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The Commonwealth of Massachusetts
=T Department oflndustr•ialAccidents
— Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print_Leaibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.Fj I am a employer 4. E] I am a general contractor and I
with 6. New construction
mployees (full and/or part-time).* have hired the sub-contractors
--
am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
Vship and have no employees These sub-contractors'have [8. E]Demolition
employees and have workers' 9 Building-working for me in any capacity. � Q addition
[No workers' comp. insurance comp.insurance.$
5. F We are a corporation and its 10.❑Electrical repairs or additions
required.]
3. I am a homeowner doing all work officers have exercised their 1 LQ Plumbing repairs or additions
- 0 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' 131-1
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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Qnature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town officiaL
—City or Town: - -- -- _
Permit/License#
Issuina 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 l.7 Commercial Building Permit May 15,2000
I
SECTION 10-STRUCTURALREER REVIEW(700.CMR.1 0J 1).
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION-70 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...,the..,r.),a.i..ns.'an.diD,enal,ti,es-o-f.,P
.............. ......
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
I rN,
10.1 Licensed Construction;upery sor: Not Applicable ❑
Name of License Holder:..__4A_0..'Ci
License Number
Address Expiration Date
4C!O
Ctvu " q-
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSU RANCE AFFIDAVIT(M G.L.q 1524 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 l.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 EKLOSED SPACE) .
9.1 Registered Architect:
_... .._.._ _.__.. W._..___..�.. ................._-..______.�__..�.w._____..k._ _,�_.�.�.__._._...__.,-._._......_._._ Not Applicable ❑
Name(Registrant):
._.__.,.-. .__. ........_ _...._ ...___,�.
Registration Number
Address
___ ..r ... ._,..• 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 Area of Responsibility
Address Registration Number
Signature Telephone I Expiration Date
Name Area of Responsibility
Address Registration Number
�Telephone
Signature Ex iration Dat e
9.3 General Contractor
'' -.-•.,1, L(,��G� -t°�1...= ��i U GL Not Applicable ❑
Company Name
Responsible In Charge of Construction
Address
ture Telephone
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON+ZONING :..
Existing Proposed Required by honing
This column to Se filled in by
Building Department
LotSize _.... _.... _.._._ ._.. .._....,. _.__.._,._....." _....._ _
Frontage
Setbacks Front
Side R ... __.... _ __.
Rear
Building Height
Bldg. Square Footage — — %
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 Q DONT KNOW 0 YES 0
IF.YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0' YES w
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
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:_ „ ry
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 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 Q Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Descripti Enter a brief desc '�tion he re.
"'viL -,/1�✓✓► �'I �' 0. ryMt
Of Proposed ork.: 2 L14(iV it
SECTION 5-USE OUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 18 ❑
B Business ❑ 2A ❑
E Educational ❑ 26 - ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard El - 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) ,.._._ _.., :.__. _ ...,_.____4._' 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
1st
1 at
nd
2 2nd
3rd rd
4 th
t
Total Area (so Total Proposed New Construction(sf)
.....
Total Height(ft)
_w
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❑
Version 1.7 Commercial Building Permit May 15,2000
-- — �� Department use;only
i of Northampton Status of Permit
u ing Department curb GutiDiiveway Perrnrrr -
I� 8 2M 2 Main Street SeW it/Septk Avatfa6ility
Room 100 Watei.ANell;Avallabilit
y
Electric iJ ,non Gas Ins i 5n pton, MA 01060 Two Sets of;Structural Plans
No tna e14M3- 1240 Fax 413-587-1272 Plot/Site Plans
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 Property Address ��
This section to be completed by office
Map Lot Unit
Zone Overlay District
---
- - -°• - ElmZt.District' CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
_ _._ _
2.1 Owner of Record:
Name(Print) SL Current Mailing Address
_.__�.�ZL- �_�L:�?. _._�„�.. _,�� �✓of
Signature Telephone
2.2 Authorized Agent:
_._ _ __. ..._..._. .__... .___. _._.._.._._•_. �_._.r._...._�... _.._._ _ __..__.. _ _..
Name(Print) Current Mailing Addressr
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
_ o. Total_0 +2+3+4+5) Check Number LrJ`
This Section For Official Use Only
Building Permit Number Dater
Issued
Si nature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0869
APPLICANT/CONTACT PERSON ADOLPH J ANDRUKONIS
ADDRESS/PHONE 32 HAJEC CIRC CHICOPEE01020(413)592-2348 Q
PROPERTY LOCATION 11 CONZ ST
MAP 32C PARCEL 120 001 ZONE URC(95)/NB(5)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 0114141; 464-_
Fee Paid
Typeof Construction: REBUILD CHIMNEY&INSTALL STAINLESS LINER
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 97277
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
1 roved 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
,De roliii lay
s?
Sign it g fficial 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.
11 CONZ ST BP-2015-0869
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 120 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: chimney rebuild BUILDING PERMIT
Permit# BP-2015-0869
Project# JS-2015-001689
Est. Cost: $5725.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADOLPH J ANDRUKONIS 97277
Lot Size(sq. ft.): 8929.80 Owner: SHEMESH AVRAHAM&MICHAL LOMASK
Zoning.URC(95)/NB(5)/ Applicant: ADOLPH J ANDRUKONIS
AT: 11 CONZ ST
Applicant Address: Phone: Insurance:
32 HAJEC CIRC (413) 592-2348 O
CHICOPEEMA01020 ISSUED ON:312412015 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY & INSTALL STAINLESS
LINER
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:
FeeTvpe• Date Paid: Amount:
Building 3/24/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
low