32C-104 (14) t,$
The Commonwealth of Massachusetts
_— Department of Industrial Accidents -
�, __ 1�W- Office of Investigations
"�l� a 600 Washington Street
~4 ng Boston,MA 02111 pir
• :._4°°� www.mass.gov/dia
,•Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organi7ation/Individual): j?ov-7 r 7 D e ',u c on 3t;,ft( ht,
Address: jtV id ""Lit S)
City/State/Zip: Xi.-- IN.A4.1'Li, /O Phone.#: '1t3 "P0(/`6''a
Are y u an employer?Check the appropriate box:
' 4. 0 I am a general contractor and I Type of project(required):
1. I am a employer with t
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Erlemodeling
These sub-contractors have �-
ship and have no e loyees 8. Er6emouuon
working for me in any capacity. employees and have workers'
co insurance.$ 9. Building addition
[No workers' comp.insurance comp.
required] 5. 0 We are a corporation and its 10.[ Electrical repairs or additions
3.II I am a homeowner doing all work officers have exercised their 11.[ lumbing repairs or additions
right of exemption MGL m self. [No workers'comp.
12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
comp.insurance required.]
*My 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: iljiA. 5 . /1//u ..c,/
Policy#or Self-ins. Lic.#: A"wC 77)< i/,;2 Z 0 R; Expiration Date:- /t j:.44 /C 7
Job Site Address: (4-,M 7 5-): City/State/Zip; /ficnr-q 11 44 4/41'0
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 u der the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 7 Q 7
Phone#: ki' . '6,6
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#:
Version1.7 Commercial Building Permit May 15,2000
SEC SECTiON.10-STRUCGTURALPEEtRREVIEW(Zt30 CMR 110 11 ` _r
independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION.i4:-OWNERAUTHORlZAT1ON=,TO:BE_COMPLEIED WHEN
OWNERS AGENT OR CONTRAGTORAPPLIES.FOR i3G111331NOTE.MYlii
•1, 1_, 1
CG (H 44KP
as Owner of the subject property
hereby authorize `'C 0 it-1 iAf0%RY Ito
act on ehaif,in all matters relative to work authorized b this building permit application.
./ ./ // _ z c 7 i
/ / s" ./J��—,.ns ,
Signatu of Own-r Date
I,, 2/46w LAiU dP V
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.
.37)0JJ .1.ANi ?V a
Print Name
A‘fifrir( \,,,Z 3/7/07 i
Signature of Otidner/Agent, / Date
SECTtOICI CONSTRUCIIOMSERMICES °i
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder 3 '1M MIL/Pie " I i ( ' G'9.�1./5
License Number
Address __ i Expiration Date
Signature/ Telephone
ti ii
SECTION'f3-WORKERS'CONMP_ENSATION INSURANCE AFFIDAVIT(MG L c.t52i§2500)
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
r
a
Version1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN:AND CONSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURESSUBBJECTTO
CONSTRUCTION CONTROL PURSUANT TO°780-CMR 116.(CONTAINING MORE THAN 35;000 C:F.OF ENCLOSED;SPACE)
9.1 Registered Architect
Ci - Not Applicable ❑
'3O 7
Name(Registrant):
Registration Number
JG'y Ai EGA } : vet ( }���J M e/aa /P/66
Address
Expiration Date
Signature V Telephone
9.2 Registered Professio al Engineer(s):
Name Area of Responsibility
Address Registration Number
I
Signature Telephone Expiration Date
Name Area of Responsibility
{
r
Address Registration Number
I
Signature Telephone Expiration Date •
I
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
1
Address Registration Number
I
Signature Telephone Expiration Date
9.3 General Contractor
k o�;i 6/ S G 6, 414,./I 1�i u'Y II 1 i :, Not Applicable❑
Company Name:
I H'J 1AJ Y
Responsible In Charge of Construction
Address
,i13- ri 9gC
Signature Telephone
� V
Versionl.7 Commercial Building Permit May 15,2000
8 DRVIAMA Ol G't ,
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i I 3 '
Frontage i 3 , .
Setbacks Front f 3 i
Side L: 1 R::---1 L:1 ( R:! ( I ;
E
Rear I
BuTdg Freight E --.
Bldg.Square Footage I I I i % i j 1 i I
Open Space Footage % 3 ,
(Lot area minus bldg&paved I i i i '
parking)
#of Parking Spaces ( i
Fill: i'
{ if
(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 Q YES 0
IF YES: enter Book 3 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 Obtained Q , 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 Q
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15,2000
t
SECTIONr4 CONSTRUCTION:SERVICES.FOR PROJECTS LESS THAN 35,000
CUBICFEETOFENCLOSED°SFACE ' _
Interior Alterations isting Wall Signs lilt/Demolition El/Repairs Additions ❑ Accessory Building❑
Exterior Alteration L'd Existing Ground Sign❑ ,New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description ;Enter a brief description here.// (Pp,51 r) y
Of Proposed Work:� ke wade I men5 4 We.neaS E,`tikre",,,„„ ' 4 i , iG' Wrt4;c tC [7 T cat et,
I
;'SECTION 5"-USE GROUP AND CONSTRUCTION,TYPEl
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 A-3 ❑ 1A ❑
A-4 ❑ A-5 0 1B ❑
__
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑/
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 ❑ S-1 ❑ S-2 ❑ 5B
[ ❑
U Utility ❑ Specify: {
M Mixed Use 0 Specify:I j
S Special Use 0 Specify:I
F i
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGO1N;G RENOVAT[ONS AD DITIOWAND/OR CHANGE"IN USE
Existing Use Group: l I Proposed Use Group: I
Existing Hazard Index 780 CMR 34):' 1 Proposed Hazard Index 780 CMR 34):1 i
SECTION&-BUILDING:HEIGHTYANDAREA:
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION � , -� * t a_ « , '
Floor Area per Floor(sf)
%,
1st 1St i i tr �w � ; -
nd i `t..t" < ^'* x.. :.,
2nd 2 ( • � 4 ,'� 4
3rd i 3 �,i1 � : 3 W4��:
3rd ' "4'`;• E ' . ' rT :,`64
,, .44
-1,1.-------P.',-,-" t"--,---ca'.3 ,qp � ,.,f'-,,,- -rs' u-a 4--a-*.
Total Area(sf) x Total Proposed New Construction(sf) ��
1 mot. `"� �. ;�-
Total Height(ft) ' I _1 ,*« x
' �c g 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` 1 Outside Flood Zone❑ Municipal ❑ On site disposal system❑
_..— 7. ,, . Versionl.7 Commercial Buildin Permit May 15,2000 . ,...0
..t.. 1 .--;--t4i.-- riv,.-A e . .41 t?.).--.4--;4 ,,,i-f447.7,- --„,,,,,,---,7*-5%,-,,,,,L.....4
__,, -„ . - ' _-,,.,- „....-7.,,.,-.F..o,-a,-:--- ' 4-- -;-:,:- -.-
City of Northampton TW Lr'!-:" 4-A:ft- 42:451.ZW*1
— , 1 Building Department WaLliZ'qii467 sT4 'til-E5:46,
212 Main Street S _ue---7 ,-* .s-,-
_-., -, _.--w-,-,....;
'.=,".ri.e.7•-•:=W'kL4i.:417-7:5:r ',c4-,::,:,+:.Z.,.4et,V.,;it&-.*IF:3:'.*::-r.4.-fZZ4WZ-,a.
Room.100
,Si,....-'-if....;,, ,1e*t.'s-tAti*ek;:,t4Tr:.'-- i,.....PU-P5fi.;I: 41.
Northampton, MA 01060 --_: ,,,4.N...-k-tii„,, ,—,.....kzA._
,, izgar4-r-*W.ZoV--*M04.11.,: lj
phone 413-587-1240 Fax 413-587-1272 .piotZ 'w-iaTISZ ,-1''-tg:*4--',1---,--'-t,,i---.fa4-S.Wii:-1417W:-.--?,:z-,-4-a-t-..:,
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- : ---2'7 "' ''....4;47'`'.:&VA.,-.......
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
-IA Propertv --:--
-Addres : 's ,,,._,,.., -------------',4- ---- ---:..--- :..„..,vtg? .1.7.Aatr
..,
1 Map *.i;,...it, ..Unit
t , ,,:t;:,,,,
I d01 ::','''it91plfPPt,15.4
. ... --4Vrook-'%7772:4 ir0-4-LOVN•
tOrniik#Iiiite* 1Af-pAcR:Distri41_______
_11__ _-',--,t.-,-,:::',7;-.4z:.•,,z4i5y.-.3....,,,c,;.;.--;:;:::.,-;i;
SECTiOW2e..--iiROP.EIlt44WNERSIHIPfAU-J14O1311 EDAGENTV_Ty;z:-.5,-,7,,
2.1 Owner of Record:
! 1 , 14,j3cLoall_21 . 1 I 317 Pc,--.; )0c 4- 54-
i '
Name(Print) .. Current Mailing Address:
097,- 7
Signature
. f-CIA4P4/-/f7:/..-Ze17.41.--,•--2--( Telephone
2.2 Authorize Aoent:
I .._ CAL) i„Axi9i2,Y 1 1 )ti,/ kr 47 ,4, 5±
Name(Print) Current Mailing Address:
ilL I "//3 - e-'1.7/- `Age-) !
Signature Ed.' - .91 Telephone
SECTION-3, MATED CONS UCTION COSTS
. ,
Item Estimated Cost(Dollars)to be -,:_i Off dial:Use„'Oply
completed by permit applicant
..-,0)--pi-iiidihg-Perrnit "'ee
1. Building i il 115i>3 C
. .. . ,
2. Electrical 1 y.5ce
1 , 1 (b)-Estimated'Totat Cost of i F
-; I ConStrtctiOri`torri(6) i
- - _
_
1 .':BiillifingPeiniifFee
3. Plumbing /7 tee
4. Mechanical(HVAC) t (..)
i ,-,
5. Fire Protection 1 _
6. Total=(1 +2+3+4+5) .6 7
0 —
- 5 p 2-Check Number
C , . " . .
• ' S ction fbrOfficia1Ute-Only
tuildin.J',BiarffiltNilitliW .
:. Eltsued
r
. .
Signature: -- .
,
.. , , Date
Building Commissioner/Inspecfdt of Buildings ,
File#BP-2007-0842
APPLICANT/CONTACT PERSON JOHN LANDRY
ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413)204-9880
PROPERTY LOCATION 50 CONZ ST
MAP 32C PARCEL 104 001 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out , )1 y��
Fee Paid uj'A'
Typeof Construction:_ADD ENTRANCE TO BAR AREA,REMODEL BATHROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 093450
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Coy,' 'ssion
d Z )c J
Signature of Building Of icial 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.
/41'141 .
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50 CONZ ST BP-2007-0842
(Hs #:_.__ _ _ COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 104 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-2007-0842
Project# ' JS-2007-001380
Est. Cost: $67320.00 .
Fee: $229.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN LANDRY 093450
Lot SizeLsg_ft.): 25047.00 Owner: WORLD WAR II VETERANS ASSOC
Zoning:NB Applicant: JOHN LANDRY
AT: 50 CONZ ST
Applicant Address: Phone: Insurance:
104 NORTH ELM ST (413) 204-9880
NORTHAMPTONMA01060 ISSUED ON:3/13/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD ENTRANCE TO BAR AREA, REMODEL
BATHROOMS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
'/ F Footings:
Rough:(1-11-07, Rough: /fl ,r House# Foundation:
Driveway Final:
Final: 7.4 .d7( Final: //9/ t ;.
��r\\V i� 7 VW" Rough Frame:6k _ ( t ,0 7 ----
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final:0t $-
Final: Smoke: �v�7.___)
THIS PERMIT MAY BE REVOKED BY T. E CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL Tie" S .-�. y,:."
Certificate of Occupanc � _Signature: r
FeeType: Date Paid: Amount:
Building 3/13/2007 0:00:00 . $229.00725
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner •Anthony Patillo
e