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32C-343 (7) .,� ... ... Y � i ..,.rcra__.. ,� Y. .k, { ' .. � ! � � �� k�. ti.. �, 1 „, v� i � � ��� . ,. ___ ;:. fi�_. ���, � _ � _ 2- ,, .J-,r. -= _. ,: s �,,-�_ t�;. __ _ . � �. �k_ '1 '� _, �, . ; � t-_. �. • . � , ,. w `..p 4 n g 6 i � � .. �. r' T �. - '_ ) .e.. .` 1? „ � t ` �.._, f° S ` �. y # ap T� __ t,_.�. 'N The Commonwealth of Massachusetts `=T Department of Industrial Accidents ,, s ;`tea ^ate Office of Investigations ,r.�t . r 600 Washington Street 1 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information g ,, ' l Please Print Leibly Name (Business/Organization/Individual): '!� � e- c . Address: �� rj��}� PGA' _ C cb 1"l A- City/State/Zip: Phone#:L11 .3 — 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_. I am a sole proprietor or,partner- listed on the attached sheet. 7: XRemodeling These sub-contractors have hip and have no employees S. F-1 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions I❑ 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 12.7 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. 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 thepolicy 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 do hereby cer ' under the pains and penalties of perjury that the information provided above is true and correct. _r. Signature: Date: Phone#: 214- 7 S Of use onllr. 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#: Version 1.7 Commercial Building Permit May 15, 2000 f SECTION 10-STRUCTURAL PEER REVIEW.(780'CMR 1:10.111 Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 -OWN ER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby aufhonze �� act on my behalf, in all matters relative to work authorized by this building permit application. V Signature of Own �� 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 penaltiesgof penury av-.i. Print me _..... )d Signs re of 0 e gent Date SEC N 12-C NSTRUCTION:SERVICES 10.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder: License Number ea) ov Address Expiration Date r Signatur Telephone SECTION 13-WORKERS'COMPENSATIOPI 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 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 116(CONTAINING MORE THAN 35;000 C.F.OF EKLOSED;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 i Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number i Signature Telephone Expiration Date i 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 Company Name: Not Applicable ❑ Responsible In Charge of Construction Address L.Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column t6 Se filled in by Building Department Lot Size Frontage _...., _.._ _..__.._.; _..... .. , Setbacks Front Side L.__.. __. R. ",.__.__ UL--..t R:'.— __,..; Rear Building Height Bldg. Square Footage ___:...: _.. % Open Space Footage ___ M; ._ % (Lot area minus bldg&paved parking) #of Parking Spaces - Fill: j (volume&Location) '._ A. Has a Special Permit/Variance/Finding ev`$rbeen issued f r/on the site? NO DONTmKNOW 0 \\ YES aIF.YES, date issued: IF YES: Was the permit recorded at the Registry of eds? NO DONT KNOW 0 YES 0 IF YES: enter Book Pag and/or Document# B. Does the site contain a brook, body of wa r or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need t e obtained from th Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the pro pf y? YES 0 NO 1 IF YES, describe size, type`and location: ..... D. Are there any proposed changes to or additions of signs intended for te 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. Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE W � t �?4 Interior Alterations Existing Wall Signs [ ], Demolition❑ Repairs[I Additions El Accessory Builxding❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief description here. ,,� -w-A-- lA> G/AU LJO Of Proposed Work: 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 El A-5 ❑ 1 g ❑ B Business ❑ 2A ❑ E Educational ❑ 2B la, ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ - 3A ❑ 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: I M Mixed Use Specify 3 S Special Use ❑ P S eci fY COMPLETETHIS 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) st _ nd 2nd 2 s 3rd 3rd 4`h 4m m Total Area(sf) Total oposed New Construction(sf) 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 [] Zone Outside Flood Zone❑ Municipal [] On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 Departme t use,only f Northampton Status of Permit: !D `� in 9 Department artment Curb Ctif/Qnvevvay Perrriit 2 Main Street Sewer/SepticAvailabillty ROOM 100 WatefANe 11 Availability N mpton, MA 01060 Two Sets of Structural Plans Erectr;c, -5 7-1240 Fax 413-587-1272 Plot/Site-Plans North=l� Win, Aq r" A Spec Ot06pe�ionS Other ify. 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: . .......... Map Lot Unit MIN Zone Overlay District - - — Elm St:District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT. P6W(�G l D L C 00 1 2.1 Owner of Record: Name(Print) Current Mailing Address 61 PLO Signature Telephone qj 7j 02-00 2.2 Authorized ent: } 0 A � 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 r......,.. __.. .. .�.. 2. Electrical (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 Check Number This.Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector.of Buildings Date File#BP-2015-0862 OPI J APPLICANT/CONTACT PERSON PAMELA LEBEAU S 1 V I I F ADDRESS/PHONE 248 Bryant St CHESTERFIELD01012(413)296-4506 PROPERTY LOCATION 27 BREWSTER CT-UNIT B MAP 32C PARCEL 343 001 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 Fee Paid Typeof Construction: RENOVATE BATHROOM&KITCHEN&REMOVE&REPLACE NON-BEARING WALL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 064756 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 at4IM it' Delay oFBuiTIdin_g Offici al 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. 27 BREWSTER CT-UNIT B BP-2015-0862 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-343 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-2015-0862 Project# JS-2015-001572 Est. Cost: $18000.00 Fee: $108.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAMELA LEBEAU 064756 Lot Size(sq. ft.): 6926.04 Owner: STANDICK TRUST RICHARD RESCIA STANLEY ZEWSKI TRUSTEE Zoning: CB(100) Applicant: PAMELA LEBEAU AT: 27 BREWSTER CT - UNIT B Applicant Address: Phone: Insurance: 248 Bryant St (413) 296-4506 CHESTERFIELDMA01012 ISSUED ON:312412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE BATHROOM & KITCHEN & REMOVE & REPLACE NON-BEARING WALL 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 3/24/2015 0:00:00 $108.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner