32A-271 (6) ..r..., The Commonwealth of Massachusetts
, :
Department of Industrial Accidents
,,,,. ,-- Office of Investigations
7--=-74,4 600 Washing on Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Nan1e (BusinesslOrganization /Individual): S�i G r C ( a j :r..... ° t- .) i- , C _
Address: T° 0 B c ( oC0i f
City /State /Zip: r - : t I v( ; 'hone #: 4 (3 ._'- (6' r 4 73 -C 0
Are you an employer? Check the approp iate box: - Type of project (required): I
1 . ❑ I am a employer with 4. ❑ I . • a general contractor an.. I
6. ❑ New construction
employees (full and/or part- time).* have - ..: - • ..- .n1 actors
listed on the attached sheet. 7. ❑ Remodeling
2. El 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.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing 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. ❑ 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: i 4 S 5 2. 0 y Yvt 5 _
00 Policy # or Self-ins. M �
s. Lic. #: r " I 1(� 0 (j D C7 � I 0 I � � �j Expiration Date: / ��
/ Pli Job Site Address: f ds . 5 ( , City /State /Zip: = `f 4 7Jf t 4 C1 DG
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 S250.00 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 rtfns a nalties of perjury that the information provided abov is true nd correct.
Signature: Date: f / Y G /
Phone #: 1( 2 C i f 36, 0
Official use only. Do not write in this area, to be completed by city or town officiaL
City or 'Town: Permit Licer se #
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 CNIR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C
, I
1, 4 u (,,:ri o tuerrck_ , as Owner of the subject property
hereby authorize
, •
--_,ca- 167004 -e v CO3154ru difor\ ,
act on my ber.0 ' ," all matte relative t r t ' by this building permit application.,
.."
Signat - .f • ner
Date
r (,.9 - 1 , 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 u der the pains and 4 alties of perjury,
,
Print Name
...---
,_....---- ■ / /.) 0 •C"..-
--..,
Signature of OwnesiAl rtrir Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 2
.. _ ......., ,
Name of License Holder .L
. s --
_ ..
License Nu er
-- W 4/ 0/ ----
Address Expiratio Date
---
, el / 3 -)_&,-- zpcc,
ignatur- 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 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 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 Genera Contractor
_ Not Applicable ❑
Comp ny Name:
elVLi
Responsible In Charge of Construction
1 ' j
Si. . ure 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..._....._..i L:_,,i R: _...
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lotarea 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 0 DONT KNOW Q YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained
, 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.
R
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 0 Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a bri f description r / J � -1 f 5 p Ct l e f
Of Proposed Work:
7 ti c ... f'.... ` a r T c ' ' � � !.t. 5 _... t / v , /
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 ❑ i 2A ❑
E Educational ❑ ' 2B 1 ❑
F Factory 0 F -1 ❑ F -2 ❑ 2C 0
H High Hazard ❑ 3A ❑
1 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 ❑
U Utility ❑ Specify
M Mixed Use ❑ Specify: .
S Special Use ❑ Specify:
C•MPLETETHIS SECTIO'. EXISTING : ILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Hazard Index 780 CMR 34): _.... _ ___ ___ .____„ Proposed Hazard Index 780 CMR 34): _
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING Alf PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
3
1st 1s
2nd ... ................ .. .k_....., 2" d
3rd 3rd
_, _ _._,.._
4th 4th
Total Total Area (sf) Total Proposed New Construction (sf) , _
Total Height (ft)
T t si 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
Versionl.7 Commercial Building Permit May 15, 2000
Department use onty
City of Northampton Status of Permit ,,
Building Department Curb=CutIDrrveway Permit
212 Main Street Sewer /Se p ticAvailabili
Room 100 Water/WeilAwailabiiity: ','
Northampton, MA 01060 Two Sets of Structural Plans
` - ' phone 413- 587 -1240 Fax 413- 587 -1272 PlotISit 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
1.1 Property Address: This section to be completed by office
'S t ,^.� � k. c 5 C C. A , „ r r Map Lot Unit
1 : _1i //
S
- f c s' I! t Zone Overlay District
�. Elm St District
CB District
SECTION 2 - PROPERTY OWNERSHIPLAUTFtORIZED AGENT
2.1 Owner of Record:
Sp ---)c—A ' _. .... ....... _ - _. ... . .. Slc� Z � t Gaf�is t('ou �✓ . .. (f!h i� .
Name (Print) Current Mailing Address / 'UO( ' �,
aal
Signature �. // ' Telephone
2.2 Autho
'Pr Agent:
c c
i � d7 iii. e ,.. �V 7 ..� 1'I b,y r 'm `_ ...... �� - ,_ .. _
Name (Print) Current Maili dyes 7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building -� [if -k ( 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'"'' c -, 6ligi 1 - 5
-t
6.- Total = (1 + 2 3 3 + 4 + 5) ?, ..> ) j e rie) , e c) Check Number '3 1/ is '~ � 3 ` C
This Section For Official Use Only
Duilding Permit Number Date
Issued
Signature.
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0607
APPLICANT /CONTACT PERSON SALOOMEY CONSTRUCTION
ADDRESS /PHONE P 0 BOX 1203 WESTFIELD (413) 269 -4360
PROPERTY LOCATION 1 BRIDGE ST
MAP 32A PARCEL 271 001 ZONE CB(48)/NB(52)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction:_INSULATE SOFFIT TO PREVENT SPRINKLERS FROM FREEZING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 065275
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
V 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
i I
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.
. a
I.: BP-2010-0607
GIS #: COMMONWEALTH OF MASSACHUSETTS
4 r. CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0607
Project # JS- 2010 - 000885
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SALOOMEY CONSTRUCTION 065275
Lot Size(so. ft.): 14113.44 Owner: GUERRA CLAUI)IO
Zoning: CB(48)/NB(52)/ Applicant: SALOOMEY CONSTRUCTION
AT: 1 BRIDGE ST
Applicant Address: Phone: Insurance:
P O BOX 1203 (413) 269 -4360 Workers
Compensation
WESTFIELDMA01086 ISSUED ON:12/17/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE SOFFIT TO PREVENT SPRINKLERS
FROM FREEZING
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 12/17/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner -. Anthony Patillo