Loading...
38B-050 (2) The Commonwealth of Massachusetts Department of Industrial Accidents = 'lil i E'l Office of Investigations • ,�c4: s 600 Washington Street •=� ¢= Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��\--, ( .N.c = -„ ���C` c Tc'. Address:�C`ci .>\.�., \- r z\-- . . )\�� �cls-cs- c\ G 4-1 City/State/Zip: - Phone.#: \\3°`� ,--•\-3N\c, ' Are you an employer?Check the appropriate box: Type of project(required): 1.Ed I am a employer with Li 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- These on the attached sheet. 7. Et Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' king Y p ty t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.0 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' 13.0 Other comp.insurance required.] *My 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. tContractors 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: -_N.- -,6,_.. Policy#or Self-ins.Lic.#: C LG ccJ`-‘"1-1\c1 Expiration Date:- - .. .-l'�` Job Site Address: \\C:c \--.. nC:=L.• City/State/Zip:' pM '`Q .\"Cs.1'''C Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). )s` -'\c '' 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 Investisations of the DIA for insurance coverage verification. I do hereby ce :fy under the pains and penalties of perjury that the information provided above is true and correct Sisnature: L Date: - - 1 _ Phone#: `I\\3 --c ,--\-.�\\.ca gy 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#: I Version1.7 Commercial Building Permit May 15,2000 t.. SEGTIOtt:]0_ SrRUGURALG?EEREVJEVIi(Z1GRAR -01 Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SEGTIONI°1- OWNERAIITHORt7AT1ON TO BE£OMP_LETED--ANNEW OWNERS AGENT OR CONTRACTOR.APP.LIES:FOR$0111 T)1NG'!RERNIM 1, ! ,as Owner of the subject property hereby authorize! to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date \r C- N P� ,as Owned Agent ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge an elief. Signed under the_pains andpenalties of penury. Print Name 1 Signffture of Owner/Agent Date ._Y -SECTIOtC112 XONSTF otOI spkwES' 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:1 C License Number CT\; =KI I Address Expiration Date S,jnature Telephone SECTION13 WORKERS'CONMPEN.SATEON1NSUR CE: .I=1DA1 ( 'I-iGL-A 441•25C:j6 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 P. Version1.7 Commercial Building Permit May 15,2000 r.. SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCT1ON-SERVICES -FOR BUILDINGS.AND.STRLI.C1 UI ES UBJECTTO CONSTRUCTION CONTROL PURSUANT TOT8O CMR 116(CONTAINING MORE T}AN 35,000 0 F.OF.=ENCLOSEDSPACE) 9.1 Registered Architect Not Applicable ❑ Name(Registrant): I-- ___ ___-------- :, � Registration Number Address i I I 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 I s i j I I Address Registration Number I } Signature Telephone Expiration Date . I j Name Area of Responsibility I Address Registration Number Signature Telephone Expiration Date l Name • Area of Responsibility I I Address f! Registration Number 1 I Signature Telephone Expiration Date 9.3 General Contractor •� .c. C.N'e , i' :Xv\Icl s - Not Applicable ❑ , Company Name: ` e-vk C-Nt=' c Responsible`, �, In Charge of Construction k Addres �'l 1 Signs re Telephone Versionl.7 Commercial Building Permit May 15,2000 r.. SECTION*:Co 1STfxt'FC I ICI ERVICESPF5R PROdEG7S- SS THAN 35,000? GUBIC`FEET'OFtNCLOSE©ISR.ACE (—Interior Alteratio ❑ Existing Wall Signs N Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other El Brief Description iEnter a b : scription here. Of Proposed Work:4 & ) ■ 'SECTION-5 -U S E GROUPANIT CONSTRUCT!Qi yPE :-r-' USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly .__, ❑ .A-2 ❑ A-3 ❑ 1A 1 ❑ A-4 ❑ A-5 ❑ lB ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A I ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential S R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 0 5B 1 ❑ U Utility a Specify M Mixed Use ❑ Specify:) • S Special Use 0 Specify: f COMPLE.TETHIS�-S'ECT.JOl It-''- XlSTJNG BUILDING-UNDERGOING RENOVATIONS,ADDI '1ONS.AND/OR CHAN EriIN 11SE Existing Use Group: . Proposed Use Group: Existing Hazard Index 780 CMR 34):t I Proposed Hazard Index 780 CMR 34):1 SEGTi0rresulumG3iE ptir .AREA r BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION '". - t �" Floor Area per Floor(sf) 1St 2nd I - �tt ' 2nd I c r.,t,j. °c'n ;— _'.. 3rd' r. h -'% ` ---i _ ,a• to ' 4 i k 3 �� r .Z`- ,, 4 -,'- : w � it ...y 1' •c K.... ,- �' Total Proposed New Construction(sf) ,, `' -` �, Total Area(sf) s � � �° k�w � Total Height(ft) i l r _ 4-t € Total Height ft ; i - - � � -ter - ?t4. 4 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone i ': Outside Flood Zone❑ Municipal 0 On site disposal system Version1.7 Commercial Building Permit May 15,2000 T"k..... d i Fg^Pot iRf; A r Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size i i 1 i 1 Frontage I I 1-- - Setbacks Front i L I i i Side LJ } R:L i L:1--i R1 ; "T, Rear i 1 L� i { -Bmtdmg Height E 1�-- ! I i _ _. Bldg.Square Footage I 1 F % fl l I. , Open Space Footage % (Lot area minus bldg&paved } I ` I i-_ i pig) #of Parking Spaces 1 n I i I Fill: ' {! (volum(&Location) ! t A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ' DONT KNOW 0 YES 0 ., IF YES, date issued: i I i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book j ! Pagel ; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: i C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: ; D. Are there any proposed changes to or additions of signs intended for the property? YES ® 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 Q ' NO GI IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Buildin:Permit Ma 15,2000 City of Northampton ti :,-°r"- _ --.:-,-,--...„--..=-;----,-„, Building Department "a �-__ -74- ;,,4. ! � t-.- 212 Main:Street 0-Y,4�4 �":� °';"- -- '& � a ti,.ts ir. 1!! w-iz; Y e ag ,mn' . Room'100 g „�, z { ,Northampton, MA 01060 -.= Y a - -'r _ft- - phone 413,587-1240 Fax 413-587-1272 4 -', ,� -Z .?— APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING • SEC170N'1 Sf1EINFO?MATION.' Y,- =.,-.,_--ti k.,.._h,, iilll`.w.Se"s-t"xalb.-�itfo tie:CDP`le-t lift e '�--. ----1-.-1-Property-Address- 1 :t«M: w 'r��:�.. ,� 5c.:� ^�""�" r� _� , - • - -- Lo �Unit� �� s�i�� -'.- "�z.. 3' ?- r ,j % - ,..t..y' ? ,x. . .a,. F^ 1 +. �._.+ ,, SEC TIQN`2 PR 15-ERTYkOWf0S IP A'UTTiORIZED' 1GEN'G c74 2.1 Owner of Record: 1" 10 � \\-- �_..-� can - + 1 t ,r��, .' .� �, N' GIi.c■ Name(Print) ' . Current Mailing Address: i Signature Telephone 2.2 Authorized Agent: i \ ��'.i\i-1� ,1 . -c `%"h: >\ L. : . -NL.". ( 1 C' ' ' ,._\1>l, 1 ."... .t. ,. ..\.'s�1 F ' Name(Print) Current Mailing Address: (l'\ c"�-1 Signature (,,_ ° C 11 Telephone -SECTION 3-5ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oft i iai filwOn1y completed by permit applicant _i',,,‘--7.f.:: ._. .,: .,.,r .: :' 1. Building ! ° (a)Building Peri'nit Fee 1 2. Electrical I (G)Estimated Total Cost Of 1, I _._ _; Constructionifrorn(6)` 3. Plumbing I _Biut�rn Pemim l€Fee 4. Mechanical(HVAC) I -: 4 5.Fire Protection f . ' 6. Total=(1 +2+3+4+5) Check:Number ���� `,] /5 d ,,, :ThisNSecfion Foicai•tase-Onfy BuiidrngPeirniNi tuber, t ate issued: r Signature: Building Commissioner/inspector, Buildings >Date File#BP-2008-0505 APPLICANT/CONTACT PERSON Kevin Netto Construction Inc. ADDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413)527-3168 PROPERTY LOCATION 19B LYMAN RD MAP 38B PARCEL 050 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: L PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ���Q �� Fee Paid [[ Typeof Construction: CONSTRUCT INTERIOR STAIRS TO 3RD FLR,ADD CLOSET,FRAME CEILING& INSULATE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 001317 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON _ INFORMATION PRESENTED: E (�(N t M I�ST W/ Approved Additional permits required(see below) 6O�DI T I 6N 1 �� f1 A Rp w t t T ;rrvt-0 K€S t CO PLANNING BOARD PERMIT REQUIRED UNDER:§ (Art S Da N� Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan NESS Tel 8€ ZONING BOARD PERMIT REQUIRED UNDER: § 4/�IUNrFD 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 C z `f bi 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. BP-2008-0505 GIS#: COMMONWEALTH OF MASSACHUSETTS t 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-2008-0505 Project# JS-2007-001353 Est. Cost: $8300.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Kevin Netto Construction Inc. 001317 Lot Sizc(sq. ft.): 0.00 Owner: NORTHEAST ENTERPRISES Zoning: URB Applicant: Kevin Netto Construction Inc. AT: 19B LYMAN RD Applicant Address: Phone: Insurance: 90 Southampton Rd. (413) 527-3168 Workers Compensation WESTHAMPTONMA01027 ISSUED ON:12/14/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT INTERIOR STAIRS TO 3RD FLR, ADD CLOSET,FRAME CEILING & INSULATE. WHOLE UNIT MUST HAVE HARDWIRED SMOKE AND CO DETECTORS 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: FeeTvpe: Date Paid: Amount: o/7/14 1 09) 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo