17C-226 •
' The Commonwealth of Massachusetts
g Department of Industrial Accidents
, -- Office of Inves e
600 Washin Street
w a s -
1 .,
..,� :. -- i t Boston, MA 02111
. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information ---- Please Print Legibly
div
Name (Business /Organiza . n' 064 _
Address: P Al
City /State /Zip: f 1 i1S 4 C � /( 0 3 Phone #:‘,13 3 7 Y°
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am . to er with 4. ❑ I am a general contractor and I
y
Ioyees (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
officers have exercised their 11.❑ PI g repairs or additions
3. El I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12. oof 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 o f 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.
Signatur � Date: 4' 1- —
Phone #: y/3 3a1 74PI
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
L 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 i Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, r _..:. _S _ I„ , K .!_4 - as Owner of the subject property
hereby authorize 1 T. i. {,..5. __C, (- ____________ _ :to
act on my behalf, in all matte relativ to work authorized by this building permit application. /
Signature of Owner 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 .er'u .
u
Print Name
/0/F1/2'
Sig of owner /Agent Dat
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . �.. -..a...---
... w ::..) O 3 ,........—._. ...___j
License Number
Address Expiration Date
b,.,m3: ftt
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NF.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil • permit.
Signed Affidavit Attached Yes No 0
Version1.7 Commercial Building Permit May 15, 2000
0
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 LOSED SPACE)
9.1 Registered Architect:
Not Applicable /
i �m ;
Name (Registrant): ....._... ,._ _ _
Registration Number M
Address i — ,_..„...,_...,..._...,
. Expiration Date
I
Signature Telephone
9.2 Registered Professional Engineer(s):
.....:......... ..............w ._ S
Name Area of Responsibility
€
Address Registration Number
i
Signature Telephone Expiration Date
1
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
_ __
i
Name Area of Responsibility
w .... _.,. __ _.
Address Registration Number
i 1 __
I 1
Signature Telephone Expiration Date
Name Area of Responsibility
,
Address Registration Number
i
. a — _ _---- „..._...„._..,._
Signature Telephone Expiration Date
9.3 General Contractor
, ...., _, Not Applicable E:(
Company Name:
Responsible In Charge of Construction
_ Ad_dress -
1
Signature Telephone
. i
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON: ZONING ''
Existing Proposed Required by honing .
This column to be filled in by
Building Department
Lot Size .__..__. _._.__.__. .:. ._
Frontage _..... .. .,..., .__._..�... __.. M ,
Setbacks Front - _ +n „N „�
Side L:
-- ■ R::.—___.; L: ._.. R:',_____; ,
4
Rear ._.__.,_..J ,
Building Height
Bldg. Square Footage ._. _... % ._,._, ._.
Open Space Footage __ _
(Lot area minus bldg & paved __ __. _ ,
parking)
y
# of Parking Spaces = # L
Fill:
(volume &Location) ..__.._.._.... _._.._ _ .. . _ -. ..
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
- NO 0 DONT 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 _ IF YES: enter Book ' Page; and /or Document # _ _._..__.._.w_._ �''
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: j
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
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 ❑ 3.ditions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief description here. ° °'
Of Proposed Work: G
_____9____7_____ Q._ ___Ju2...) ‘1174/7. _ ;
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ED A-2 ❑ A -3 ❑ 1A 1 ❑
A -4 0 A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B " I ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ I -1 0 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 0 R -3 ❑ 5A ❑
S Storage ❑ Si - 0 S -2 ❑ 5B I ❑
U Utility ❑ Specify: `N _.
M Mixed Use ❑ Specify: t i
S Special Use ❑ Specify: m_n ,.-..... __ _...a,�.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: ___.__.__ , e., ___„_ .. . __ Proposed Use Group:
Existing Hazard Index 780 CMR 34): _ ._,, ..__, ,. _ Proposed Hazard Index 780 CMR 34): µ
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY .
Floor Area per Floor (sf)
st µ..... __.....__.. _ ... 1 st
,_.._ ..... -. 2nd i
2 'd
3
4 h 4
Total Area (sf) Total Proposed New Construction(sf)
_.._. ..._..._..__....._.....`
Total Height (ft)
Total Height f t. . . . . . . . . . . . . . .__-.� -� - ..._,n
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
Version1.7 Commercial Building Permit May 15, 2000
RECEIVED Department use,only
CVC V City of Northampton Status of Permit.
Building Department Curb Cut/Driveway Permit.!.. -
OCT - 9 Y012 212 Main Street Sewer /Septic Availability
I Room 100 Water/Well Availability
DEPT. OF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON, MA o1 ,,,
o6Onh,.' 413 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
P�'�'� 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
This section to be completed by office
1.1 Property Address:
Map Lot Unit /14 I -1L N ,14 - Crr , Zone Overlay District
_. EImSt. District CB D istrict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) / Current Mailing Address: _.....,,_. ,__._..._.
Signature � - Telephone
2.2 Authorized Agent:
T �
1
Name (Print) Current Maili Address: __.._..__._.—_ - .._._..r_
Signature Telephone
SECTIO 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3 5 oc,..2Gx. (a) Building Permit Fee 4.
2. Electrical (b) Estimated Total Cost of I
Construction from (6)
. ,
3. Plumbing 1 Building Permit Fee
4. Mechanical (HVAC)
1 .
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 5. a w Check, Number ,.c__,2Y_______05
This Section For Official Use Only
Building Permit Number Date
Issued
- -- -- ... _Signat
`_, /0(!) t //: . . , . .........
�
B � o j °s lon-r /lnsp- ctor • . - moldings Date
12 NORTH MAPLE ST BP- 2013 -0406
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 226 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0406
Project # JS- 2013 - 000650
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 3615.48 Owner: SIENKIEWICZ TODD J & LAURIE J
Zoning: GB(100)/ Applicant: TIMOTHY J LUCE
AT: 12 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 - 9800
LEEDSMA01053 ISSUED ON:10/10/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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 10/10/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner