24C-019 (2) , 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 Please Print Legibly
Name ( Business /Organization Individual): Soak l Ia L)fr3 r flC
Address: 22- 2 xi 1■611 S
Cit /State /Zip: Nit) (-ha ivtp-4O n , NIA Phone #: 413-59-4 a3 I G
Are you an employer? Check the appropriate box: Type of project (required):
1. 1 a employer with 2.C.1 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. n Remodeling
2. E] I am a sole proprietor or partner-
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. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have their 11. Plumbing repairs or additions
3. El am a homeowner doing all work ave exercised
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' 136ther
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 nacre 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. n
Insurance Company Name: A l M M ihtoj /i u,raro _
Policy # or Self -ins. Lic. #: HCC 2OOC. (J"1 30 1 Expiration Date: �"{ 1 i /2 Cro
Job Site Address: 2 -' (' T(9.ve Cit /Zip: Af t d-hafO rn 1 ( 1
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.
Signature: Date: /ii 1 2ct
Phone #: 1i4 -1 3/0
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):
rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
t 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 O No O
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
, 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 Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ,fl 1113. _ A _ � .l li vac.{ (7`u
License Number
Address Expiration Date
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVITI(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 0 4,, , N, No
Versionl.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 Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
2>Z ? f\Jbd -h S+. I\ir+h �np r� ..N l .LLtL2C),
Adds
Signature Telephone
Versionl.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
Building Height
Bldg. Square Footage _.. _.,,.
Open Space Footage °
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book `i Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
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 0
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
Versionl.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 Descrip on Enter a brief description here.
Of Propo d or : „See_ jV4 r )/ 1ve
SECTION 5 - USE ROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 0 A -2 ❑ A -3 0 1A I 0
A -4 ❑ A -5 ❑ 0
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard 0 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 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)
1 st
l
2 nd
2 nd
3
3 rd
4 th
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 ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system
• It. . ,
.,.
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/Well Availability
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 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:
t32(0 coS()e( S 4 r-e-el- Map Lot Unit
t\)oiz-k-AiNap-c ./\k/\ c )i o(,.0 Zone Overlay District
1 k*e._.' tReq,. \o /1\ ik Elm St. Di CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 0 ner of
1 Record:
(41V; 11 l 14 ..
L
Name Pr Current int)
j
i i hi, 'vA14.1tz)4-g
C__e._ C, 7-
Cu Mailing Address:
tor),
( Signature ,
Telephone (LI I '7 5 --ey-'70e6
( .._..st
2.2 Authorized Agent:
Name (Print)
?2/41/ V I AA 01- ) 4 t ' t 4 '
Signature /I , i4t/t (i 4"
CTION 3 - ESTIMATED CONSTRUCTION COSTS
Telephone
Current Mailing Address:
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building see. ..;Z. S 0 0 e•v (a) Building Permit Fee
A/A A. Rat i've,
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
. ,
4. Mechanical (HVAC) . .. . . . .
5. Fire Protection .. .
6. Total (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
YMCA Building Narrative
Construct 12'-4" wide X 11'-1" high two hour fire
rated wall at the basement Electrical room. Wall
consist of 3 5/8" 20 gauge metal studs 16" on center
with two layers of 5/8" sheetrock on each side. Wall
has two hour rated metal door and frame swinging
out from the room with panic bar and closer per Mass
Building Code Revision Seven.
f
File # BP- 2010 -0290
APPLICANT /CONTACT PERSON D A SULLIVAN & SONS INC
ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413) 584 -0310
PROPERTY LOCATION 286 PROSPECT ST
MAP 24C PARCEL 019 001 ZONE URA(15)/URB(85)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ?a /65
Fee Paid /3,2/5—
J o
Typeof Construction: SEE NARRATIVE � � /
New Construction • ML /, / . , ■ '
Non Structural interior renovations
Addition to Existint , AP_LitfA „�zr
,
Accessory Structure
Building Plans Included: / �f o ?�
Owner/ Statement or License 053668 b ��
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
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.
286 PROSPECT ST BP- 2010 -0290
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map_Block: 24C - 019 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY- F-- UND4MGL e:14-2-Ai i • ;
`1
R T - P
Category renovation LDIN ERMI
BUI 9 `
Permit # BP- 2010 -0290 v t
Project # JS- 2010- 000273
Est. Cost: $2500.00 _
Fee: $55.00 PERMISSION IS HEREBY GRANTEI3TO:
Const. Class: Contractor: License:
Use Group: D A SULLIVAN & SONS INC 053668
Lot Size(sq. ft.): 190792.80 Owner: HAMPSHIRE REGIONAL YOUNG MEN'S CHRISTIAN ASSOCIATION
Zoning: URA(15)/URB(85)/ Applicant: D A SULLIVAN & SONS INC
A T: 286 PROSPECT ST
Applicant Address: Phone: Insurance:
82 NORTH ST (413) 584 -0310 Workers
Compensation
NORTHAMPTONMAO1060 ISSUED ON :9/15/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT BASEMENT 2 HOUR FIRE
PARTITION FOR NEW ELEC SERVICE ROOM
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 CIT OF NORTHAMPTON UPON VIOLAON OF
ANY OF ITS RULES AND REGULATI •
Certificate of Occu • anc Signature:
FeeType: Date Paid: Amount:
Building 9/15/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo