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16A-002 (3) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations TM 600 Washington Street • t Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` , Please Print Legibly �/ Nance ( Business /Organization/Individual): gatak / / /�/7,f ��� c A r � /' /[ ���'!0 Address: gg w m'5 City /State /Zip: r,� P hone #: y/5'-1uU -9>`U Are you an employer? Check the appropriate box: Type of project (required): 1. [ifKrn a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub- contractors 2 ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' g Y ❑ [No workers' comp. insurance comp. insurance.t -- 9. Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have their 11. Plumbing repairs or additions 3. C3 I am a homeowner doing all work ave exercised ❑ myself. [No workers' comp. right of exemption per MGL 12.0 Roof re airs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ther • 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. #: /) t ©o/01 6/757 Expiration Date: 6' /7 Job Site Address: ger Arid reemf t CG!' City /State /Zip: Rert//;y'Pt, o 5c 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 co py 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 t s true and correct. Signature: , / Date: 31,2 Phone #: 4f49' /i ,o6-0/ 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): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • Y Versionl.7 Commercial Building Permit May 15, 2000 4 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 I, ..... _ __ , . _ . , as Owner 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 andaenalties of,per ,._,- Print Name _._ . ._.___.._._. __ __.._..... _. Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : .M 7 . License Number � � �� Address _ Expiration Date _–_ _..,, _.. _. .... Lei_ /7---1 1— y?s�.r 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 0 No /Jt'y1 029(' n Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTIONiSERVICES - FOR BUILDINGS -AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EIJpLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): ... ,. Registration Number Address Expiration Date Signature Telephone 9:2 Registered Professional Engineer(s): ................... ..v,...._............�,......._ .... ,.._ Name Area of Responsibility _._.. Responsibility ._.. ___... _. Address Registration Number Signature Telephone Expiration Date _. Name Area of Responsibility Address Fte Number n w w m y Signature Telephone Expiration Date Name .�____d 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 _..: M..._...._. 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 rre filled in by Building Department • Lot Size Frontage Setbacks Front Side L R. _ 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 0 DONT KNOW 0 YES 0 IF. YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 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 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 Obtained , Date Issued: mm C. Do any signs exist on the property? YES 0 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 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. Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE i , Interior Alterations ❑ Existing. Wall Signs ❑- Demolition ❑ Repairs ❑ Additions ❑ Accessorylding ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs 0 Roofing ❑ Change of Use ❑ Other ❑ Brief Description ;Enter a brief description here. OK4 / , 5 ) ! 1r � 3 'ei / A 'tv� ` „ Of Proposed Work: t, 4 "lit .tL `a \ _.___ _.....d...... _._ _ SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - 1 ❑ F Factory ❑ F -1 D F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ i 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 0 S -2 ❑ 5B { ❑ °` U Utility El Specify: M Mixed Use 0 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) e. . --- 1 st j 1 . / / _O2i /4- v ( _ 2nd ...,....._._ , ... �_ ._._... 2 nd '.`_ 3 ? _ .. _. 4th _ _._ 4 ...._.._ Total Area (sf) c3 �9 Total Proposed New Construction (sf) _ Total Height (ft) /7 Total Height ft , _ , _ , 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone ___ __„ Outside Flood Zone❑ Municipal 0 On site disposal system Version1.7 Commercial Building Permit May 15, 2000 City of Northampton n F �� �� _ Building Department • Out/D 212 Main Street eelfiu�aa� ;°'° Room 100 ��� F 1a blif���� p� 1 E�l ov 1 Northampton, MA 01060 1 $:" ' a phone 413 - 587 - 1240 Fax 413 - 587 -1272 1Iat/Sif F lan$ Other Specify £ .ro 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 / //�,ei —k 01Q/4 10jt . Map Lot Unit t'G t � rn � v✓ - Zone Overlay District Elm St: District` CB District • SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .. 0 Name (Print) Current Mailing Address: Signature Telephone 2.2 Authoriz - . • •en.. Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee . 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing I Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) l 1 i Check Number This. Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0856 APPLICANT /CONTACT PERSON WAYNE YOUNG Oe1lr Pars ADDRESS /PHONE 2171 ROARING BROOK RD CONWAY (413) 512 -0601 0 PROPERTY LOCATION 300 NORTH MAIN ST - LOOK PARK ` 1 d A MAP 16A PARCEL 002 001 ZONE URA( 51) /WP(20)/URB(2)/HB(0) /WSP(0)/ r ` f' • k"24 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid v Typeof Construction: MOVE BUILDING ONTO NEW FOUNDATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 31539 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Demolition Delay C-f ( I Z- Si tore of Building 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. 300 NORTH MAIN ST - LOOK PARK BP- 2012 -0856 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A - 002 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 -0856 Project # JS- 2012- 001502 Est. Cost: $12285.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WAYNE YOUNG 31539 Lot Size(sq. ft.): Owner: NORTHAMPTON CITY OF LOOK MEMORIAL PARK Zoning: URA( 51) /WP(20)/URB(2)/HB(0) /WSP(0)/ Applicant: WAYNE YOUNG AT: 300 NORTH MAIN ST - LOOK PARK Applicant Address: Phone: Insurance: 2171 ROARING BROOK RD (413) 512 -0601 0 WC CONWAYMA01341 ISSUED ON:4/23/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:MOVE BUILDING ONTO NEW FOUNDATION 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 4/23/2012 0:00:00 $0.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner