Loading...
18D-051 (3) The Commonwealth of Massachusetts Department of Industrial Accidents trl Office of Investigations 600 Washington Street AL_= cM Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Associated Builders,Inc. Address: 4 Industrial Drive City/State/Zip: South Hadley, MA 01075 Phone #: 413.536.0021 Are you an employer? Check the appropriate box: Type of project(required): i . 151 I am a employer with 30 4. 0 I am a general contractor and I 6 la New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers'comp. insurance comp. insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 13.❑ Other employees. [No workers' comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. F 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 :mployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers Policy#or Self-ins. Lic.#: DTJU13-8298M11-4-12 Expiration Date: 11-01-13 Job Site Address: 347 King Street City/State/Zip:Northampton, MA 01060 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 certify under h a' 'es of perjury that the information provided above is true and correct. Signature: _ Date: 1/19/13 Phone#: 413.536.0021 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!.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 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Carla J. Cosenzi I , as Owner of the subject property Associate. :udders. Inc. hereby uthorjze to act o my t ha1f�`in- a ers r•lative to work authorized by this building permit application. Sign e f O�� Date 9 Kimberly M. Masiuk of Associated Builders, Inc. 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. Kimberly M. Masiuk,Associated Builders, Inc. Pri Na W nt Date SECT ON 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable U Name of License Holder: Scott Downie CS 63481 License Number Associated Builders, Inc., 4 Industrial Drive, South Hadley, MA 01075 04/24/2013 Address Expiration Date (413) 536-0021 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 0 No 0 • Version!.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 El Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Kimberly M. Masiuk, Associated Builders. Inc. Site Civil, Architectural,RDP Name Area of Responsibility 4 Industrial Drive,South Hadley, MA 01075 40474 Addre Registration Number (413) 536-0021 06/30/2014 ignatu 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 Associated Builders, Inc. Not Applicable ❑ Company Name: Scott Downie Responsible In Charge of Construction 4 Industrial Drive outh Hadley, MA 01075 Address GI . (413) 536-0021 Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 2.659acres Frontage 282.39' Setbacks Front 81.5'' Side L: R: L:'41' R: 1321 ............ . Rear 106© Building Height 28 (b Bldg. Square Footage % 1786 15% Open Space Footage (Lot area minus bldg&paved 150a 12.% parking) #of Parking Spaces 291 Fill: (volume&Location) 5865 cy for entire A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 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 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 0 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 ®i NO 0 IF YES, describe size, type and location: Traffic signage per plan. Bldg signage by others. 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. p 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 U Other❑ Brief Description Enter a brief description as/ 1 Of Proposed Work. 11, c) 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 p 2A ❑ E Educational ❑ 2B I p F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage GI S-1 GI S-2 p 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 OFFICE USE ONLY Floor Area per Floor(sf) 1st 1st 17,812 2nd 2nd 3rd 3rd Ott, 4th Total Area(sf) Total Proposed New Construction(sf) 17,812 Total Height(ft) 28 Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone p Municipal p On site disposal system❑ ( d_ ' Versionl.7 Commercial Building Permit May 15,2000 Department use only t i Fil) 2 5 City of Northampton Status of Permit: M ?013 Building Department Curb Cut/Driveway Permit , ,,, . 212 Main Street Sewer/SepticAvailability 0, . rv.,4r F,,;. ur's Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Piot/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 Property Address: This section to be completed by office Map / 6 Lot y; l Unit 347 King Street f v Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Rec.,rd: ' Cosenzi °uto otive Realt imited Parntership 40 Russell Street,Hadley, MA 01035 Name(Print) / Current Mailing Address: /� (413) 570-1302 ' sll Signature s ./ �, Telephone 2.2 Authorized Aqe Kimberly M. 4 . k, Associated Builder_s, Inc. 4 Industrial Drive, South Hadley,MA 01075 Name(Print) Current Mailing Address: / y (413) 536-0021 Signature ///' 1/ /("V Telephone SECTION STIMATED •NSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $1,821,952.00.. (a) Building Permit Fee 2. Electrical $271,420.00' (b)Estimated Total Cost of Construction from(6) 3. Plumbing $111,207.00 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection $229,756.00 / // fo 6. Total=(1 +2+3+4+5) $2,434,335.00 Check Number /d c $o This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-0780 2 601' O K APPLICANT/CONTACT PERSON ASSOCIATED BUILDERS INC • ADDRESS/PHONE 4 Industrial Drive SOUTH HADLEY (413)536-0021 P 1), (o N Q IT I C' i 1 PROPERTY LOCATION 347 KING ST "� FT�SJ MAP 18D PARCEL 051 001 ZONE HB(100)/ j< THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out y / 9 t Fee Paid / (!� Typeof Construction: CONSTRUCT HYUNDAI DEALERSHIP 17,812 SO FT 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 INFQRMATION 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 (2e-L Z 3 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. 347 KING ST BP-2013-0780 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-051 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:NEW COMMERCIAL BUILDING BUILDING PERMIT Permit# BP-2013-0780 Project# JS-2013-000819 Est.Cost: $2434335.00 Fee: $8906.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ASSOCIATED BUILDERS INC Lot Size(sq.ft.): 223027.20 Owner: COSENZI AUTOMOTIVE REALTY LIMITED PARTNERSHIP Zoning: HB(100)/ Applicant: ASSOCIATED BUILDERS INC AT: 347 KING ST Applicant Address: Phone: Insurance: 4 Industrial Drive (413) 536-0021 WC SOUTH HADLEYMA01075 ISSUED ON:3/22/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT HYUNDAI DEALERSHIP 17,812 SQ FT 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 3/22/2013 0:00:00 $8906.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner