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19-012 (23) ^ � ' � JDR Builders Inc. ° POBox 4 North Hatfield, Ma.01066 CSL#O741O5 H|[# 18475S (413)374-7903 October J9,ZU18 Louis Hasbrouck Building Commissioner City mfNorthampton 212 Main Street Northampton, Mass.O1O6O ]oboite: 22Industrial Drive East Scope: Replace 7 leaking sliding windows on the 2 nd floor with new windows. Dear Sir: I request that you grant a modification to waive the requirement for controlled construction for the project at 22 Industrial drive East, Northampton, because the work is of a minor nature,will not affect health,accessibility, life and fire safety,or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work.Thank you for your consideration. Respectfully, James Q7Ross y � President ]DRBuilders Inc. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �} Please Print Leeibly Name (Business/Organization/Individual): Address: Q(�6: Gc, City/State/Zip: l/'� d�'J 1�►'t r1 - 010`i"3 Phone Are you an employer?Check the appropriate box: Type of project(required): 1.�„am a employer with!�employees(full and/or part-time).* 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. f7Remodeling any capacity.[No workers'comp.insurance required.] 9. nDemolition 3.Q 1 am a homeowner doing all work myself[No workers'comp.insurance required.]' 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. l will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no 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. 51, Insurance Company Name: ,fr�/�, Policy#or Self-ins. Lic.#: ,V V C 1 d iY`7 l'l Expiration Date: Z Job Site Address: .� Jn'D�!fR t b?� �il�s City/State/Zip.k/ , t ti Attach a copy of the workers'compensation policy declaration page(showing the policy number expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificati Ido hereby certif u de the ins and pens ' , o perjury that the information provided /abo e ' true and correct. Si nature: Date: t I Phone#: 1,10 Official use only. Do not write in this area,to be completed by city 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#: I City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: � 2 pqvjN-,A%- The debris will be transported by: W'i'rc The debris will be received by: Building permit number: Name of Permit Applicant �� r I� I V Date Jign'ature of Permit Applicant Version 1.7 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t�pt.-Schii — 0 / 17 Ce— m a r't aty&';/ as Owner of the subject property hereby authorize J, b, �. 'Z U)U Z-5 /,K/` to act on my behalf, in ail matters relative to work authorized by this building permit application. Si �00wner ! Date 1, LI1, - , 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 penalt' s of perjury. Print Name Signature of p edAge t Dat SECTION 11-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable O Name of License Holder, NtnS �-�' 6f! "? f 4 License Number V- ) M'1 errs G Ll-1- 20 Address l-1- Address �.-----— Expiration Date /]- �' 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 b ilding permit. Signed Affidavit Attached Yes No 0 Version 1.7 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 ll}Contractor ;+-- '�)IC� Not Applicable ❑ Company Name: -j, �\ , �©�� Responsible In Char a of Construction U. ho W►I�-I �{D�'ri Address 790 Signature Telephone 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 \01 (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/F' ding ever b\edon site? NO 0 DON'T KNOW 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry NO 0 DON'T NOW 0IF YES: enter Book and/or Document#B. Does the site contain a brook, ody of water or wDON'T KNOW 0 YES IF YES, has a permit been r need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the roperty? YES 0 NO IF YES, describe size, pe and location: D. Are there any propose changes to or additions of signs intended for the property? YES 0 NO a IF YES, describe si e, 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 l.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. Of Proposed Work: )4f CP 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 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H Hi h Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A [] S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ 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: 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 OFFICE USE ONLY Floor Area per Floor(sf) 1 1 se 5t 2nd 2nd 3rd 3rd O _ 4th en 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 ❑ ZoneOutside Flood Zone[:] Municipal [3On site disposal system❑ i�v D orv.S Gv Version 1.7 Commercial Buildinp,Permit MaX 15,2000 REG City of Northampton Status t ' t"M a; �uildin De artment 9 p Curb Cu O way'PWft -f u NOV 1 ?018 212 Main Street r ` I Room 100Wier `Av�i ' North DEPT.OF BUILDING INSPF.CTIOM ampton, MA 01 060 TWO�of, NORTHAMPTON.M h 87-1240 Fax 413-587-1272 Other "°T APPLICATION 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 ,Qf 1.1 Prooerty Address: QThis section to be completed by office p/t�1�SM-l,gZ1�►'�6A j,q'��— _ Map l Lot ClZ Unit ' Zone Overlay District - Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n j- r�_ Name(Print) Current Mailing Address: Signature '—Qr17C p Telephone 2.2 Authorized Agent: Name(Print) /'of ale 4k� CurrentMailing Address:t Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee c,J 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection j 6. Total= 0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit NumberTissued ate Signature- ;'e, ignature:;'-- 1 Building Commissioner/Inspector of Buildings Date 45 INDUSTRIAL DR BP-2019-0544 GIs#: COMMONWEALTH OF MASSACHUSETTS M@V:Block: 19-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit 9 BP-2019-0544 Project# JS-2019-000881 Est.Cost: $3500.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JDR BUILDERS 074105 Lot Size(sq.ft.): 10 1930.40 Owner: MALVERN PANALYTICAL Zoning. Applicant: JDR BUILDERS AT. 45 INDUSTRIAL DR Applicant Address: Phone: Insurance: P0BOX 4 (413) 665-7587 WC NORTH HATFIELDMA01066 ISSUED ON.-111612018 0:00.00 TO PERFORM THE FOLLOWING WORK.-INSTALL 7 REPLACEMENT WINDOWS 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: mo e: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee7VYve: Date Paid: Amount: Building 11/6/2018 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner