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
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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#:
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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
{
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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. _, �..
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Address Registration Number
lephoire
Signature ne Exp iration Date
9.3 General Contractor
Not Applicable ❑
Company Name( S-3 f
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Responsible In Charge of Construction
14s
Address
Signa T lephone
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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.
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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"
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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❑
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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
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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