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The Commonwealth of lVfassachusetts
— •_=-� Department of Industrial Accidents
Office of Investigations
m 600 Tf%ashington Street
Boston, MA 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (
T le Business%Oraan '
izadoniIndividual): �' �� — PC
'�
Address: 2- i '
City,/State/Zip: Phone#: 1>
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 7 I am a general contractor and I
have hired the sub-contractors 6• ❑New construction
employees (full and/or part-time).* 7. Remodelina
2.A I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.]
5. 0 We are a corporation and its ME] 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. Roof repairs
insurance required.) t c. 152, §1(4),and we have no �.❑ Other
employees. [No workers' 1,
comp.insurance required.]
Any applicant that checks box III 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 of this statement maybe-forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify ui d r th pain td pena Yes o erjury that the information provided above is tr a and correct.
Sianature: Date: IC `
Phone# l l 3 ,3
Official use only. Do not write in this area,to be completed by city or town official
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.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 0 No O
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative 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&aind per�yties,of
�(�
Print Nam
Signature of Owner/Agent l3ate
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Stwervisor, Not Applicable ❑
Name of License Holder:: _
License N mber
. . '., .. . I .C4
....._...... _'_moo.
Address Expiration Date
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 No 0
a`
Version L7 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
Address Registration Number
Signature Telephone Expiration Date
..:.......
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name ArResponsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Compwy Na e:
Responsible In Charge of Construction
ZVV�It �-ty�
Address
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
Frontage
Setbacks Front _
Side L: R: L R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage % _.._.,
(Lot area minus bldg&paved
arkin )
#of'Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 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#
YVIN
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
0
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 26 Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign El New Signs El Roofing El Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: 4 P I m t // uiL C
Cafii," et s 1)oin i etc.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B le ❑
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 ❑ 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)
i st
St
2nd �. _. 2 nd
3 rd 3rd
�, .,.,,_..,,...
4'" 4th - __ .,
Total Area(so Total Proposed New Construction(so
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public E] Private [] Zone Outside Flood Zone[] Municipal ❑ On site disposal system[]
1k
Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton status of PemTit`.
Building Department Curb cut/briveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
a
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 e A re/ss: This section to be completed by office
GU br'17P /7flt'aTG(cd Map Lot Unit
X1 f L74 F' y! G�6�C> Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERS H IPIAUTHORIZED AGENT
2.1 Owner of Record:
Name Print Current Mailing Address:
Signature LGL' Telephone .1-/3 SZY 7797
2.2 AuthRi' ed ent:
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 r. (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) '7 t Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
R
File#BP-2009-0686
APPLICANT/CONTACT PERSON PAUL MCCUTCHEON
ADDRESS/PHONE 27 WEST FARMS RD UNIT D FLORENCE (413) 584-3352
PROPERTY LOCATION 9 WOODBINE AVE
MAP 25C PARCEL 046 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE CABINETS&SHEETROCK REPAIR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 062544
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN7pproved ATION PRESENTED:
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
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.
BP-2009-0686
GIS#: COMMONWEALTH OF MASSACHUSETTS
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-2009-0686
Project# JS-2009-000997
Est. Cost: $7400.00
Fee: $55.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PAUL MCCUTCHEON 062544
Lot Size(sq. ft.): 4094.64 Owner: JAESCKE RICHARD E& SANDRA H
Zoning: URB(100)// Applicant: PAUL MCCUTCHEON
AT. 9 WOODBINE AVE
Applicant Address: Phone: Insurance:
27 WEST FARMS RD UNIT D (413) 584-3352
FLORENCEMA01062 ISSUED ON:211012009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE CABINETS & SHEETROCK REPAIR
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 2/10/2009 0:00:00 $55.007562
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo