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39A-76 (62) File#BP-2005-0637 APPLICANT/CONTACT PERSON MATT MURPHY ADDRESS/PHONE 110 PETTICOAT HILL WILLIAMSBURG (413)268-7892 PROPERTY LOCATION 492 PLEASANT ST-DIVAS MAP 39A PARCEL 076 001 ZONE GB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ,�,,// �t Fee Paid /OW e�1v Tvoeof Construction: CONSTRUCT PARTITION WALLS&DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066916 3 sets of Plans/Plot Plan THE FO ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Commis "I 1/7114:1'i Signature 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. Version!,?Commercial Burldin• Permit Ma 15,2000 = f Northampton ii ' .Ing Department _- t 2 Main Street _„„ ---:±"--- -''''':::::';,ti:-:.=7:- Room100 •-z:..-1?:',-....,..- - 1 :CO4 Nont x. pion, MA 01060 phone 413}587. 240 Fax 413-587-1272 i y ,'rI r <. 1 APPLICATION TO CONB@2['ICT RE^: R,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING :SECS(ON_1-$fTEINFORMAT30N — _ As^ChttTlecUonYO'ltaomptete t .m e it _..M�ramrtY-Addeess:--. - C,19_,61-...., c.>.♦.�.. .' , I I4 t r""A_ .7 I � �Aap,. .Lo Unrt - ! 4/9 2. �'/e su �- .� ,� la ,Aid,Ca,-YYL+al I YO1J, MA . i m� . x .. 2 ire- SECTION 2-PROPERTY OWNERS_HIRIP/AUTHOEDAGENT 21 Owner of Record: i j Name(Print) Current Mailing Address' I Signature ,- .. Telephone 7.2 Authorised Anent: /^ b Oki 11 • iM,46Ard I . Name(Print) a .. Current Mating Address: Signature Al,I I f_ 61.4,_ Telephone SECTION 3- TIMATED:CONSTRUCTION COSTS item Estimated Cost{Dollars)to be - Metal Use Only. completed by permit applicant . I. Building 1...gg000 1 (a)Building'Permit Fee { d ! i 2. Electrical ( yr5 /nt NCJ (b)Estimated Total Cost of �—� /� i w+- u Construction-1mm(B)' i. ��t,50 3. Plumbing I O 1 Building.Permi[Fee 4. Mechanical(HVAC) y� 5.Rte Protection V 1....... 6. Total=(1 +2+3+4+5) -Check.Number j06 / 5j-- This Section or Offici Fal Use Only Building Remit Ararat: ,Date-' Issued Signature: Budding OOMMISsiceerietSpeetOr of Budbigs Date VersionI 7 Commercial Building Permit May 15,2000 SECTION 4..CoNsTRDCTdOkSERvicEttoiRPRMJEC.TS"LESS.T AN 35,500 'O CUBIC FEETFEPICLOBED$P.ACE interior Alterations ❑ Existing Wall Signs 0 Demolition❑ Repairs 0 Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Esy Brief Description (En�ter�a,r,brief description here. Of Proposed Work Y"`'antrLuh is tan' Epp 'Dont SECTION 5.USEGROUPAND CONSTRUOTION`TVRE _ USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-i 0 A-2 0 A-3 0 to 0 AA-4 A-5 ❑ t8 0 B Business C 2A 0 E Educational 0 2B 0 F F«dwy 0 F4 0 F-2 0 2C 0 H High Hazard ❑ 3A ❑ 1 Institutional ❑ I4 ❑ 1-2 0 1-3 ❑ 38 D M Mercantile ❑ 4 0 R Residential ❑ R-1 ❑ R-2 ❑ R-3 0 5A 0 S Storage 0 St 0 5-2 0 58 0 . U Utility - ❑ Specify. M Mixed Use ❑ SPecify.I $ Special Use C] Specify. COMPLETE THIS.SECTIONiF:EXISTINGBUILDING UNDERGOING RENOVATIONS,A00MONS AND/OR CHANGE IN USE Existing Use Group: 1 I Proposed Use Group: i Existing Hazard Index 780 CMR 34):n i Proposed Hazard Index 780 CMR 34): i SECTION 6.autroi HEIGHTAND:AREA. BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ^ -"' i, ;,-la.Sl a ,4s c ori tt17., --4- - Floor Area per Floor(sf) i y ' FAsF r e x ''-: 1' i J3 SQ �- ,rte . - _ a aro! 3"' , } 5 a =v-r' e. 4e 4" I az ,. ssye Total Area(sf) J Total Proposed New Construction(sf) p"a f` x' w, i Total Height(ft) I � r a Total Height ft /O' r"1 r '" * - 'TM 7.Water Supply(M.G.L.c.40,§54) 7.1 flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private 0 Zone_ 1 Outside Flood tone❑ Municipal 0 On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 ::,A- LI,f—.La?. 41gitril f.. Existing Proposed Required by Zoning This column to be filled in by Building Depamnnt Lot Size I i r ! '.. Frontage II • Setbacks Front —_ , Side L:'— Ra LCA: ! � !. . I Rear 1 I Building et - i - , Bldg.Square Footage I 1 % O F Open Space Footage (Lotaez minus bldg&paved , , 1 I I1 I paling) #of Parking Spaces r� L_____1 Fill: i, 1, . (volume'&Location) N Il A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ' DONT KNOW O YES 0 IF YES, date issued: 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO g DON'T KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: i i D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size. type and location: E. Will the construction activity disturb(clearing,grading,cation,or filling)aver I acre or is it part of a common plan that will disturb over 1 acre? YES 0 1 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version'.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES-FORSUILDINGS AND STRUCTUREGSUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR lie(CONTAINING MORE THAN 35,999 C:F.OF ENCLOSEDSPACE) 9.1 Registered Architect Not Applicable D Name(Registrant): Registration Number it I Address L.. ......."` { Expimtlon Date Signature Telephone ' 92 Registered Professional Engineer(s): Name Area or Responsibility I Address ..... _.... ..— Registration Number -. Signature i Telephone Emiction Date F Name Area of Responsibility .. _. I Address Registration Number Signature Telephone Expiration Date ' 1 NameJ Area of Responsibility 1 —. _r Address Registration Number I I ..— SigSignatureTelephone Expiration Dale Name Area of Responsibility m Address Regi Number Signature Telephone Expiration Date n 9.3 General Contractor 77 1 l&' / 7' Dto/ a/44, �LL 6abff6 Not Applicable Company Na e Y il1mr &3 , C ia3Y7?I. Responsaie In Charge of Constn.o on _ 1 //D f!eyf7Ca/gf Al-/// /Q2) ars✓<- a I Addres / i.t fast rxn7p5, . _, Telephone Version 1.7 Commercial Building Permit May IS,2000 SECTION 10•STRUCTURAL PEER REVIEW¢80 CMR 1303 1)-- - - . Independent t 11)- Independent Stnouxat Engineering Structural Peer Review Required Yes 0 No 0 SECTION t1-OWNER AUTHORIZATION-TO BE COMPLE[ED:WHEN OWNERS AGENT� OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, A vc A.. f ry bivo _... as Owner of the subject property hereby authorize 1 Al p.iT /11 kKPl,1/ !to act on In 9alf,in an ma•_ /el ""T" tto work authorized by this building permit application. _ < y l7 l ✓ry�T�r� ` Sign- re• Owner / ,r._ .- 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 16.1 Licensed Construction/ tripervisor,,�(�7 Not Appriabie ❑may Name of License Nplder _nig�77- /�'u2 E,�ta.32/ I n.. _ - q/ License Number Address ,kation Dare 44a2f i l (a 7?C Sgnetu ""�� _ Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,-E 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 0 No 0 opSw/rrD t_ _ _ ,,� 45 Crim of pTnrfliat)tptol) / i•@ Mi-1E 3i wEchnsnl.' -. DEPARTMENT OP BUILDING INSPECTIONS ' 212 Main Street . Municipal Budding Northampton, Mass. 01060 r WORICER'S COMTENSA 110N. ENSURANc.h AF1`IJAvIy I, Selr MV (Armi- _wvith-e piincapal phr^ orbiIsne residene _et //o P-eht,'re)H'7- 12/ ie (p'hone'y ry�il_77¢/a (so- deity/swrizip) do hereby cerrifp, under thepains and penalties of perjury, ih.=.1 ( ) I am an employer providing the following worker's compensation coverage for my • employees wohijng on this job. - (Irisin=Comr•r-v) (Poiic: Nu_ r) (Erp noon Dae) () I am a sole proprietor, general con¢-actor or homeowner (cicie one) and have hued the coon:actors hstecl below who have the following worker's compensoon policies: (Naruc of Co..^.!-lcmrl (I nsura lie: Companp/Pobcr Numbs) -- (Fi;nrmsn Datc) (Name of Cournmor) (lnsaranec Compaay/Poicy Nw±cr) (E.ipin;ion Daae) (Name of Counano:) (lnsuancc Compan)'/Pobcy Number) (Ex-pindoo Darc) • thIamc of Contractor) (Insurance Company/Policy Numhrr) (E.wyuadon Dale) (.nuemi:wl L.c Uam..n to al&adC inrum.ti m perinins to w commee a) • I am a sole proprietor and have no one working for me. ( ) I am a home owner performing Al the work myself NOTE:plc..c bc am1c...._v1Jn bcmzuv+a vto ploy pooh.to Y rmeem..... .tr ..o a rc mart m.dm.11 .s of am mom tho threc amiu in..hid the bommwc r, idm or 03 tba ground.appummem theme cz oc L•.•..ally oc-3 cd tote ar Ioym Mc the wo*n —-ern Act(G LIY2n I(5)%-pplir.Coo M.homm=m fey.bC c«?nit 2r midaz lh 1m:d.tau.of to employe"wader 6.o waha.Compme.tioa em. I eedmumi the a can of du.=.m.=m.y b.r - • du MaDcywmua ofl.,.t..-u iu.Mad Oho.or lemma(or the cove-ego`ciGcsi`a M Ilei L"d,,7c u town to.crNsc tmda=man]Sw of MOL 152 on leap ec--e.ehnn of awiail pen ii, mmisircE oft Gna of up to 51)00.00.nd/o..inryviac®ey ofup to ea nee end civil pm.11ia to ex(of.Slop wortot.cid. (m o(S'WOO.thy.p.im me For anluxe only P lain Number :11 al ed- _ 477 O ),�,P._ LaI . Signnrt uIL �4•y'u¢ Date .. .J 1 T . , f( C . M , 2I V t Z C 5.01 LZ" .. V , > - ; 3 i �o t .1 c1YF!' __nN i s,7=a 117:Y 110 I j 1 'IC Lid h .lZ 3 v L I .(nCCIN 1 M i fi rr2r H 1 .21.a' 4 „ ) vv 1 NTJO pJ � I 7LFITFOKW'. 1 i I ELVP-ior I -n ' ACCENTS I_OuNOE , P1 7) VvH15 N16HTCLUP 1.1 't i ot <. _. ___ __-_ _ -_..____ __-_-- 27/ IPSO--. __.. -. > v p°o sl it 0 P ri r 1 4 ATS17t7 buil viF1 1 0P enl 6rl-I!1. MOOR -DOuKA 1< „t ,..g > Ik 01 $ > E -- res I I ---,. File#BP-2005-0637 APPLICANT/CONTACT PERSON MATT MURPHY ADDRESS/PHONE 110 PETTICOAT HILL WILLIAMSBURG (413)268-7892 PROPERTY LOCATION 492 PLEASANT ST-DIVAS MAP 39A PARCEL 076 001 ZONE GB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ,^,// *SO Fee Paid /06/ *SO Tvoeof Construction: CONSTRUCT PARTITION WALLS&DOOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owned Statement or License 066916 3 sets of Plans/Plot Plan THE FO ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Commis Z•i Signature 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. Version!.7 Commercial Buildin:Permit Ma 15,2000 (-Di if Northampton � It 'Ting Department _ 2 Main Street 6 `,.�, .� Room 100 s -sz %'E' 4Nor _ 1 'nntt pton, MA01060 phone 4134587- 240 Fax 413-587-1272 [ y —:„..-.:4- . APPLICATION TO CONSTRUCT REP, R,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING _ "— OTHER THAN A ONE OR TWO FAMILYDWELLING _SECTION)-SuE INFORMATION .ALL ' ' t-ThiSsectior'tq beeomplefed-by'oftiC0-. . ". +.1r ePem Aaaress .. I SpA �y9Glegsc� sr . � SECTION 2-PROPERTY OWNERSHIPfAUTHORIZED`AGENT - 2.1 Owner of Record: Name(Print) ' . Current Mailing Address: Signature - Telephone _ 2.2 Authorized Anent: I l 0l'C1 /'``nn 1 . itlit6NC7 Name(Print) -\ Current Mailing Address: Signature a . / // eir/ Telephone SECTION 3- STIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building I t.gOda '.(a)Building PemnR Fee 2. Electrical 4 /n dU (b)Estimated Total Cost of - �r n �J Construction from(6) r�4 C 3. Plumbing I 0 Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection I 0 6. Total=(1 +2+3+4+5) -Check.Number /06. V Cif j�— This Section For ONlcial Use Only Building Permit Number' Date Issued Signature: Building Commissioner/Inspector of Buildings - Date Vermont Commercial Building Permit May 15,2000 • SECTION01-CONSTRUOL10N5 ESFOICPfbJEETSL SO THAN 35,000 CUBIC F.EETOF ENCLtSED=SP� `' Interior Alterations 0 Existing Wall Signs ❑ Demolition Repairs 0 Additions 0 Accessory Building 0 Exterior Alteration 0 Existing Ground Sign❑ New Signs 0 Roofing Change of Use❑ Other[' Brief Description "Enter a brief description here. Of Proposed Wait . - i 4`Do oolZ. SECTION S-USEGR2IURAND CONSTRIlCTIONsTYPE - USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-i 0 A-2 0 A-3 0 IA I ❑ A-4 0 A-5 ❑ lB 0 B Business IS A-5 _ 0., _ _ 2A 0 E Educational ❑ 2B 0 F Factory 0 F-1 ❑ F2 0 2C 0 H High Hazard 0 34 ❑ I institutional 0 1.1 0 1-2 0 1.3 0 38 f7 M Mercantile 0 4 ❑ R Residential 0 R-1 0 R-2 0 R-3 0 5A 0 S Storage 0 S-1 0 S-2 0 58 I ❑ U Utility '❑ Specify:I — -_ M Med Use ❑ Specify: S Special Use o Specify. COMPLE ltTHISSECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDOIONSANDIOR CHANGEIN USE Existing Use Group: I. - Proposed Use Group: ".— Existing Hazard Index 780 CMR 34): ( Proposed Hazard index 780 CMR 34):1 t SECTION S BUILDING"HEIGHt}W DAREA, BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION " "'"` -'I 17- "sx k1 . , ✓ v-YB-moAt Floor Area per Floor(sr) x y ' 'SC; I— – t tee„ 2'4 ' id pl 3 a i - i 3 -'-7--1.7 7,(1 y i Nrt 4e ET" 4a --.... - . 1-- .. 4' =''Y"a Total Area(sf) i 1 Total Proposed New Construction(sf) r . tit '--i.7.2.2.:-:;_., Total Height %) I „g " a tiseati. ;of 11114 Total Height ft 1d' t.:Z _ 7.Water Supply(M.G.I.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private ZoneI L Outside Flood Zone Municipal On site disposal system Versionl.7 Commercial Building Permit May 15,2000 s, ftp 1e§ ,a1 r,TJ_'N ,, Existing Proposed Required by Zoning This column to be filled in by Building Department •Lot Size 1 I I I I Frontage II I Setbacks Front , I Side I<` I Rv I L:C1 R= rilri Rear I ' l II Bolding el - _ l _ ,. Bldg.Square Footage I % F-11 I_ I I Open Space Footage % ri (Lot area minus bldg&paved 1 1 1 I I I i ! I , parking) #of Parking Spaces I Fill: ' I; (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ?a DONT KNOW 0 YES 0 IF YES, date issued: 1 IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document#I, B. Does the site contain a brook, body of water or wetlands? NO 7`^ DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO 0 IF YES, describe size, type and location: j 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,ex ation,or filling)aver I acre or is it part of a common plan that will disturb over 1 acre? YES 0 I NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version'.7 Commercial Building Permit May 15,2000 SECTION B-PROFESSIONAL DESIGN MO CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURESSUBJECTTO CONSTRUCT1OF1 CONTROL PURSUANT TO 780-0311 116(CONTAINING MORE THAN 35,000.C:F.OP ENCLOSED SPACE) S.1 Registered Architect i _ "� Not Applicable 0 _ ,1 Name(Registrant): .. JRegistration Number Address I i Expiration Date Signature ........-Telephone _ . 9.2 Registered Professional Engineer(s): Y Name Area of Responsibility 1 _ Address Registration Number — Signature a ^......Telephone Egtitation Date NameArea of Responsibility ...... — Imo. .. Address Registration Number L 1_____ Signature Telephone Epiratin Date 1 II i _ _ -. Name Area of ResponstbA'ty I E Address Registration Number Telephone Expiration Date __J Name Area of Responsibility 1I Address Registration Number _ i Signature Telephone Expiration Date 9.3 General Contractor ))�� /`1 /� 1 rf%rr0 ante 4/9 CL-# i46 f/C7 Not Applicable C Company Na e: _Megair_n9_? �Y ar )3Y 77J Responsible In Charge of Construction Addres ht. at. R17-717 Ft _„ — Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 130.11) ' - IndependentStructuralEngineeringStructuralPeerReviewRequired Yes 0 No 0 SECTION 11-OWNER AUTHORIZATION-TO BECOMPLEfED.WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. Aot r P- ///K 6NJ ,as Owner of the subject property hereby authorize M/9. /17 vK VA/ 'to act on m e If,in all marelat a to work authorized by this building permit application. /p/qs� /�/y// Sign ureGF Omer fr_ Date MIMIMIIIIIIIIIIMIIIr- I 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 penury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction�[`5q�u.�piervisor: Not�Ap�pliicca(bl�e El Name of License Holder:1 / ' r l7t male AT ; 1_L�! �- / License Number '//a Pette cun7 M/l Lf &irk i / -0a' Address 1�" Expiration Date Signatu ✓� 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 0 No 0 I • =oRnwfrroy r_ - — _ ,,rof of Portllaulpton t,54.41.74. sidev D EP ARCM ENT OP nUI WING INSPECTIONS • -• 212 Main Strcct ' Municipal Building _ Northampton, Mass. 01060 �r•" " R'ORICI2'S COMPENSATION, IINSURANCh I, 1r._7l /11v_gelLy 1Jla nmttcc) _..----- nE212--121 nr;p=I prasea_busiress/r noe-zt-.y.--_ //o /"'etSOXIT �//'- £ l— (phone')_�� �Lag (4fci/ci ty/saleizi p) do hereby certify, under the pains and penalties of perjury, th.=.: () I am an employer providing the following workers colnoenseuon coverage for my employees working on this job. Qnsurnc Comcan-) - (Polio Ncrir_r) (rxpindon Dais) ( ) I am a sole proprietor, general conrracror or homeowner (ci tie one) and have hired the coon-actors Listed below who have the following worker's campensauon policies: (Name of Co^.n^.c:on (Innuanc Company/Policy Nuri.-r) (-tru:muoc Dam) (No=of Coomaor) (InsJrznc. ComoanvRolic Nwdcr) (Lipir..rion Dale) • • Mame of Comaaor) (lfuvranc. ComPany/PoUq Nambs) (Expos-sties Dale) (Name of Contractor) (tasuranc Company/Policy Numbs) (Eapia000 Dale) ems,*:a;socsi tS,a .-y to 'u&frnsoc F.=-•46s o.11 oo -fl) Jr ^' am a sole proprietor and Gave no one working for me. ( ) I am a home owner performing all the work myself, NOTE pl.-.-bt 5.rch.:wtalc bem9wter uM®play pevom to r. (t oekm.d".ILa or 1551 mug L1=51—Ste=its in with Nc' a gado.ac w to pwod appurteoec tbc-eo..z L.fly ccc4da u be Tc11411oyci uode 5c uuhen..-.-p—.,'c Act(GL14ivl(5))yeliaiotb hoameaa fo a Lev:or pmv.zy Einax the ISJ.u..elan gloy.r uWm rho Woeoa.Compaant.i.on An 1 >bd »'y of d cm.tonacsi m'y b.rmm.d.J to W.pry..un of b>az:J Amdmf Otto...!Imam for muc>_bt wiGmico M NV LJuc to srt bovcrae mia anion]s A of Mob 152 CLO lad La thc..,rea.On ofc;aioil PC13411i0 n.+u'4 o(.rine e(Lo?•o SIS00.00 uWor innprvtomy or up ta ea year end ovil pa.rm w to(um or.5559 W o.t On!c.nd• r of3100-00•dy against roc For d tlsn .tu.n mty y Pamir Number /�/ !!/ /d4 1'f Harps Lot Sipa uxc I •is'ume _2 _ .... _. W ' NUJ.J 7 1 A 1 I y ,... _ I P+ i A- n f a7'Jo.s' > r IZ i 43`r I Z , w NV I .3 i y — OPEN &Ail2Wt+CE I I -Dao R_ I 1 avcK I _._._ r4 ' .z/./ y ,. T I vv N1)o,..1 l I _Et tVKro._ 1 T h p I J� o, r NtcENTS L-COO N C,C - 'N' I VvWs NIG i rcLVB a E ._. ___.._... ...___ -_.____. __—__ ,27, I a5 .. . ... _ . . . __ -. i 1 -1 P 1a } ' 4.._ _ �- - ��t�la t�.CL 1 tioo ?"-)vi I_ ;Doo � J�V"AtiV furl w��� OPeni �ro Fe) > lk ,s >_ ' =As z ` 'ri