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It is impractical in that the cost of controlled construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, 0 - 40° 9' Brian Fournier General Manager Ernie's Towing 376 Easthampton Road Northampton, MA 01060 (413) 586 -1021 • N".`d "111(14'Al Ned w' byl.. 91£' Thomas M. Aquadro General Contractor 38 Linseed Rd West Hatfield, MA 01060 Hired Sub Contractor: I have hired the sub contractor listed below. This sub contractor carries liability insurance and does not have any employees working for him. Robert Piekarski National Grange Ins. 6/4/11 — 6/4/12 • The Commonwealth of Massachusetts Department of Industrial Accidents �:- -- Office of Investigations 600 Washin Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business / Organization /Individual): 40 Alf Aft ' i Lj Address: 0 -0 - 0_ . i . -^ City /State /Zip: „ ¢- L4 11 Phone #: • 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. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees 8. ❑Demolition working for me in any capacity. s' 9. ❑ Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions ❑ officers have exercised their 11. Plumbing repairs or additions 3. I am a. homeowner doing all work ❑ myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §I(4), and we have no 13. ❑ Other 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. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 5250.00 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 penalties of perjury that the information provided above is true and correct. Si• nature:- 41 .of 11 . i .v /J _! Date: /�� 2 Phone #: j3 '3 4/6 J if ^ cz 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 #: Version1.7 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 • SECTION 11 - OWNER. AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING i PERMIT I, f - _- _ . 4‘ .. _.A , , ? _4,� _ _.. _.._.W ___ ...>._w ___ ___ _.. .._ as Owner of the subject property hereby authorize' . 2fl/ M-f_ -A QuitLIRD act onf, in all t• - • ers relati,• work authorized by this building permit application. ignature of Owner Date to _._.. _: , 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 penaltiesofser u�yr _ ____ - nnt Name r , • «�..i = Ae .cam — ..+ .410 ' `�, ._ _.__ ._...._, ign -ture of Owner /Agent Date L SECTION 12 - CONSTRUCTION. SERVICES r i 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder . , .G)..Ila ... :.d.. *. ......,..,_.. __ C ? G e .. . License Number ....3-4S._,Z . t. C-Ad..__ .. lAl 7`_ . _.t . 44, X17,1 41,x.1.._._ r ._.. _._. _.. _.. Address Expira ' n Date Signature Telephone SECTION 13 - WORKER / S' 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 410 No Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN CONSTRUCTIONSERVICES - FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR116 (CONTAINING MORE THAN 35,000 • C.F.-OF EIJSLOSE© •SPACE) 9.1 Registered Architect: _ } Not Applicable ❑ r ---- Name (Registrant): _ --- _ __,__.....___ .. Registration Number Address __ ___ . _._.._...._...._...,. Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name • Area of Responsibility Address Registration Number t Signature Telephone Expiration Date ....— r I Name Area of Responsibility t Address µ Registration Number t Signature Telephone Expiration Date Name Area of Responsibility f Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor , .____.._m_._._ _._. ._..... . .—_ ----- Not Applicable ❑ Company Name: _ Responsible In Charge of Construction w__..._ m .______._..� .�_. �� ,�..__„M.._....�... _ Address Signature Telephone , pjo Version1.7 Commercial Building Permit May 15, 2000 ., 8. NORTHAMPTON ZONING , Existing Proposed Required by Zoning , This cokann to filled in by Building Department , Lot Size 1 ; „ .: Frontage : _ Setbacks Front ' Side R:=— i L: .....i R::__ '.i , !, , ., Building Height - , 1 Bldg. Square Footage ------1 i ------- % 7 . 1 ' i Open Space Footage % (Lot area minus bldg & paved : parking) # of Parking Spaces Fill: (volume & Location) * <- A. Has a Special Permit/Variance/Fin• ng ev - been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: !, IF YES: Was the permit recor. -d at the Registry of I -eds? NO 0 De T KNOW 0 YES 0 i --- IF YES: enter Bo. ° Page° ° and/or Document # B. Does the site contai a brook, body of water or wetlands? 0 0 DONT KNOW 0 YES IF YES, has a p: mit been or need to be obtained from the •servation Commission? Needs to be •btained 0 Obtained , Date Issued: C. Do any si• rs exist on the property? YES 0 NO COI IF YE , describe size, type and location: ___ D. Are ere any proposed changes to or additions of signs intended for the wroperty ? YES 0 NO 0 _ _ ........._ YES, describe size, type and location: ___ _........_ E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre • 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 1.7 Commercial Building Permit May 15, 2000 4 ' ......, .. SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE ' T III 1. Interior Alterations tgi Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ -.._ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing❑ Change of Use ❑ Other ❑ , , /. . 4 a Brief Description Enter a brief description here. Cv nr *v ca`- A2iii/4/ - mod �v% h v, ri '� D 2 -.ilGe . 1 Of Proposed Work: jVj 4 LL 4 xip,f i'l 000R %N "VA d e d F Ex)Zsb'■/i i',A/dt ' on/,c f¢ S.4'="e el 451'46"/A1-- SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) , CONSTRUCTION TYPE A Assembly A -1 0 A -2 ❑ A -3 ❑ j IA ( ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B r ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard 0 - - 3A ❑ 1 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 1 iK U Utility ❑ Specify: ; M Mixed Use ❑ Specify: 7 S Special Use ❑ Specify: F E 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) t 1 sr —.w 2nd . ._ . m __ 2nd .... _ _.. _____ _ __ i 4m_ _. _ _ 4u, ' ..__ _ _ __...___ _.... € Total Area (sf) "'Total Proposed New Construction (sf) - 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 0 Private ❑ Zone ___ __ _ Outside Flood Zone❑ Municipal ❑ On site disposal system❑ \ ] ,.J� Version1.7 Commercial Buildin: Permit May 15, 2000 L■"v� D ®art t o e '.; �� fl':. City of Northampton y m IN • I I Building Department ,, 212 Main Street a. , .& Room 100 a a y� aim i7t . '.- i. - w:i C \lorthampton,; MA 01060 � � R? I ; ' t on 413- 587 -1240 Fax 413 - 587 -1272 J o0,,S ns . ° DEC - 1 2011 :�ge A 0 ..,,.. � , ' APPLICATION TO CO ST CT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING ( OTHER THAN A ONE OR TWO FAMILY DWELLING DEPT(,r bJ ^ , SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 274` FAC-1h A � n Map Lot Unit At O ff,, l4vnp dD iv/ f}. ed d b� Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Signature A.,/ ,� , fil--- ` - *" --- " -- " 2% Telephone 2.2 Authorized Agent: Name (Print) Current Maili,Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS L Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ( a) B uilding Permit Fee ww 2. Electrical 7 (b) Estimated Total Cost of o ¢0 _ o Construction from (6) __..___._. „ .___ .._._ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) _.. --.. - --- 5. Fire Protection -_.,__ _____ ___ ._ ._.. _ 6. Total = (1 +2 +3 +4 + 5) gj OD • af." Check Number �'�� 0 ° ` � This Section For Official Use Only Building Permit Number Date . Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0541 APPLICANT /CONTACT PERSON THOMAS AQUADRO ADDRESS/PHONE 38 LINSEED RD WEST HATFIELD (413) 348 -4444 PROPERTY LOCATION 376 EASTHAMPTON RD MAP 44 PARCEL 056 001 ZONE GI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i2.j 4741° Fee Paid /!�v Tvpeof Construction: CONSTRUCT INT WALLS FOR OFFICE,EXT DOOR & EXTERIOR STAIRS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 083682 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Conunittee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay 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.