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GOODNOW
Y CONSTRUCTION
225 Old Chesterfield Road
Williamsburg, MA 01096
413-296-4387
www•goodnowconstruction-net
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The Commonwealth of Massachusetts
_ Department oflndustrial Accidents
E`— Office of Investigations ,
f
600 Washington Street
y Boston,MA 02111
'? www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: C-)Lg-s- Cdd
City/State/Zip:tk/�/J/ a" M A 6M b Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑New construction
loyees(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
- These sub-contractors have
ship and have no employees 8. F-1 Demolition
working or me in an capacity. employees and have workers'
g Y P h' 9. ❑Building addition
[No workers'comp.insurance comp.insurance.$ --
required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
.3.❑ I am a homeowner doing all work ❑
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
__ _ 13.❑Other
employees. [No workers'.
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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Si afore: j Date: 6
Phone#:
F cial use only. Do not write in this area,to be completed by city or town offciaL
or Town: Permit/License#
ing Authority(circle one):
I.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
J
SECTION 10-STRUCTURAL PEER REVIEW(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 BUILDING PERMIT
..... '
as Owner of the subject property
hereby authorize S ��'nL7 � to
act on my behalf, in all matters relative to work authorized by this building permit application. _
IF
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 pains,and penalties of a 'u
Print 4ame
nature of er/Agent Date
SECTION 12-CONSTRUCTION.SERVICES -
10.1 Licensed Construction Supervisor. Not Applicable ❑
VcVy( aS �Oo f✓ ` �' gO� � U�
Name of License Holder:
License e Number
Address Expiration Date
Signatur Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIQAVIT(M G.L.c1452:§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
qla
1
Version L7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION!SERVICES-FOR BUILDINGS-AND STRUCTURES 6UBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR;116(CONTAINING MORE THAN 35,000 C.F.OF E, LOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): i
Registration Number
_.. _.. _
Address
Expiration Date
s
Signature Telephone
9.2 Registered Professional Engineer(s):
I
1
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
....._
Name Area of Responsibility
Address 1�2qistration Number
Signature Telephone Expiration Date
t
Name ______ _ Area of Responsibility
Address Registration Number
P
Signature Telephone Expiration Date
.. ...__
Name Area of Responsibility
i
Address Registration Number
Signatur Telephone Expiration Date
9. General Contractor 0
of Applicable ❑
Company Name:
°° Z>L-1
Responsible In Charge of Construction
0dre�s
S cure Telephone
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPT0N,ZONIN6
Existing Proposed Required by Zoning .
This column to 5e filled in by
Building Department
Lot Size
f ;
Frontage
Setbacks Front j
Side L:---- -...€ R:-------i L:EM, R:&
Rear
Building Height
Bldg. Square Footage i % t
Open Space Footage
r---} --t - --?
'—-- - (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 DONT KNOW 0 YES Q
IF.YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book ' Pagel and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 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 Q
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 ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. /✓e-w i� fic1Le r1 AAJ- Dim i/1 y (26)1—4-T
f t o n
Of Proposed Work rQ Ir V A 0�/ ��f{vi1 " �Gi Fta n T Pe r c
SECTION 5-USE G UP 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
IE Educational ❑ 2B r ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ - -- - 3A ❑
—-- --
Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
IS Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:f
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:4
COMPLETE THIS SECTION IF EXISTING BUILDING UNDER(jOING!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 OF-.,FILE USE ONLY
Floor Area per Floor(sf)
IS
_,__.° 1st
St ....—.._.. .__.__.._.._.__....._...__._._...____�..__.....» "_,"."^...._.t
_. 2nd ,
2nd
3rd 3rd
4th 4m
i
Total Area(sf) Total Proposed 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 0 On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
of Northampton
epartment
in Street
AW * emu
//�� � m 100.
+�6 �0Aort on, MA 01060
Electric � y
Fl�mb 13-5 7-1 40 Fax 413-587-1272
Northar,pton Gas In e
Adq Ot p Peotions
APPLICATION TO CONSTRUCT,"REPAR,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
-_i_-
/ As /n qs y� t Map ` 7� Lot Unit
/ J i
26,ne Overlay District
y
sC aistrict° CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) Current Mailing Address:
Signature / 4 Telephone
2.2 Authorized Apent: _
Name(Print) Current Maili Address:
Signature Telephone
SECTION'3`- STIIVIATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use.Only
completed by ermit applicant
1. Building g�000 (a)Building Permit Fee
2. Electrical (b).Estimated Total Cost of
Construction from 6
3. Plumbing ? 0 op -µ ? Building Permit Fee
4. Mechanical(HVAC) J
5. Fire Protectionb0
.6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0266
APPLICANT/CONTACT PERSON DOUGLAS GOODNOW
ADDRESS/PHONE 225 OLD CHESTERFIELD RD WILLIAMSBURGO1096-9318(413)296-4387
PROPERTY LOCATION 14 HASTINGS HGTS
MAP 17A PARCEL 014 001 ZONE RI(100)/URA(100)/WSP(14)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid P 5t 16 t
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 5 X 7 DINING RM ADDITION 5 X 17 PORCH&REMODEL KITCHEN
i
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building Plans Included:
Owner/Statement or License 082188
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
Approved 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
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoni ermit oes 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.
14 HASTINGS HGTS BP-2016-0266
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-014 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
category: ADDITION BUILDING PERMIT
Permit# BP-2016-0266
Project# JS-2016-000410
Est.Cost: $42300.00
Fee: $600.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS GOODNOW 082188
Lot Size(sq. ft.): 13503.60 Owner: KULP JASON M&MOHINI S KULP
Zoning: RI(100)/URA(100)/WSP(14)/ Applicant: DOUGLAS GOODNOW
AT. 14 HASTINGS HGTS
Applicant Address: Phone: Insurance:
225 OLD CHESTERFIELD RD (413) 296-4387
WILLIAMSBURGMA01096-9318 ISSUED ON.91812015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 5 X 7 DINING RM ADDITION, 5 X 17
PORCH & REMODEL KITCHEN
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 9/8/2015 0:00:00 $600.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner