32A-138 (3) The Commonwealth of Massachusetts
!* Department of Industrial Accidents
= = ,
='�>V1= Office of Investigations
r C..-
=�' ;- 600 Washington Street
111 Boston, MA 02111
"4111111 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Kohl Construction, Inc.
Address: 31 Campus Plaza Road, Suite 3
City/State/Zip: Hadley, MA 01035 Phone #: 256-0321
Are you an employer? Check the appropriate box: Type of project(required):
1. 0 I am a employer with 14 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. I 7 CI Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.0 Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual Insurance Company
Policy#or Self-ins. Lic.#: WMZ 800287201 2010 Expiration Date: 02/10/14
Job Site Address: 25 Main Street, Northampton MA City/State/Zip: 01060
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: 256-0321
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#:
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
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ti-t ry o g.e. E � _..._ � Y.._P_ ..--.`/.. _.mp\. ..'.Sfq ... .
..... ..._�co.. ',as Owner of the subject property
hereby authorize. .. C . v fis to ff L, to
act on my behalf,in all m ters relative to work authorized by this building permit application.
Signature of Owner Date
CC'�'�� �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 dpains and-penalties of per 6.
Print Name
-II,1...„111111711.1111 ailliik
1 lib ` E- I 5 i 2-° 13
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.i P.lcMA TD '"
License Number
ate- -cN AVE i 1■.r '?-TM,P- 2 k`{-
Address Expiration Date
<-4E,A5vto 4- g • Geis :11:3 9--
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affid it must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bu' ing permit.
Signed Affidavit Attached Yes 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
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 T- -phone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone xpiration Date
Name Area .f Responsibility
Address Registratio Number
Signature Telephone Expiration Date
9.3 General Contractor
(<6.W, Cb11J&1( C t lb Not Applicable ❑
CompanytName
Responsible In Charge of Construction
S t Ga S,L4s 1. U-a A -x, ID
Address
41 ,11..P;if 01% (C t3) WIs l 23`(-
Signature Telephone
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 0 xistin 9 Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other El
Brief Description --15 RC c7 VA-7-C— II V c,n-4 CA LA C.v I
o
Of Proposed Work: G� 4 n -i.4 I 0-(I./.0 ` ._.__.
SECTION 5-USE GROU AND CONSTRUCTION TYPE
USE GROUP(Check as applicabl CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 131 &(L4 T 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A
S Storage ❑ Si- ❑ 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: ..__ ., .. - (1 .., .,,__... Proposed Use Group.
Existing Hazard Index 780 CMR 34)::..... _.__ Proposed Hazard Index 780 CMR 34): w__
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf) NA) C.bA-Afr,I`fte/C.
tW C—,
1st 1st
2nd
3rd
3rd
4th ''
4th
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water pply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage isposal System:
Public Private ❑ Zone Outside Flood Zone❑ Municipal On site disposal system
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 :.__ N 6,,,... t
Frontage O'Jv Il.,,.,.
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 Spe al Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was t permit recorded at the Registry of Deeds?
NO 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 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 0 Obtained Q , Dat Issued:
C. Do any signs exist on the property? YES Q NO NIXT AT I..%)(Jr( lo-A c5c
tact- D blv E
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exc ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,----.__ Versionl.7 Commercial Building Permit May 15,2000
f i _ Department use only
ity of Northampton Status of Permit
5, t3 uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/ pb Availability '
Room 100 Water/Well Availability
T. BUILDING Two Sets of Structural Plans
p P
�OF {pMPTON ,oi06o INSPECTIONS ampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 PlottSite Pans
Other s p - 4 ,
er`
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
z5 \MACK) ST(L'cre l Map; Lot Unit
" ttl.W1 t.LX'S 6LA tc-O1■■%\,
Zone Overlay District
1-410 tZ'twv..IP c bav i v►n,A I o t o 6 a
EIm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
T 0 ZQ€ 't i? -.S R- 3 ! CA vv∎RAs . c b _ it Le Y
Name(Print) V V ( H4 VVli 5Pk- Go 0.17 Current Mailing Address:
(t «)_e./5 4. • O ,2-( __
Signature 0 i Telephone
2.2 Authorized Agent: % ICs-,14 ICs-,14 1. Go NS-(-R.ttic.Tl O'h1
R2. GARp C--c---D Y'�__.
... _._. ..... t.... MPuS.....Pta4...._2P, H�Dt-cY, w�} U(o 'S I
Name(Print) Current Mailing Address:
t 2 56 d i(_ �_..
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $ CO, 0025 ,..._— (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing 4- Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 (0,54/b Check Number JO2rl _ +IJ (Ac3
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-0909 61N---'APPLICANT/CONTACT PERSON KOHL CONSTRUCTION �
ADDRESS/PHONE 31 Campus Plaza Rd HADLEY (413)256-0321
PROPERTY LOCATION 25 MAIN ST y ----"A -9.--*/
MAP 32A PARCEL 138 000 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,q / 2
Fee Paid ! rJ o7 �J
Typeof Construction: RENOVATE VERACRUZANA LOADING DOCK&STAIRWAY TO BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 96576
3 sets of Plans/Plot Plan
THE F LLOWING 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--). -; 7 I i d 13
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.
25 MAIN ST BP-2013-0909
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 138 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-0909
Project# JS-2013-001554
Est.Cost: $10500.00
Fee:$63.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KOHL CONSTRUCTION 96576
Lot Size(sq. ft.): Owner: CHAMISA CORPORATION TO:HAMPSHIRE PROPERTY GROUP
Zoning: CB(100)/ Applicant: KOHL CONSTRUCTION
AT: 25 MAIN ST
Applicant Address: Phone: Insurance:
31 Campus Plaza Rd (413)256-0321 Workers Compensation
HADLEYMA01035 ISSUED ON:4/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE VERACRUZANA LOADING DOCK &
STAIRWAY TO BASEMENT
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 41)2113 $63.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner