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17C-300 i The Commonwealth o Massachusetts T� Deoartment of In dus trial Accidents �- Office oflnves igations 600 Washington Street Boston,l'►L4 2111 k v s• www.massg v/dia -Worl-ers' Compensation Insurance_-Affidavit: Bt[ilders/Contractors/Electriciaus/PIumbers _kpolicant Information 601 Please Print Legibly Name (Business/Organim on/Individual): Address: City/State/Zip: Ph ne-: Are you an employer?Check the appropriate box: TyEN fproject(required): . � I am a general c tractor and I [2..❑ I am a employer with 6. ew construction employees(full and/or part-time)_* have hired the -contractors ❑ I api a sole proprietor or partner- These on the attached sheet_ 7. ❑R modeling shin ar+rl have no—1o;,ees These sub-contra ors have .8. ❑Demolition working for me in any capacity. employees and ve workers' 9 ❑Building,addition [No worke*;' comp.insurance comp. insurance. 5. 7 We are a corpora 'on and its 10.7"Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have'exe cssed their 11.❑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 rkers'- 13.0 Other comp.insurance required-] 'Any applicant that checks box#1 raust also fill out the section below showing their wo 'coTmensation policy information. Homeowners 'who submit this affidavit indicating they are doing all work and then i outside contractors must subtrtit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showins the name of tic sub-conttactors and state whether or not those entities have employees. If the sub-contractors have employees,they trust provide their'worke s'co .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. #r: Expiration Date: Job Site Address: Ciry/State/Zip: _,kttach a copy of the workers' compensation policy declaration pag (showing the policy number and expiration date). Failure to secure coverage"as required tinder 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 penzities in the form of a STOP WORK ORDER and a fine of up to 3250.00 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 itsiarlace coveraze verification. I do hereby ce n to i and penalties of perjury that the in rmadon provided above is true and correct Siznature: Date: ' -T> Phone r: Official use only. Do not write in this area,to be completed by city cr town off-zeiaL i City or Town: Permit/LJ,i cense T Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerlr .Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: hone#: i 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 Q No a SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date i, 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 perjury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date 2z S.._. _. Signal Telephone -T 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 No 0 Version 1.7 Commercial Budding Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVIC ES-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 f Address } Expiration Date Signature elephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility { i Address Registration Number Signature lephone Expiration Date Name j Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility i Address Registration Number Signature elephone Expiration Date Name Area of Responsibility .__ _ 1. _, �.. i Address Registration Number lephoire Signature ne Exp iration Date 9.3 General Contractor Not Applicable ❑ Company Name( S-3 f i Responsible In Charge of Construction 14s Address Signa T lephone i i I Version 1. Commercial BuildinLy Permit May 15, 2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be Filed 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 arkine) #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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW Q YES 0 IF YES: en er Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES NO 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 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. i I Version].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 B^ui�ldi ❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Ro fing❑ Change of Use❑ Other LAS Brief Description Enter a brief description here. 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 ❑ A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 36 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B F-1 U Utility ❑ Specify: M Mixed Use ❑ Specify S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Prollosed 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 1 St .I 2nd 3rd i 3r° 4 t 4t" i _ I Total Area(sf) Total Proposed New Constr ction(sf) „ Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Informatio 7.3 Sewage Disposal System: Public Private ❑ Zone Outside lood Zone❑ Municipal ❑ On site disposal system❑ i Versionl.7 Commercial Buildinl-Permit May 15.2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability __ , ; Northampton, MA 01060 Two'Seta of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify F�'PPLICATION 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 1.1 Property Address: This section to be completed by office L/G° L.kkt. S+- Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i°!iiWOCi! /�? L/0' 5� Name(Print) Current Mailing Address: Signature Telephone l — 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone (,6r✓ SECTION 3 AfTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �,� (a)Building Permit Fee 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+5) 2-10 Check Number p7 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date i I i i i i f i i i i I i i i i i i BP-2008-0566 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-2008-0566 Proieet# JS-2008-000858 Est. Cost: $3230.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Jeffrey Cranston 101176 Lot Size(sq.ft.): 13068.00 Owner: BOUTHILETTE KEVIN F&ELLEN M Zoning: URB Applicant: Jeffrey Cranston AT. 40 LAKE ST Applicant Address: Phone: Insurance: P O Box 307 413 268-3504 WILLIAMSBURGMA01096 ISSUED ON.121512007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & DOORS 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 12/5/2007 0:00:00 $25.001829 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo