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22B-043 (11) , Board of Building Regulations and Standards Construction Supervisor License License: CS 67805 Expiration: 4/19/2010 Tr# 23688 Restriction: 00 WILLIAM D CROCKER JR 36 SPRINGFIELD ST - WILBRAHAM, MA 01095 Commissioner ,,, The Commonwealth of Massachusetts w Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information ((11 Please Print Legibly Name (Business /Organization/Individual) : ��e� ee V \ � v Ccy t{ 1d,�, y, Address: City /State /Zip: c, . z c \J , b \,,0L Phone #: C`i Are you an employer? Check the appropriate box: Type of project (required): 1. N., I am an employer with 'zt�. 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part time).* have hired the sub - contractors 7. Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required] 5.0 We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required] t c. 152, § 1(4), and we have no 12. ❑ Roof repairs 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. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach 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: 4! M N1 ki ra\ .L,tS Ca ca.. Policy # or Self -ins. Lic. #: L.) ma }' pS tisOc ( Q 2,9 Expiration Date: 3 J3 0/ QO ID Job Site Address: as G L4cJ e SV City /State /Zip: ■NA 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and pe alties of perjury that the information provided above is true and correct. Signature: � Date: 7 /0?WO? Print Name: Lc., //,. , u erc3Cle.0-C J/C, Phone #: '�13 737 76'+ 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 Heath 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: t , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M_A 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. n 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 listed on the attached sheet. 7. ❑ Remodeling 2. [1] I am a sole proprietor or partner- ship and have no employees These sub - contractors have g. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 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, § 1(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. ' 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Sicnature: Date: Phone #: 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 #: 1 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 OD SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT M.A tf \ ■W(\- Vk -��5. LL-C as Owner of the subject property hereby . uthorize ' "^^ -- . to act on y behalf, ,TI ma s relative to work authorized by this building permit application. Sign r- of Ow - Date e ,. , 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 p�enalties of perjury �v \� .%�.r• V'.COCkS)..SZ J e Print Name Signature of Owner /Agen Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : �� A✓ e. .�R�C �� a wv .,.. .._.�._. 6 — ) License Number Address Expiration Date 737 7go_? 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 building permit. Signed Affidavit Attached Yes ® No 0 • • ... • 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 t� Setbacks Front Side Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved fc.1 11) _ parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 9113 DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW (3 YES Q 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 Cr) IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued. C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • 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 El w Name (Registrant): A' -1 a �...� e,as�� � �S'�.�S�.L� /a Registration Number Ada * )13 Expiration Date :'..nature 4111 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 Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address )8 Signature Telephone F Version1.7 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 gj Existing Ground Sign ❑ New Signs ❑ Roofing 1=1 Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: .11--..vS:R \\ Mil N\. SN i it c' CJZ EA s 'z k '` - ' S -i'4s0 \Ate A-' �P�e - SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I El A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 1 2A ❑ E Educational ❑ 2B I� ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ y 3B '010 M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage liZ( S -1 I S -2 ❑ _ 5B I ❑ 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) 1st 1 5t 2 nd 2 3 rd 3 rd 4 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 'b°, Private 0 Zone Outside Flood Zone❑ Municipal xi On site disposal system 4 • • ` Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer /Septic Availability Room 100 Water/WelfAvailability Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR D IvIOLISH ANY BUILDING OTHER THAN A ONE OR TWO F'AMIL.Y DWELLING, , ; I SECTION 1 - SITE INFORMATION „) i 2 J 2009 LL 1.1 Property Address: This section to be completed by office a , t.l«C3s1N..Ck Map - jr Lot '� Unit �� OCew,CQ M 14 Zone - Overlay District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: M N \ -, . L �C a 6 cN ► LL Cik=(z:•0. !\'‘ Name (Print) Current Mailing Address: ( 7y (.7 Signature Telephone 2.2 Authorized Agent: • gi g.. 1 B S \ �# Name (Print) Current Mailing Address: (.. I t ) 8a3 Signature li/ Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3� O © O (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 0-16 6. Total = (1 + 2 + 3 + 4 + 5) *6 ) 33 .ci CheckNumber 30 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 4 BP- 2010 -0107 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -01 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0107 Project # JS- 2010- 000123 Est. Cost: $30000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CROCKER BUILDING CO INC 067805 Lot Size(sq. ft.): 130680.00 Owner: NONOTUCK MILLS LLC Zoning: GI(100) //WP Applicant: CROCKER BUILDING CO INC AT: 296 NONOTUCK ST Applicant Address: Phone: Insurance: 186 STAFFORD ST (413) 737 -7803 Workers Compensation SPRINGFIELDMA01104 ISSUED ON: 7/29/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL METAL SIDING BY LOADING DOCK REAR 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 7/29/2009 0:00:00 $180.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo