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23A-107 (3)
The Commonwealth of Massachusetts * v Department of Industrial Accidents "°""`�1 t Office of Investigations •�� '' 600 Washington Street IOW Boston, MA 02111 - `-0 0 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): •' . F \ .. • u: f i K Address: /0( kJ-h.-it PLA,. 4re F City /State /Zip: fig /if p /Q>G Phone #: W3 y57-3O.sd Are u an employer? Check the a propriate box: Type of project (required): 1.,'_J I am a employer with 4. 0 I am a general contractor and I 6. ❑ con struction employees (full and/or part- time).^ have hired the sub - contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. odeling. These sub- contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp. insurance comp. insurance.$ re aired. 5. 0 We are a corporation and its 10.0 Electrical repairs or additions q ] officers have exercised their 11.0 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' 13.0 Other comp. insurance required.] L 1 *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. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / / / Insurance Company Name: 1 is 7 c° r �, ,,, ‹z9( Z - 1 - Policy # or Self -ins. Lic. #: 'Q t)( 3581M Expiration Date: 8 /0 / /x/ 3 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. 7do hereby certify and thep ' s and penalties of perjury that the information provided above is true and correct. Signature: Date: /% -11 - /2 Phone #: 013 5 0 ? 3'4 S 62 11 -official use only. Do not-write in- this - area, -to be completed by city or town official (I City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Hearth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone #: v Version1.7 Commercial Building Permit May 15, 2000 SECTION 10 STRUCTURAL PEER REVIEW (780 CMR 910.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 p. SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, . 1�P7_......CLAAt ..._,. ......... _1, as Owner of the subject property hereby authorize . _.. _ , ....)s,h, -, .. 'to act on my behalf, in all ma relative to work authorized by this building permit application i. Signatu H of Owner( Date , ` __- --- _.Z-st- t" �._.._..,.. �__ . _� , „ .. .... ... , 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 gent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Q Not Applicable ❑ Name of License Holder tt'tG� C ,,5' 7 p License Number , _./.0 Y: /tie,— 1 L. -',/,--_ 54- , --;/,/,,,?,/— Address 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 er No 0 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 CI _ . Name (Registrant): 1 Registration Number Address _. _ .._.µ. _._ � Expiration Date Signature f Telephone 9.2 Regi tered Professi • nal 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 Version 1.7 Commercial Building Permit May 15, 2000 & NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department i Lot Size Frontage..._. _ . ' Setbacks Front Side L.., ... __ R.,. _� L:.. , . _ R ..,. it Building Height Bldg. Square Footage % _ "..... ,.... Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces ff A Fill: �f (volume & Location) N ....._ ., A. Has a Special Per j it/ aria ce /Finding ever b =-n issued the site? NO 0 DON OW 0 YES Ali IF YES, date issued: IF YES: Was the permit recorded at the Regi.try of Deeds? NO 0 DONT KNOW al s • IF YES: enter Book Page , and /or Document #' B. Does the site contain a brook, body of ater or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need try be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued C. Do any signs exist on the property. YES 0 NO 0 IF YES, describe size, type an location: } D. Are there any proposed change to or additions of signs intended for the p roperty ? YES 0 NO 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. 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 Description wtocd( (1 /i '> (`Creo j 0''^ Of Proposed Work c ic -te. rs D i `li' w� 6 �F iet o -f e ��'d r cc41 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 El A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ -3 FS i 1 l 4 ❑ R Residential ❑ R -1 ❑ R -2 R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B L El 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:....._ .__ i 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) _._ _, ,..___ _ ,._ . st 1st _ 2 nd , i 2nd 3 m :~ 3 rd ' 4 th __..._ Total Area (sf) - Total Proposed New Construction (sf) Total Height (ft) = I t 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 Version1.7 Commercial Buildint Permit Ma 15, 2000 c_______ r� x FF.wt x r' i, 1 2012 1 City of Northampton 1 uilding Department d ``�� 4 T O — E € p01 p 212 Main Street �; ° a te dEp THAMPTON, Room 100 i , > 3 , �� 'u o Northampton, MA 01060 # fi t`i phone 413- 587 -1240 Fax 413 - 587 -1272 T° t � , 1' p ew n, 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 137 - 0 . v� IA l v re ` ' Map Lot unit f4 re. f j #14- i i . ,,,,,, - 1--.7 . 0 ' ! Zone Overdaytotstrict Eim St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 6 .. 6 c< , v , , -- .. ,,H.. ".. / 7 . _ � . ..... .a 51 E v yt i -E. . Name (Print) V i Current Mailing Address: // 3 Signature iy ' /` Tele phone 2.2 AutA "_ . - �_. Ay ti c W mow. Name (Print) Current Mailing Address ...... . Signature / / Telephone � 5.7.-34540 " �� .._ SECTION 3 - ESTIMATED C• STRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i 4ac,c ° (a) Building Permit Fee t 2. Electrical t — "" (b) Estimated Total Cost of r3 ©C Construction from (6) ........ ...... 3. Plumbing i y e ! Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 +3 +4+5) S8 00 Check Number ,//U P:3 This Section For Official Use Only Building Permit Number Date Issued Signature: Building C ommissioner /Inspector of Buildings Date File # BP- 2013 -0519 APPLICANT /CONTACT PERSON JOHN LANDRY ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413) 204 -9880 PROPERTY LOCATION 137 SOUTH MAIN ST - UNIT 1 - 1ST FLR MAP 23A PARCEL 107 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out s Fee Paid / (/ Typeof Construction: REMODEL LIVING RM (SHEETROCK,TRIM, FIREPLACE) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 093450 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 em ' 'o elay 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. 137 SOUTH MAIN ST - UNIT 1 - 1ST FLR BP- 2013 -0519 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 107 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- 2013 -0519 Project # JS- 2013- 000833 Est. Cost: $8800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 12371.04 Owner: CLAUSEN GREGORY C & KARLA H Zoning: URB(100)/ Applicant: JOHN LANDRY AT: 137 SOUTH MAIN ST - UNIT 1 - 1ST FLR Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMA01060 ISSUED ON:11/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL LIVING RM (SHEETROCK,TRIM, FIREPLACE) 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 11/5/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner