25C-095 (10) 'i ,
i
i
i
i ,
i
� I
I !
ii
I, ,
1 ''
11
1 ;
j '
I '
i
I
� ',
i
� i
{ '
� '
� ,
',
i
---fir- -- ---— i----- — r7. t
Ilk
Sz
gy iv,
_ c
}
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): L S G '`�G•2 S
Address: ;'q i-1 F�iE`� D��✓1ri�-� � �,d
City/State/Zip: 0),)5'3 Phone.#: q1 3 ` 675-- tK(P7 7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.X 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'
[No workers' comp.insurance comp. insurance.
# 9. Building addition
required.] 5. ❑ We are a corporation and its 101-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11-[1 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 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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IContractors 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 file
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 under the pains and penalties of perjury that the information provided above is true and correct
Sienature: s�'"'�_ f�. �"�-- Date: —7 G—T
Phone#: `� / 3 S 77 `7
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#:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 1(1"CTURA EER--REVIEW(Z80 GMR 19011
Independent Structural Engineering Structural Peer Review Required Yes No Q
SEGTtON 11==OWNERAUTHORIZATION;-TO BE-COMPLE-ED-"WHEN
OWNERS AGENT OR CONTRACTOR APPLIES:FOR BUILDING PERMIT
IV "�' n / ��le- G C-61 Owner of the subject property
i
hereby authorize to
act on my behalf,in al tte elative to work authorized by this building permit application.
t
. I
Signature of er Date
a
as OwnerlAuthorized
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.
Print Name
Signature of Owner/Agent Date
.s>_crioN_�: coASrRUCZION sER�lc> s :�
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
p : loss3 0.7
Address Expiration Date
Signature Telephone
SECTION 4 -WORKERS'COMPENSATiONANSURiaNCE A€FEDAVIT(M GL c t52 §2 Cf6))
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
w
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-"PROFESSIONAL DESIGN AND;CQNSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES�1JBJECT.TO"
CONSTRUCTION CONTROL PURSUANT T0780-CIVIR 116,{CONTALNING MORE THAN 35;000 C.F.OF"ENGL05EDPAC1:).
9.1 Registered Architect:
Not Applicable
7
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
1
Address Registration Number
i
i
Signature Telephone Expiration Date
t
Name Area of Responsibility
Address Ree istration Number
i I
Signature Telephone Expiration Date
j
Name Area of Responsibility
s
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
I 1
Signature Telephone Expiration Date
9.3 General Contractor
i I Not Applicable❑
Company Name:
i
Responsible In Charge of Construction
L 0✓ i 5 �'. G d'sA./6 44
3
Address _ s q
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
� 3Ns7A1Ti11Ty *�,.
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i #
Frontage
Setbacks Front i
Side L: ,-R:= L:= R:= 1 f
Rear ' I
But mg et
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arldn )
#of Parking Spaces �� 1
Fill: I
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued: f
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 10 YES 0
7
IF YES: enter Book Page; and/or Document#1
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 , 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 NO
IF YES, describe size, type and location: I
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 ® ` NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4 CONSTRl7CT10N SERVICES fORPROJECTS3=ESS THAN 35,000
_.
C1)Bl.0 1=EETOF::ENCLOSED'SF?ACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs% Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
------------
Brief Description IInter a brief description here. PA Al
Of Proposed Work:I F�An E 7'b✓v oa/t p� iv�. 5 I.aT'i�S?ALL – 3v X08 t9lJL'✓Z$
SECTION 3=USE GROUP AHD CONSTRUCON TYPE'
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly AA ❑ A-2 ❑ A-3 ❑ 1A ❑
_ ❑ A-4 ❑ A-5 El 1 B ❑
B Business r 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ r-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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 ri Specify:s
S Special Use Specify: j
COMPLETE.T{ (S SECTI„ON fF EXISTINGBUILD!ING UNDERGOING RENOUATIONS, IDDITfONS AIVD/OR CHA1*IG1=IN'USE
Existing Use Group: 1 Proposed Use Group: I
Existing Hazard Index 780 CMR 34):! Proposed Hazard Index 780 CMR 34): i
SECTION"S BUILD1NiE1GFT AND F1REA: =-
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sfl � � z
St
ist
nd
2nd i 2
3rd 3 I
3rd
4m i
4d'
Total Area(so
Total Proposed New Construction(so
Total Height(ft) - � � ;
Total Height ftI aN
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewa a pisposal System:
Public Private ❑ Zone!—, Outside Flood Zone❑ Municipal On site disposal system[-]
Versionl.7 Commercial Buildin Permit May 15,2000
City of Northampton
Building Department
212 Main Street R
Room 100 µ
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
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=S1TEiN)=ORMA]'10N - - _ __ _
' � Tlts sectto Eoe campfefedyaffice
--- -"-Property-Addres
p x
I Nc?✓k- Al 5 Tr aci mot Untl
is I s' O�e� �ili3�15�rlC� �
S! �
Zv
SECTION2 :PROPERTY,OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
IL To Po SA n /t
Name(Print) Current Mailing Address:
I
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current t Mailing Address:
Signature Telephone
SECTION--3-:ESTIMQiTED,CONSTRUCTION e6sTS
Item Estimated Cost(Dollars)to be Official.Use Only
completed by rmit applicant
1. Building , Ca .l3uildmg..Pern�iLFee
2. Electrical (b)°Estimated Total-Cost'of i
..3e7P�s JL� i = Gonstruct+ohfrom ti ;
3. Plumbing ABiiildmg-PertnitFee
4. Mechanical(HVAC) I w
i - �l
5.Fire Protection I
6. Total=(1 +-2+-3+4+5) _ tJm s Chedk Number
Tri'is Section For.OfficiaE fse On1`,
-issued
Signature:
Building Commissionedlnspecfor of Buildings Date
File#BP-2008-0033
APPLICANT/CONTACT PERSON LOUIS J GINGRAS
ADDRESS/PHONE 244 HAYDENVILLE RD LEEDS (413)586-7420
PROPERTY LOCATION 211 NORTH ST
MAP 25C PARCEL 095 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
uilding Permit Filled out
( Fee Paid I 1
T_ypeof Construction: Frame and install 2 doors
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 F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ALTION 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 C ssion
�4= �� 6
Signa e 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-2008-0033
GIS#: COMMONWEALTH OF MASSACHUSETTS
aw 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-2008-0033
Project# JS-2008-000043
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOUIS J GINGRAS
Lot Size(sq. ft.): 8189.28 Owner: Todd Barron
Zoning: URB Applicant: LOUIS J G I N G RAS
AT. 211 NORTH ST
Applicant Address: Phone: Insurance:
244 HAYDENVILLE RD (413) 586-7420
LEEDSMA01053 ISSUED ON.711112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-Frame and install 2 doors
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 7/11/2007 0:00:00 $50.001144
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
BP-2008-0033
211 NORTH ST
COMMONWEALTH OF MASSACHUSETTS
GIs#:
CITY OF NORTHAMPTON
Map:Block: 25C-095 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Lot: lo
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Category:
Permit# BP-2008-0033
Project# JS-2008-000043
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const. Class:
Group:
LOUIS J GINGRAS
Use
Lotsize(sq ft): 8189.28 Owner: odd Barron
Zoning:URB Applicant: LOUIS J GINGRAS
AT. 211 NORTH ST
Applicant Address: (413) 586-7420
244 HAYDENVILLE RD
LEEDSMA01053 ISSUED ON:7/1112007 0.00.00
TO PERFORM THE FOLLOWING WORK.-Frame and install 2 doors
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W. g p
Underground: Service: Meter:
Footings:
Rou h: f/ f� House# Foundation:
Rough: g r(�7 � / Driveway Final:
Final: Final:/-()////7 l Rough Frame:(Jk J d
Fireplace/Chimney:
Gas:
Fire Department
Insulation:
Rough: Oil:
Final: Smoke:
THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA IONS.
Certificate of Occu anc
� Si nature:
Feel e: Date Paid: Amount: --�...
Building 7/1112007 0:00:00 $50.001144
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo