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The Commonwealth ofMassachusetts
Department oflndustrial Accidents
gal
Office of Investigations
600 Washington 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):
Address:
City /State /Zip: 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
' ` have hired the sub - contractors 6. ❑ New construction
employees (full and/or part- time). :
2_0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
These sub - contractors have
ship and have no employees 8. Demolition
working for me in any capacity. employees and have workers'
g Y P h'• 9. [] Build nQ addition
[No workers' comp insurance comp.: rncirranC� #- -_ -, . .
required.] 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions
i
h
d i
have ave exercse their 11.
3. ❑ I am a homeowner doing all work ❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §I_(4), and we have no
employees. [No workers'
13. ❑ Other
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 him outside contractors must submit a new affidavit indicating such.
} Contractors that check this box must attached an additional sheet showing the nave 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 $250.00 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 and • pains and pena perjury that the information provided above is true, and correct
Si. iature• — -- Date:
Phone #: ///,3 S r 7 5 A/ ®
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
I Contact Person: Phone #:
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10 STRUCTURAL PEER REVIEW (780 CMR f1011) „
Y
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION 11 - OWNER .AUTHORIZATION TO B.E COMPLETED lIIIHEN
OWNERS AGENT OR CONTRACTOR APPLIES 'FOR BUILDING PERMIT
I, - as Ownerr of the subject property
hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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 Constructs Supervisor. Not Applicable ❑
Name of License Holder I -, - - -, - ---
License Number
C� , A 0 ' t 4i - (4 4,4 Sl frLJ1- 1/A4G l ti A 4 I
Address Expiration Date
Signature '° Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c -. 152 4 § 25 C(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
Version1.7 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 MORETHAN 36,000 C.F. OF EI, r LOSEO SPACE)
9.1 Registered Architect:
Not Applicable ❑ — —
Name (Registrant):
I Registration Number
I
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
- � l
Name Area of Responsibility
s •
Address Registration Number
Signature Telephone Expiration Date
I . .
- a
Name Area of Responsibility
Address Resistration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
3 —_ — ......r— .— �......w. _
a f
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_ Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON , ONIN
Existing . Proposed Required byZoning .
This column tole filled in by
Building Department
Lot Size ii - i
Frontage F. __ ? ,
Setbacks Front i 1 ' l
Side L:? I R:} J L:1 R:! J j
Rear l £
Building Height l i -- i 3
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved g -- -
parking)
# of Parking Spaces
Fill: _.�_ i _—__...____._.. Vi
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO CD DONT KNOW 0 YES 0
IF.YES, date issued: i '
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 Page; and /or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO 0
IF YES, describe size, type and location: t
_ D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
S
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPADE • '1
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. i Y\ s `' ■r S (. i--ow\ h\ \ \ S 1 4-0
Of Proposed Work: _ \�,Q a �\ t *\ � _
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) ' CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ . • A -3 ❑ 1A 1 ❑
�, / A-4 ❑ A -5 ❑ 1B ❑
B Business t� 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H-High Hazard ❑ - - - - �_ - _ : = 3A ❑
I Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage . ❑ S -1 ❑ S -2 ' ❑ 5B ❑
U Utility 0 Specify:
M Mixed Use ❑ Specify: ( I
S Special Use ❑ Specify: 1
COMPLETETHIS SECTION IF EXISTING BUIUDINGUNDERGO12sfG REN .OVATIONS ADDITIONS AND/ORCHFANGE IN USE
Existing Use Group: Proposed Use Group: ! .�!
Existing Hazard Index 780 CMR 34): ` ( Proposed Hazard Index 780 CMR 34): > i
SECTION. 6 BUILDING HEIGHT AND AREA
4 OFFICl USE fINLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ,-
Floor Area per Floor (sf)
...... ..- ...__- ------ - - -- -- - ----- 1st
1 st
3`1 3 rd
f _
3
4
m ' 4 i
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 ❑ Private ❑ Zone 1 Outside Flood Zone❑ Municipal ❑ On site disposal system E]
a 1. , A.
— f ersion1.7 Commercial Buildin: Permit Ma 15, 2000
. ..:` , ....(, -7 - 77 :7 777, 7- 7 -7-71. v.i,i-,fr4 1 '..-'",.. .
■. ,,,-' ,.._., „..„.„,—. „'
, RECEIVED City of Northampton ti'l,r -
v Building Department ,.1:1.,....,--. -i 1
.,-; r,-.,....,„,,,,„; ,
is-. .,-.1 .,...............: ,,,..
.,.. „.„...._,.,_., ,,, „_.-„:„
DEC 3 0 LOU ,.,,..,...,:,..1.:„,...„-.,,,,,,,--.7,,,,;,„,„,;,„.„4-,::7-04-,*
212 Main Street ' '9-,.‘,0,-:.ar,i'...40.,?'-ir.i-;---,,ii i.v.:::...7it.i3O2.A
11 of -,::::::,,,,..,,, ,. ..'..., -, , ,, ...:1 - 5,
R oom 100 , ,,, , ...,r,e , ,, ; , 1,-- , ,
,,,,-;.,,-,„.., ,,,,,--, ,,,.
--,--- -- --- ,7.. , iftil 1?-.-- „,„
Northampton, MA 01060 1,,,, ,„,,,,
DEPT OF BUILDING INSP
plioNte 413-587-1240 Fax 413-587-1272
NORTHAMPTON, MA 1060 r - '1, ...,. 7 -7 – .7,, , ,, :%:..,,, r t2. ti
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
This section to be completed by office
1.1 Property Address:
____
-r-, „
1 Lot
37 e SOU Hip feYi I'Vt . ' Map Unit
o / o &, 1 i' ' ' lay District
' Aiar 4+ 1 ‘ 141/1 1 0 itlY) i / 4 0 1 ..,.?,,,, Over
---EIrri-St-District - - CS bistrict
,
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
•
2.1 Owner of Record:
-----
,
, _0__— J/ _. i 1 1 1.1_,2 7
Name (Print) Current Mailing
2 /77, t'-'„/
Add ess:
___,
.■4 ! Z1/3 — "4" 5 / —aa7(4/3,,
Si - -- .4 1111111111111111111 : ■ . I .r,_ o e d mii_elephone
2.2 Authorized Agent:
P 1 ,
_________,
, _ __ _ __ ___ _____ _
Name (Print) Current Mailing Address:
. I
i --------
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be - - Official Use Only
_
completed by permit applicant = _ _ _
1. Building I (a) Building Permit Fee
--_-,—__I--- .
5 oc0 • Z Electrical I (4 Estimated Total Cost of
„ , Canstrubtion from (6)
., ..
3. Plumbing 1 Building Permit Fee
4. Mechanical (HVAC) _,.... , -
5. Fire Protection
6. Total=(1+2+3+4+5) Check Number ...,i5 e (25 cp 0 —,,,, •
This Section. For Official Use Only
Building Permit Number Date
_ Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2012 -0608
APPLICANT /CONTACT PERSON RONALD HODGES
ADDRESS/PHONE 60 NORTH MAPLE ST FLORENCE (413) 586 -1150
PROPERTY LOCATION 376 EASTHAMPTON RD 5'75 -51 ) l
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 �"J �I 4,:e
Fee Paid S'S / ' v.4
Typeof Construction: MOVE STAIRS FROM HILLSIDE TO SIDE OF BLDG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 003042
3 sets of Plans / Plot Plan
THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
FO 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 Commission Permit DPW Storm Water Management
,;. ela
/ 3
Sign. - of :u' din fficial 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.
376 EASTHAMPTON RD BP- 2012 -0608
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44 - 056 • CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0608
Project # JS- 2012- 000903
Est. Cost: $5000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RONALD HODGES 003042
Lot Size(sq. ft.): 21300.84 Owner: FOURNIER FRANK N III TRUSTEE
Zoning: GI(100)/ Applicant: RONALD HODGES
AT: 376 EASTHAMPTON RD
Applicant Address: Phone: Insurance:
60 NORTH MAPLE ST (413) 586 -1150
FLORENCEMA01062 ISSUED ON:1/4/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:MOVE STAIRS FROM HILLSIDE TO SIDE OF
BLDG
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 1/4/2012 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner