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DEPARTMENT OF BUILDING INSPECTIONS ° {E
_
212 Main Street • Municipal Building ' a _
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
censerIpermittce)
with a principal place of business/residence at:
Re //rieTT ,A 6w/ f 4 (phone //) 1 t-
(s1 city /state) ip)
do hereby certify, under the pains and penalties of perjury, that:
an employer providing the following worker's compensation coverage for my
employees working on this job:
,re) -31 f)7/ , ol0 /ki k ik?0
ce Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
.r ;
' s ;: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
:a.
• (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
: milan }' cy
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional thcet ifnecessary to include information pertaining to ell contractors)
• ( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
1 NOTE: please be aware that while homeowners who employ persons to do m* intmanrx_, con tructioa or repair work on a dwelling of
{ not more than three units in which the homeowner resides or oa the grounds appurtenant thereto are not generally ooasidaed to be
employes under the worker's compensation Act (GL152,ss 1(5)), application by a homeowrxr for a license oc permit may evidence the
legal status of an employee under the Worker's Compensation Act
I understand that a copy of this ataiemcni may be forwarded to the Department of Industrial Areideatie Offioe of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of penalties
consisting of a fake of up to S1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a
fora of £100.00 a day against me.
Far dcpartenerea1 use nary
Permit Number
o/t3 c,1 / m Lot #
It3t
Signature of Licensee/Permittee e
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 11011)
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION 11 = OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
AVA) 1 V t7 , as Owner of the subject property
hereby authorize L it cN i N L rg n'/,1 y to act or
my behalf, in all matters relative to work authorized by this b ilding permit application.
Ss /tlo d 0 /
Signature of Owner Date
I , A.42. a R...4 , as 9remar /Authorized Agent
hereby declare that the statements and information or the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
L $13 4 -o ,
Print Name /
g'✓a J d/
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : .4 1 — f 6 /4 XL.
l yy License Number
Address Expiration Date
Signature Telephone OJ 7
SECTION 13 - WORKERS' COMP 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 he building permit.
Signed Affidavit Attached Yes 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 ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15, 2000
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 ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO • DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
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 Existing Ground Signs Additions El Roo ' g ❑
❑ El
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ pri v - 7 5)4i ei
❑ Accessory Building [ ] Repairs [ ]
VESeg.4+- P - Tr 4) tJ
SECTION 5` --USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly I El A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ _ 2B I ❑
F Factory ❑ F-1 ❑ F -2 ❑ 2C ❑
H High Hazard El 3A ❑
I Institutional ❑ I -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 ❑
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 '' . ' , OFFICU$EONLY6
Floor Area per Floor (sf) -
1st i
r
1st 2nd '� ',
4# i �1 �° � Y p�
rd 2 3 ra0 x '4, ��� _. e � i
4th *s r0
3 rd A..` ;Hx
4th - 4; f , £ ll . 4. { . s
1 t
Q � Ara
'- .. ..,... 4 - t o ,.
Total Area (sf) Total Proposed New Construction (sf) � ,, .0 f �
Total Height (ft) - I' r : � ' l �� �
Total Height ft y
} :
Version 1.7 Commercial Building Permit May 15, 2000
City of Northampton eta#
Building Department C�C�t v are
212 Main Street 4ewr � , �-
Room 100 F ' er /W ,v `tl.` ® 1
Northampton, MA 01060 '- 0 5e of Turf- t
phone 413-587-1240 Fax 413-587-1272 Plat /Stte`Plan �, }' T r
Ot�,er Speet � ' c f � ` t 'ax x°� � � ,l
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLIS ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE IN FORMATION
1.1 Property Address:
This section to be completed by office ,_
7 9 Fin et) ' / 4 M Lot Unit
'/Q 1', G c' Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
_
A,,,,) D4 20 c 45 - 7 TA - ,v
Name (Print)
Current Ma Address:
YC +� G _ .SS G-S(1 l fr -6:it) c et ^c se
Signature Telephone
2.2 Authorized Agent: / a� ��/
rWt
73o,440 0 !�f 32 a 7, /� / � ��1� -76A) 1'4-
Name (Print) / Current Mailing Add
Signature Telephone
SECTION 3 - 'ESTIMATED CONS TRUC ION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building i �- (a) Building Permit Fee
y '7Q Q
2. Electrical (b) Estimated Total Cost of
Construct from (6)
Building Permit Fee
3. Plumbing ....../
4. Mechanical (HVAC) --- 5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) , '7° ? 6 b = " Check Number
is Section For Official Use Onl _ z .0:.. 2. : 7 :_ . Building Permit Numb er: ' �- Date Issued: �C ��
Signature:
Building Commissioner /Inspector of Buildings Date
579 FLOAEN'C i BP- 2002 -0493
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 004 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP-2002-0493
Project# JS- 2002 -0756
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 30056.40 Owner: DELUE ANNA M
Zoning: SR Applicant: B & R Siding
AT: 579 FLORENCE RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK :INSTALL VINYL SIDING
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/9/01 0:00:00 25 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo