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1,-,.., ___ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
W ' 600 Washington Street
Boston, MA 02111 .
`�� www.nzass.gov/dia
Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Ap plicant Information / � r �
Please Print Legibly
U
Nam
(Bt siness/Organization/IndividuaI): , �. a.
Address: C f . . k. :." l
City /State /Zip: Arsc ,1 M A q(c)Lo Phone #: L f (J i — 25 c"
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4 0 I am a general contractor and I
have hired the sub - contractors
employees (full and/or part- time). * 6. ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling and have no employees loyees These sub - contractors have. 8. 0 Demolition
ki capacity. employees and have workers'
working for me in any p t'• 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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 appiicant that checks box #1 must also fill out the section below showing their workers' cornpensation 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.
IContractors that check this box must at 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 certi under the pains and penalties of perjury that the information provided abov is tr a and correct
Signature: Date: (9 I IT
Phone #: -
Official use only. Do not write in this area, to be completed by city or town offciaL
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 #:
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
1 C 16V U ` +
0 as Owner of the subject property
hereby authorize i fp- cAz to
act on my behalf, in a rs relat ' to work authorized by this building permit application.
Signature ne " Date
I, , 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 : ,r
0\
License Number
C �. E, ors' - 6 ` r d
Address ��1/yy Expiration Date
IS '2 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 b ilding 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
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
Lti�.c xlt .. t( i i S
c% � ,, <<�. r Not Applicable ❑
Company Name: `
Responsible In Charg of Construction
f., C \tl 1 `ca_. -
Address --r•
qJ 23'1-cil'ZO
Signature Telephone
Version1.7 Commercial 13uilding Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
A[ Building Department
Lot Size ,2.3 U A
Frontage
Setbacks Front
i
Side L: R: L.
Rear
Building Height /7
Bldg. Square Footage 75 1/
Open Space Footage
/-1( ',
(Lot area minus bldg & paved (• ,
parking)
# of Parking Spaces 7
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DON'T 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 W DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES i►.4 NO Q
IF YES, describe size, type and location: �� v K,1A , ( �/ 1-‘
D. Are there any proposed changes to or additions of :signs intended for the property ? YES do NO 0
IF YES, describe size, type and f
location: K I , f �. a,1 �' a 6\ Jp, l ,K ID
1 1 .
trC k \
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 0 NO f4
IF YES, then a Northampton Storm Water Mana•emen': Permit from the DPW is required.
Versionl.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 Use ❑ Other ❑
p brief description here. ee,Nf t. ` - t ,
Bri Description Enter a br el , \-T4'31 n- ts, J1-_'`
Of Proposed Work: f r�Q Yrfrt G '. ` ivy. (} � '"
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 ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 0 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 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 EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf) / /'
15t 2 15-D CF . �,
2 , R 4 � ..
2nd ` `
Std
3 0 LT\ VV 7 Z7
4 m
Total Area (sf) 1- V Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water upply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sew a Disposal System:
Public Private ❑ Zone Outside Flood Zone Municipal] On site disposal system
•
Versionl.7 Commercial Building Permit May 15, 2000
D epartment use only
City of Northampton Status of Permit:
�''\ wilding Department
Curb Cut/Driveway Permit
212 Main Street Sewer /SepticAvailabifity
i Room 100 Water/Well Availability
2 5 2008 ampton, MA 01060 Two Sets of Structural Plans
jUIN1 phon 13 7 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify
T,4;' 1 PAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
•
p
e 1X - . J-% 1 (6aL e_ Map Lot Unit
r - _ Zone Overlay District
/ Y Eim St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
C /Gilt LIa ,Tf�f. "P'"'
Name (Print) Current Mailing Address:
Signature y�i! - 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 )2 ( (a) Building Permit Fee •
2. Electrical //p (b) Estimated Total Cost of
"j Construction from (6)
3. Plumbing
3 6116
Building Permit Fee
4. Mechanical (HVAC)
Fire Protection
6. Total = (1 + 2 + 3 +4+5) Check Number //3 tJ
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2008 -1174
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/NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out // car_
Fee Paid / 7 `✓
Typeof Construction: REMODEL RESTAURANT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 058422
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 D. to
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- 2008 -1174
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- 2008 -1174
Project # JS- 2008 - 001736
Est. Cost: $19000.00
Fee: $95.00 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/NB Applicant: Gerry Shattuck
AT: 1 BRIDGE ST
Applicant Address: Phone: Insurance:
53 CLARK AVE #11 (413) 584 -6265
NORTHAMPTONMA01060 ISSUED ON: 6/26/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: REMODEL RESTAURANT
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 6/26/2008 0:00:00 $95.001134
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo