31B-181 (3) The Cornrnonwealth of Massachusetts
Department oflndustrial Accidents
t Office of Investigations
=t r 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/Ind//ividua]): CA IIGI `. �� �v► I ���Z44�JUCC
Address: 3 L-O
City/State/Zip: Q SA,61 �V/) A6. 010_2 7 Phone#: Yl j �O
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. ❑ 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.El Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 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.
lContractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. )
Insurance Company Name: w e5 L 0
Policy#or Self ins.Lic. #W— 3 0 0C� Expiration Dater �6
Job Site Address: f p'yan V AV*V- �Ok t,�•' U _ 1605
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 n Ities of peijury that the information provided above is true and correct.
Sif,,na ture: L Date:
Phone#:
Official use only. Do not write in this area, to be completed by cio,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#:
it
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 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 authorizt' afters to 14
aft on ha relative to work authorized by this building permit application
Signature of ner 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.
Signe under the pains penalties of perjury,_.. _ ......... ......._.__
_ 1 r
Pr' ame . . . ..... _._
i
Si nature of wn r/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervisor: Not Applicable ❑
_.
Name of License Holder.'..... ) . .. 10 Y. ..
License Number
s �-
11 -1-91'
Address Expiration Date
r 76
J.r ^ rlor-'7:(9 -:�
Signature Telephone
SECTION 13-WORKERS'COMPENSATION 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 O 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 ENCLOSED 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
Signature Telephone Expiration Date
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 Expiration Date
9.3 General Contractor
El
Name: Not Applicable
Responsible In Charge of Construction
Address
Signature Telephone
i
i
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: ,,, R. „ !! L 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 0 DON'T 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 0
IF YES: enter Book Page. and/or Document
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
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 Q 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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
a
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing all Signs s Demolition
9 9 ❑ ❑ Re airs
p ❑ Additions ❑ Accessory Building❑ A ;,
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ r
Brief Description Enter a brief description here. q Q l)l� O w S
Of Proposed Work:t ► J �„
ca ci_teo c4
............_.._
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE;;.
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ v. .r,.
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 El 2C ❑
H High Hazard ❑ 3A [�
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential R-1 ❑ R-2 ❑ R-3 ❑ 5A
S Storage ❑ S-1 ❑ S-2 ❑
56
U Utility Specify:
M Mixed Use ❑ Specify:
Special Use ❑ Specify
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
........_
Existing Use Group: =Proposed Group.
Existing Hazard Index 780 CMR 34): ard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
1
St _ _. 1 St 1.
2nd 2nd
3rd : _ 3rd
4h m
4
......... .........: .............._
Total Area(sf) Total Proposed New Construction(so
_.. ..... .........
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❑
Versionl.7 Commercial Building Permit May 15,2000
Department use only,
City of Northampton Status of Permit:
�o
Building Department Curb Cut/Driveway Permit -
a 212 Main Street Sewer/Septic Availability
>� c� Room 100 Water/Well Availability
cv
r Northampton, MA 01060 Two Sets of Structural Plans
N phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
Lid
AWIC _ TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
z OTHER THAN A ONE OR TWO FAMILY DWELLING
Sm4E INFORMATION
This section to be completed by office
1.1 Property Address:
( (rCY At b() r Map Lot Unit
®� cv, 10fri- Zone Overlay District
..... Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: A A
0
Name(Pri%t)^. Current Mailing Address:
5Lt 11
i�.
Signature Telephone
2.2 Authorized Agent:
IF
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3-ESTIMATE CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 00 em (a) Building Permit Fee
2. Electrical r (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+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0396
APPLICANT/CONTACT PERSON KEITH HAMILTON
ADDRESS/PHONE 3 LORD ST EASTHAMPTON01027(413)587-0763 Q
PROPERTY LOCATION 40 TRUMBULL RD
MAP 3 1 B PARCEL 181 001 ZONE URC(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: INSTALL 9 REPLACEMENT WINDOWS(GROUND LEVEL)&SIDING REPAIR TO
REAR PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074129
3 sets of Plans/Plot Plan
THE FOL G 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
D ► '
r
a -4 5
Si re of Building Official 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.
40 TRUMBULL RD BP-2016-0396
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 181 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeoa: windows replace.i BUILDING PERMIT
Permit# BP-2016-0396
Project# JS-2016-000629
Est. Cost: $7000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITH HAMILTON 074129
Lot Size(sq. ft.): 11891.88 Owner: LOCOCO ENACE J&JUDITH R
zonin : URC,100)/ Applicant: KEITH HAMILTON
AT: 40 TRUMBULL RD
Applicant Address: Phone: Insurance:
3 LORD ST (413) 587-0763 O WC
EASTHAMPTON MAO 1027 ISSUED ON.•912412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 9 REPLACEMENT WINDOWS
(GROUND LEVEL) & SIDING REPAIR TO REAR PORCH
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 Siiinature:
FeeType: Date Paid: Amount:
Building 9/24/2015 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner