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17C-220 (5) NOTICE NOTICE TO � TO r a EMPLOYEES EMPLOYEES $4 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Healthcare Self-Insurance Group, Inc NAME OF INSURANCE COMPANY 10 British American Blvd. Latham, NY 12110 ADDRESS OF INSURANCE COMPANY 019003100004107 4/01/2007 - 1/01/2008 POLICY NUMBER EFFECTIVE DATES Webber & Grinnell Ins. Agency 8 North King Street Northampton, MA 01060 413-586-0111 NAME OF INSURANCE AGENT ADDRESS PHONE# Se.rviceNet, Inc. 129 King Street Northampton, MA 01060 EMPLOYER _N /. ADDRESS EMPLOYER'S WORKERS' COMPENSATION OF I ER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the 3D NAME 0 HOSPITAL x AD RESS TO BE POSTED BY EMPLOYER 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): Address: 4,)-!? City/State/Zip: & f o A,, IM Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1 I am a employer }l 4. [] I am a general contractor and I with � 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 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 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 ❑ g P 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: A14 f1 e6rZZ ,,I&t, Policy#or Self-ins.Lic.#: 0/9100.5/CJ GOQ y/D Expiration Date: G'/ e7 t Job Site Address: {S/� /V 1�'1/?/� f'/ City/State/'Gip ' e-/. 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 InvestiLyations of the DIA for insurance coverage verification. I do hereby certify nder the pains and penalties of perjury that the information provided above is true and correct Signature: Date: G Phone#: 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 -7—RUCTURXZP-EERREVIEW{780CMR L1011 _ Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 =OWNERAU.THORIZATION TO=BECOMPCETED WHEN OWNERS-AGENT OR`CONTR 4CTOR4PPLIES.FOR BUILDING PERMIT A �/ jhl- - as Owner of the subject property hereby authorize � f��� c� 3 H C.�/16=5 Ito act on my behalf,in all matters r ative to work authorized by this building permit application. - i Signature of Owner Date as:Cu thorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the nowledge and belief. Signed unAVhe pains and eenaltiea of a'u Print Name Signature of Owner gent) Date SECTfOt�G12, COHSTRUCTt01�SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ 0,5 -70 Name of License Holder: � ''� T - — License Number 1A A Addr Expiration Date Signature Telephone SECTION 13:WORKERS'COMPENSATfO PC1NSURATICEAFFIDAU1Tni;M 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 Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINOS AND STRUCTURES SUBJECT.TO CONSTRUCTION CONTROL PURSUA ",T' 780-.CMR 116{CONTAINING -MORE THAN-35;000 C.F.OF ENCLOSEMSPAGE) 9.1 Registered Architect: Not Applicable ❑ i Name(Registrant): Registration Number Address `` ! Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date f Name Area of Responsibility Address ' R�stration Number t � � Signature Telephone Expiration Date r Name Area of Responsibility l Address !Registration Number E � Signature Telephone Expiration Date Name Area of Responsibility t Address Registration Number i Signature Telephone Expiration Date 9.3 General Contractor�I f P /77 9�-U f J Not Applicable ❑ Company Name: Responsible In Charge of Construction Ads Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size { Frontage Setbacks Front $ t Side L:`' R:� L:! i R:E J Rear �� Bldg.Square Footage ! % �z 1 Open Space Footage % (Lot area minus bldg&paved arldn ) #of Parking Spaces Fill: j; (volume&Location) f I A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: I i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page; and/or Document#j B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES i 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 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 t.. SECTION 4:66N'ti'RUGT1 SERVICES=FOR�PROJECT�ESS THAN 35,000 CUBIC FEETOF ENCLOSEDPraCE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration_ ,R'Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description :Enter a brief description here. . Of Proposed Work: f�/ n7 > SECTION 3..USE GROUP AND CONSTRUC'WON.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 ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-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: i M Mixed Use 0 Specify: S Special Use 0 Specify: I COMPLETE THIS SECTIONIF EXISTING BUILQI�IG UNDEE�GOII G RENOVATfONS;,AbO 'ONS�ANDIOR CH?;NGE IN USE �F. Existing Use Group 1 Proposed Use Group: Existing Hazard Index 780 CMR 34): i Proposed Hazard Index 780 CMR 34): SECTION 6,BUILDING IEtGHT 1ND AE2EA, - BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION �FFIGEUSEONL � # Floor Area per Floor(sf) St i € nkx�� rtk n St nd 3 b Total Area(sf) Total Proposed New Construction(sf) + a, r�'w`'". F Total Height(ft) € �� Total Height ft a �` 7.Water Supply(M.G.L,c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone i } Outside Flood Zone❑ Municipal ❑ On site disposal system E] Versionl.7 Commercial Building Permit May 15,2000 P -- �f Northampton i1 il�g Department r-- 2 2�Main Street 2 (}� om.100 AEG ? �Klorthpmpton, MA 01060 phone 41-3---1a7-12 0 Fax 413-587-1272 � . hS J _ OF AP IGATIO r� 4 _ S REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 7='S1TE'1NFORM�4TION�-_ � _ _ - - '•-� � , ` 3Thts sectton��tQ�e compfeted.by-oft'ice ---- -"-Property Address: -- I1dap Lots Und p� 2 ;S- ! 1 � �"��rF�x =� `,� �"• „ .r fur ;,k '�-«;5����� «a. � 'f•,...+r? —s SECTION 2; PROPERTY_OWNERS'HIP!AlVTHORIZEDAGENT - - n_n _ 2.1 Owner of Record: Name(Print) Current Mailing Address yid Signature Telephone 2.2 Authmized Age t: !Gn'7 �O S.• I '7 Name(Print) Current Mailin2 A ress: J 61 A,-WP I Signature `i � �' Telephone SECTION-3-:ESTIMATED GONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Offciai Use Oral} cornoleted by rmit applicant _ .. . . . . 1. Building I (a ' wldmg'PermitFee r I 2. Electrical , (b)'Esfimated Total Cost of 1 '—" i ,'`�Constriaction froii 6, ` 3. Plumbing ' i Buldtng Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total--(1 +2+3+4+5) _ Check Number ®3 J This`Section For.DfficiaFllse Oni Build ing.Pernit Kumtier Date° =_ -Issued; r , Signature: Building Commissionernnspecforof-Buildings Date File#BP-2008-0191 APPLICANT/CONTACT PERSON Thomas Gross ADDRESS/PHONE 237 Plumtree Rd SUNDERLAND (413)665-8235 PROPERTY LOCATION 17 NORTH MAPLE ST MAP 17C PARCEL 220 001 ZONE GB 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: REPLACE 5/4 PT DECK BOARDS ON RAMP New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 059093 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOJIATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OK 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 lu 08 ?--310 7 Signature of Building icial 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-2008-0191 GIs#: COMMONWEALTH OF MASSACHUSETTS 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-2008-0191 Project# JS-2008-000290 Est. Cost: $1000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Thomas Gross 059093 Lot Size(sg ft.): 10410.84 Owner: ServiceNet zoning: GB Applicant: Thomas Gross AT: 17 NORTH MAPLE ST Applicant Address: Phone: Insurance: 237 Plumtree Rd (413)665-8235 Workers Compensation SUNDERLANDMA01375 ISSUED ON.8/24/2007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 5/4 PT DECK BOARDS ON RAMP 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 8/24/2007 0:00:00 $50.006035 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo