32C-343 (7) .,�
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'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