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31D-162 (5) t °> The Commonwealth of Massachusetts Department of1fidustrialAccidents Office of Investigations �. �(t. w} _r - 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applic ant Information Please Print Leaibl Name(Business/Organization/Individual): 7�7,2 _ Address: y�i�iprt, - City/State/Zip: 010-3 Phone#: �- / Are you an employer?Check t e appropriate box: Type of project(required): 1.,tI am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2._0 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 mein any capacity.h• employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.' - required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ myself ' . right of exemption per MGL Y �o workers comp. 12.7 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 131_j Other 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. '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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:_ Policy#or Self ins.Lic.#:�� dad. IIJ Expiration Date: Job Site Address: / d 2L 7T City/State/Zip: & ©1!S 3 3 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 certty un yrepah s nd pen Ides of perjury that the information provided above is true and correct. Sienature: Date: Phone#: L 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 t SECTION 10-STRUCTURAL PEER:REVIEIN(780 CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 -OWNER AUTHORIZATION-:TO BE COMPLETED.WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGJ PERMIT as Owner of the subject property hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. gnature 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_ _ er_the Dains,and enaIties of f Print le Signature of Owner/Agen Date SECTION 12-CONSTRUCTION-SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: —T_ License Number AddI'm _ Expiration Date T Sig Telephone SECTION 13-WORKERS'COMPENSATIOWINSURANCE AFFIDAVIT(M G.L:d.:152 4 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 1.7 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 jj:6(CONTAINING MORE THAN 35,000 C.F.OF EWLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone W 9.2 Registered Professional Engineer(s): Name Area of Responsibility _..... __._..... _.._. _. .w._ _. _ _.. i Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number - mm i Signature Telephone Expiration Date Name Area of Responsibility Address Registration_Number _....._.............._......_............. _.:_......._..._.--. Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone I Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name:: Responsible In Charge of Construction Address — - ��C/3 3'l_ Signatu e Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZON3.NG Existing Proposed Required by Zoning This column to 15e filled in by Building Department Lot Size Frontage Setbacks Front Side L:' R La _ R r Rear Building Height .........� __..._.! Bldg. Square Footage ._.___.._t __.... _.... % Open Space Footage _ _ % . --- (Lot area minus bldg&paved parking) #of Parking Spaces --• _ --- Fill: __.... __ _.......... ......... _,_. ..,._..... ........___.__.._._._. (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES Q :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# rv� B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES C 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 0 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. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,OOQ CUBIC FEET OF ENCLOSED SPACE- Interior Alterations ❑ Existing Wall Signs ❑ Demolitiono Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief description here. Of Proposed Work. f�� -� f i 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 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H-Hi h Hazard ❑ __ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 36 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility F-1 Specify:1 '-'__._.....�. __...-.-......_._..�.___�...�... ..._-..,-_.�...._ ..._.,._._______.,. M Mixed Use ❑ Specify , S Special Use ❑ Specify:I COMPLETETHIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONSAND/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(so q. 1 ac ..,....w..._......_._.___...._... ____..1 2nd 2nd .. . . .. ..... .. ._.. ... _ 3rd ' 3rd _.._..._,._.M_. _ __ _ 4th u, Total Area(so Total Proposed New Construction(sf) _q 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 ❑ Private E] Zone Outside Flood Zone[] Municipal ❑ On site disposal system Versionl.7 Commercial Building.Permit May 15,2000 City of Northampton - Stattisof Permit D partme u !fir �—,-� t se,on vv Building Department Eurb�CuDrruewayF?ermrt: ' i 212 Main Street Sewer/SeptrcAyarlairllty , 1 v� JUN 7 2014 Room 100 Wat&N.Vell Availability Northampton, MA 01060 Two Sets of Structural Plans ne 13-587-1240 Fax 413-587-1272 Plo El ct t%Srte flans ric, Plumbing&Gas Ins ec ions Northampton, MA 01060 fy ©thr Speer 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 This section.to.be completed by office 1.1 Property Address. ,._ _...._._..__._._..._._.._. K. d2-J mayH 34"�.._� _' Map �I 1� Lot �L Unit Zone Overlay District s - EIm St District CB District SECTION 2-PROPERTY OWNER SHIP/AUTHORIZ.ED AGENT 2.1 Owner of Record: t r s Name(Print) Current Mailing Address Signature Telephone 2.2 Authorized Agent: _ Name(Print) Current Mailing Address: Si nature Telephone — , -: 0 9 SECTION'3-ESTIMATED::CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit a plicant 1. Building ^^ ©U (a);`Building'Permit;Fee 2. Electrical - M - j (b)Estimated Total Cost of Construction-from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection __.... _ _............. 6. Total=(1 +2+3+4+5) Check Number This.Section For Official.Use Only' Building Permit Number Date Issued Si nature: Building Commissioner/Inspector.of Buildings Date i File#BP-2014-1353 APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT ADDRESS/PHONE 68 AMHERST ST GRANBY (413)552-7410 Q PROPERTY LOCATION 182 MAIN ST MAP 3 1 D PARCEL 162 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ZfQ Fee Paid Typeof Construction: REMOVE SPIRAL STAIRS TO ROOF&INSTALL T GUARDRAIL New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 010788 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: pproved 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 Dem iti ay Signature of Buil ding 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. 182 MAIN ST BP-2014-1353 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 D- 162 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-1353 Project# JS-2014-002270 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GERALD ARCHAMBAULT 010788 Lot Size(sq. ft.): 1873.08 Owner: BERMOR LIMITED PARTNERSHIP Zoning-: CB(100)/ Applicant: GERALD ARCHAMBAULT AT. 182 MAIN ST Applicant Address: Phone: Insurance: 68 AMHERST ST (413) 552-7410 O Workers Compensation GRANBYMA01033 ISSUED ON:611912014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE SPIRAL STAIRS TO ROOF & INSTALL 4' GUARDRAIL 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 6/19/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner