32C-270 (3) {` The Commonwealth of Massachusetts
== Department of Industrial Accidents
Office of Investigations
N ice`
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaiblv
Nan1e(Business/Organization/Individual): 1z�\ `
Address:
City/State/Zip: Phone#: S X'l
A�you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. F-1 I am a general contractor and I
�- 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. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑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.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [-No workers' comp. right of exemption per MGL 12.[Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r 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 narne 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: -( �r..� 1
Policy#or Self ins.Lic. c Expiation Date: ' 7?- o
Job Site Address: �� W\\��kv,- �O A�1. ', . 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
finp nr to $1,500 00 and/nr nnr-year imprisonmeAt,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 the painsnand penalties of perjury that the information provided above is true and correct.
Y
Sianature• \ ,�' %;--. Date: 0
Phone#• ce�o
Of use only. Do not write in this area,to be completed by city or town official
City or Town:
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 1.7 Commercial Building Permit May 15,2000
SECTION 10 STRUCTURAL PEER REVIEW(780,CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
fi1r s Cs fN 0_.�A!g1!\ . _.. . as Owner of the subject property
hereby authorize U x c�� �i �... _ _. . _..._ .. to
act y behalf, in all tt ers relative to work authorized by this building permit application.
ig ure 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, enaltiesFof perjury
m
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder:
Licen Number
_3 _ rn � ._.. ___
Address q Expiration Date
�
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance at5davit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the 1kilding permit.
Signed Affidavit Attached Yes No 0
ow
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
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
_. ........___,. .._ .. _,.,_._._. ... ......_ _w
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
- - ddress - --- -- - - -- -- —-- ---
Signature _Telephone
Versionl.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONIKE7
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 S aces
Fill:
volume&Location) _._... . ,,.... __...,_..... .. ......_. . . _.. .,__.,._...
A. Has a Speciat Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW 0_.. µYES 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 Q
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 0 NO 0
IF YES, describe size, type and location:
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.
Version 1.7 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❑ RoofingJ6 Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE �'('e�"r QrL �C S 11�q S
USE GROUP(Check as applicable) CONSTRUCTION TYPE 1
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 16 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I 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 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify
S Special Use F-1 Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _.__.. ___. _. w....__._.__' Proposed Use Group ._.,......
.
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION i.OFFICE USE ONLY
Floor Area per Floor(so
St
St
2nd , 2nd
3r°
4m ...,... ..,. _ _,_._.._.. __......_ __._. 4m
Total Area(so Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flo od„Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[:] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Buildin Permit May 15,2000
i Department use only
s
City of Northampton status oaf Pertrt t
i
Buiiding`Department Curti u#JE?rV uvay Pe rnat d
'iw i '.3t +so = p
,emu 212 Main Street Sewer/SaptacAvatiabt[ity
Room 100 ellariatlty�
P Northampton, MA 01060 Two Sets o#Structural"glans
phone 413-587-1240 Fax 413-587-1272 PlottSite Plans
Other,Spea +'
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
j
Map Lot Unit
Zone, Overlay District
'Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) Current Mailing Address:
Signature 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 ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)'Estimated'Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) _ ... . ............_. __.._., _,.___..
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number 3s
This Section For Official'Use Only
Building Permit Number Date
Issued
Signature:
Building CommissionerlInspector of Buildings Date
x 0NIL BP-2009-0968
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mo.-Block:32C-270 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-2009-0968
Project# JS-2009-001396
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq.ft.): 8494.20 Owner: DONOVAN BARBARA&BRIAN K
Zoning.URC(100)/ Applicant. BOB THIBODO ROOFING & SIDING
AT. 42 WILLIAMS ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 O WC
NORTHAMPTON MAO 1061 ISSUED ON.511912009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 2 PORCH ROOFS
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 5/19/2009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo