalties of pezjuiy that the information provided above is tr e and correct.
Signature: Date: .17 1
Phone #: ( / t r -! v s!
1 ' i `
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 1.7 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
, as Owner of the subject property
hereby authorize —10�T\ ( J 'tom �+r _ to
act on my behalf , ' ers el ty to w rk authorized by this building permit application.
, 'n al att
1 l [J,} 71, h t�
Signature of O er � ( l 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 DERRY SHATTUCK Applicable v �
❑
C J ._. . �
Name of License Holder . _ -
b Clark Avenue 4011 License Number
Northampton, Massachusetts 01060 __._ . , L ' Of 58476265_ Z
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 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
E pirotion 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:
_ _..._ -53 Clark "Avenue #I1_
Northampton, .Massachusetts 01060 -. ..
Responsible In Charge of Construction (413) 584 -6265
--
Address / . - -
Signature Telephone
vosion17 Commercial Building Permit May 15. 2000
8. NORTHAMPTON ZONING
| |
�� °�
�^.�in� Proposed Km4u-..6yZoning
This colunin to be flhled in by
Building Department
Lot Size
Frontage
Setbacks Front - - ' - - -
- --
Side L: R� � R:
-__
Rear
Budding Height
---
13 |0g- SQu8pFyotRg7
—
Open Space Footage
(Lot area minus bldg & paved
n=u"u
#ofParking Spaces ---- .
Fill:
(vol umn& Location) -- -- - ---- - --- - --_ - - - '-
A. Has l Permit/Variance/Finding ever been issued for on the site?
0 /-� 0
NO DON7KNOYY YES \��
IF YES, date issued:
IF YES: Ws the permft recorded at the Registry of Deeds?
�� ��
NO DON'T KN�YY YES
\_� \� _ \^~�
IF YES: enter Book Page � and/or Document#
0 YES ��
B. Does the site contain a brook, body of water or wettands? NO X� �� KNOW \�� J DONTKNO�5 \_�
'
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained /~-\ Obtained Date Issued:
- �--------- 7
\`~/ \~/ ' '
C. Do any d �� gnsexis�onthepruperty7 YES \+�~ NO
� - '-- -
IF YES, describe size, type and location. � �J \
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 aUon.ur over 1 acre or is it part of a common pion
that will disturb over 1 acre? YES �� / } NO
V�
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 0 Existing Wall Signs ❑ Demolition❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
PriQf P t r ripti9n En a hrigf docriptinn hgrg, 4 1i r c i 1 r/ 0 ,Ac A r-' ct ,,
Of Work: - Proposed > P _
p -- � f l p Y `� { � k it °A \ �- e�,.T • ( \ r, l.J+ C{
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE 11
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
0 ❑ A-5 ❑ 1B ❑ —
B Business ❑ 2A ❑
E Educational ❑ j 2B ❑
F Factory ❑ F -1 ❑ F-2 0 2C ❑
H High Hazard ❑ — , 3A ❑
Institutional ❑ 1 -1 0 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
micl ntial R-1 R-3 [ 5A 0
S Storage ❑ S -1 ❑ S -2 ❑ 5B l ❑
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 [X I STING PRi PORED NEW GQN §ThLICITIQN OFFICE USE ONLY
Floor Area per Floor (sf)
1 51
1
2"
2 nd
3rd
.._._....._ ....__ _. .. - . ._. _.......... 4 15
4 °i
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 Di Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
G Room 100 Water/Well Availability
v 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 tiro e Address: !! Tftis I oction to bo corpIot@d by offico
PrT L{ i c0 �'1 vr+ orte Map Lot Unit
/ e t,.,1(A)Z" Zone Overlay District
�
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
C C1 to V O (.) U e t r t
Name (Print) Current Mailing Address:
� n
t /� b �x �4
Signature � .� �' ( ✓ _ Telephone
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
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 -4 i This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0222
APPLICANT /CONTACT PERSON GERRY SHATTUCK
ADDRESS /PHONE 53 CLARK AVE #11 NORTHAMPTON (413) 584 -6265
PROPERTY LOCATION 1 BRIDGE ST
MAP 32A PARCEL 271 001 ZONE CB(48)/NB(52)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ‘156//.5 `�
Fee Paid c > 3
Typeof Construction: ADD EGRESS DOOR IN BAR AREA
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Ow ner/ Statement or License 058422
3 sets of Plans / Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required (see below) «p00
PLANNING BOARD PERMIT REQUIRED UNDER:§ II �� ' UV
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
/ ''''/- .0.1: .■": :
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.
•
• BP- 2010 -0222
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0222
Project # JS- 2010- 000276
Est. Cost: $800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERRY SHATTUCK 058422
Lot Size(sq. ft.): 14113.44 Owner: GUERRA CLAUDIO
zoning: CB(48)/NB(52)/ Applicant: GERRY SHATTUCK
AT: 1 BRIDGE ST
Applicant Address: Phone: Insurance:
53 CLARK AVE #11 (413) 584 -6265
NORTHAMPTONMA01060 ISSUED ON:8/28/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD EGRESS DOOR IN BAR AREA(DOOR
ONLY)
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 8/28/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo