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38B-104 The Commonwealth of Massachusetts Department of Industrial Accidents :, _ -- Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information p Please Print Legibly_ Name ( Business /Organization/Individual): S +t o /%9 /td,r M 7711.5 i.L C- Address: / - 5 - 2 " STIZEf% Loft/ G/(j /9.60.1 /to jY/r ©C' City /State /Zip: 1 .i 62,Yt'G Phone #: q/.3 --37 7 9 7. Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. New construction listed on the attached sheet. 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance omp. insurance.$ required.] 5. Ig We are a corporation and its 10.0 Electrical repairs or additions 3. lam a homeowner doing all work officers have exercised their 11.r1 jlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 $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 cer ' nder the pains and penalties of perjury that the information provided above is true and correct. / Si•nature: o Date: 3d�` Phone #: L / 4 .�7�/'SfO� 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 #: } 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 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 1, 3K.1/9 L . GL . , 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 N.u- 3. 30 .1 / Si. a ur- . . - /Agent Date SECTION 2 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : / of #1" 4 4 ' License Number `ter ..% ® Joe,4 l✓( 44 . _✓`7..' ,_o /( .. ..,.._ ._ . -. "... 1. ._ Address Expiration Date Ali .. 7 4 1- t ,5761 ,... Si r 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 No 0 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 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 Rtgistration 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 Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Version1.7 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. Rear 7 . W Building Height 3o H ,_ Bldg. Square Footage 5p-ep Open Space Footage % (Lot area minus bldg & paved parking) i # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW ift YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ' Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 • 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. Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,00 0 r CUBIC FEET OF ENCLOSED SPACE " # i uiI b j Interior Alterations 0 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building di Exterior Alteration ❑ Existing Ground Sign ❑ New Signs Roofing ' Change of Use q Other ❑ 1 A Brief Description Enter a brief description here. si Of Proposed Work: 4 PLf l 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 ❑ 2A ❑ E Educational ❑ 2B . f ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ I 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 58 ❑ 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: 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) 151 1st aZ q 4. ._, . , , _ .. .._ ,..__. nd 2nd ;-D L1 _,._ 2 U �.._.. . ...... _ 3 rd 3 4 th _ . Total Area (s f) e/ 1 4., Total Proposed New Construction sf) , _ i Total Height (ft) 3 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 Outside Flood Zone❑ Municipal On On site disposal system __.■ Version1.7 Commercial Building Permit May 15, 2000 w "I Department ease ,.; 5 Ci ■ of Northampton St atu s�r mr k . Y ! f ev A -t i v a s k - €: ta°t� F,n x b �n Bu ding Department CurCutiotW4wayf Pemrt t ` - 1111 3 4v 2 Main Street w r §e va i s st g:� Room 100 ttVtafer/Vlelf. vai ?at i i o of BUo*NG u+sPECZ! ; : rt i - pton, MA 01060 Two Sets of Stmeturat Ptans - • 1 3- 587 -1240 Fax 413- 587 -1272 PlotlSate Plans Other S pe c ify >. 4x a .; 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 1.1 Property Address: This section to be completed by office /g fGlAigef (57XE Map Lot Unit Zone Overlay District _ - Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: $ °/ ._P./ 7 "4, . Name P » t) Current Mailing Address Signature Att - I .. Telephone L / /7 7Y 2.2 Authori • . • . nt: 1 /et!t'■ s- G✓H� Cam ___ _ _ ,._v _ . .fin �� , ...._ _ Name (Print) Current Mailing Address: Signature //1( �- Telephone SECTION 3 - IMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ,/ O (QUO (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 - - ._'.. .. - /'� (0 6. Total = (1 + 2 + 3 + 4 + 5) /0 � 0 Check Number 41.. This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 13 MUNROE ST BP- 2011 -0786 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -0786 Project # JS- 2011- 001293 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BRIAN WALLACE 96771 Lot Size(sq. ft.): 11979.00 Owner: SEQUOIA PROPERTIES LLC Zoning: URB(100)/ Applicant: BRIAN WALLACE AT: 13 MUNROE ST Applicant Address: Phone: Insurance: 488 PORTER RD (413) 374 -9502 SPRINGFIELDMA01128 ISSUED ON:3/31/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF 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 3/31/2011 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner