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32A-227
The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 04 r^ -°`1 600 Washington Street • Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): go 642-v'‘ Address: ) Oct vr 'a halt' li b t v73 City /State /Zip: Phone #: Cal 7- 3 3 3 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 pIoyees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. I am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling These sub - contractors have ship and have no employees 8. n 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. ❑ Electrical repairs or additions CI have exercised their 11. Plumbing repairs or additions J. 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' 13.0 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 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 co py of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby rti y un er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: ` a crS - a0l 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 I Y 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' i 0. to act on my behalf, in all matters relative to work authorized by this building permit application. Si of Owner Date 1 ,- , as Owner /Authorized At hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed unnd.er the pains and penaities of perjt Print Na Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder _1L..K`.1 eV `3.....[.._. _,.. . �- �.�.n.� z-.. ,.. License Number Addre Expiration Date 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 • a ' 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 ENSLOSE ©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 Address Signature Telephone 1 Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by honing , This column to 6e filled in by Building Department Lot Size _. . Frontage ...._ ., Setbacks Front Side Rear __.. .. -_ Building Height Bldg. Square Footage % , Open Space Footage % __._ -- . (Lot area minus bldg & paved parking) ....,, _> ..... _, # of Parking Spaces - L___._.__. 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 0 DONT KNOW 0 __ YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: 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 (3 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , t Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 , CUBIC FEET OF ENCLOSED SPACE c s Interior Alterations ❑ Existing Wall Signs 0 Demolition ❑ Repairs ❑ Additions ❑ Accessory B uild' g Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Er Change of Use ❑ Other Brief Description Enter a brief description here. 54v 40 3 at- D j + . r e1 Gt.' Of Proposed Work: f t2ca. 4 - 0 -'t {-In &tar- '„�,� � P,k u..... -V t.% YlJect,7 , �QWI d i,+2 S lv t t t� v rtl SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly El A-1 0 A -2 ❑ A -3 0 1A 1 ID A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - I ❑ F Factory ❑ F -1 0 F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1 -1 0 1 -2 ❑ I -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 0 R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 0 S -2 ❑ 5B ❑ 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: ._ .___ ..._.__.__....__ ,w.. _._,_.- .. -...'_ Proposed Use Group: __ _ m.__._ w .._ -,. ___________ ..' 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) 15 1 st , 2nd 2 nd 3rd 3r w - Total Area (sf) Total Proposed New Construction Lap__ Total Height (ft) "� Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zonelnformation: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone _ _____ Outside Flood Zone Municipal ❑ On site disposal system❑ v Version1.7 Commercial Building Permit May 15, 2000 _.._-- Departmeht use,only FC ,: i= atcrs= f -- ° City of Northampton s ei1%Et #1 �a i e ,"f � uilding Department C ur b �C uffDrt veway Petri . 4 �`'' AUG a 9 2i 212 Main Street S e+ er jt ' ` ,: :� "` Room 100 V{faterIVU�CeIt ;A ai1a ' " ° g P :* L ; 7-oNS NO hampton, MA 01060 wiSets 4 a Pl , ,,, ° -4+3 -587 -1240 Fax 413 -587 -1272 Plot/Site Plans Other Sp 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 PO ► , ev.o.3 - Fee eit'oz. Map Lot Unit Zone Overlay District SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ . Name (Print) Current Mailin Address :, _. .(..2203 7 - .) ..Y4. x ,�_Dlud�� - h Signature J �� T elep hone .a3 -- 5,�6 --Co ,, 2.2 Authorized Agent: :1 1, ,'..S._ „;0 Zg Name (Print) Current Mailing Address o Signature T elephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Pemnit Fee 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) ( i3 . i 9,g 0 , c Check Number 37 0 ' This. Section For Official Use Only #55. f' Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2013 -0227 APPLICANT /CONTACT PERSON ROBERT CARRIER JR ADDRESS/PHONE 16 David St SOUTHAMPTON (413) 527 -0333 PROPERTY LOCATION 58 POMEROY TER MAP 32A PARCEL 227 001 ZONE URC(99) /SC(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 0790 [�� Fee Paid �L Typeof Construction: REPLACE 3 SQ ROOF & INSTALL 8 REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 059154 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: L / 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 w... 0 R 3 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. 58 POMEROY TER BP- 2013 -0227 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 227 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 /REPLACE WINDOWS BUILDING PERMIT Permit # BP- 2013 -0227 Project # JS- 2013- 000372 Est. Cost: $8290.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT CARRIER JR 059154 Lot Size(sq. ft.): 56148.84 Owner: COLLEGE CHURCH INC THE Zoning: URC(99) /SC(1)/ Applicant: ROBERT CARRIER JR AT: 58 POMEROY TER Applicant Address: Phone: Insurance: 16 David St (413) 527 -0333 SOUTHAMPTONMA01073 ISSUED ON:8/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE 3 SQ ROOF & INSTALL 8 REPLACEMENT WINDOWS 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 8/31/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner