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35-132 (2) IQ001 07/03/2007 11.08 FAx Lo 's b rc- 1 �5 tit C�a I � -ka) Y Flan nQ ce) l � 15",3 25-,3S-21 a� J - Iva 60:TT LOOZICO/L4 �0 0 i�► The Commonwealth of Massachusetts Department of Industrial Accidents F Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dig -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 ` Please Print Legibly Name(Business/Organization/Individual): -- Address: i 3 kk je IA 11 '� p�, c 433 City/State/Zip: Lk5\\,o-,A,,i .j t- of o Phone.#: gh 3--3-ac7 Fj VI:2 Are you an employer?Check the appropriate box: Type of project(required): 1.E?f7I am a employer with 3 4. F� I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. [J New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no enTloyees These sub-contractors have. g. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.: 9. Building addition required.] 5. F'� 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 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.f Other_i ka�Dr,iAkk e 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. xContractois 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: "j�,� Policy#or Self-ins.Lic.#: �j ©��' 5���C�ia01 Expiration Date: - q- g-Df3 Job Site Address: r yo QS�AaV IR-) City/State/Zip,' i-tcx—e.V%x, 01061A 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 ce nder the pains and penalties of perjury that the information provided above is true and correct. Si afar P eS. Date: 6 _ •0' Phone#: A'�Q El 7_1 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#: Version 1.7 Commercial Building Permit May 15,2000 a SECTION 10=4TRl1CTURAL PEERREVIEW(780 CMR 110 71) Independent Structural Engineering Structural Peer Review Required Yes No Q SEC-TION 1A -DWNERAUTHDRIZATION:-TO BEEOMPCETED WHEN- OWNERS.-AGENT OR CONTRACTOR APPLIES•FOR BUILQING PERMIT --- ------- -- -------------------- t — I, ,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 } 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/Agent Date SECTION C2 COI�iSTRUCTION SERUJCES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:! (a6O r fo { License Number Address L L,t t9dA-C Q eA ri�& t /N,"t ExP f io 7��� 4 Signature Telephone ��(r SECTION 13 WORKERS'COMP-ENSATfON:=1NSt7RAT10E AEFFDAVII";�M 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 r Version 1.7 Commercial Building Permit May 15,2000 SECTION .9-PROFESSIONAL DESIGN ANDCONSTRUCTION SERVICES-EORBUILDINGS AND STRUCTUREStJB,TECT:TO CONSTRUCTION CONTROL PURSCJANT TO 780 CMR 116�CON7A lNIN ,MODE THAN.35;00 C.F:OF ENCLOSEDSPACE) 9.1 Registered Architect Not Applicable ❑ I 3 --- - --- - ---------------- Name-(Registrant): ---- ------- - — - --- -- -�--- Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): i 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 i i Address Registration Number Signature Telephone Expiration Date i � Name Area of Responsibility Address Registration Number i Signature Telephone Expiration Date 9.3 General Contractor i tA-, wke\ �,�1��r r��`: �v.G- Not Applicable ❑ Company Name: Responsible In Charge of Construction c�� �.1� QJ r i-,0 Addres (� Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 Ul�,laI®R =" Existing Proposed Required by Zoning This column to be filled in by Building Department i � Lot Size Frontage Setbacks Front ' Side L: R:= L:{ i R:! i Rear I Building Heighti 1 i — Bldg.Square Footage % j Open Space Footage % (Lot area minus bldg&paved F-7 ? ' #of Parking Spaces Fill: volume&Location) � i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Reg' try of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book } j Page! ' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO i 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: j 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. t .fir Versionl.7 Commercial Building Permit May 15,2000 r SECTION 4=nCON Si-U-,C1t1AN MESS THAN 35,000 CUBI,CFEETOF�ENGLOSE[�SP..AGE , Interior Alterations ❑ Existing Wall Signs ❑ Demolition d Repairs Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ ,New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief description here. 13Ae,(� (L�o yvr= NEU) T U6ESl WW �Lao� SAGk WAt,t s Of Proposed Work: ' i Rem-tc�,cr� cx e e,�i� 1' SECTION-5-:USE=GE4OUP AND CONSA�ON USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ I A-2 ❑ A-3 ❑ 1A ❑ ___ __ ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ 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 F-1 Specify M Mixed Use El Specify S Special Use El Specify I COMPLETE Ti-7TS SECTION fiF EXISTING BUILDING UNDERGOING RENOa/1�TEONS,:f#DD1TiONS AfVD30R CHANGE 1N USE Existing Use Group: 1 Proposed Use Group: ? I Existing Hazard Index 780 CMR 34):` Proposed Hazard Index 780 CMR 34): I SECTION-16'SUIC:D11�7G NEIGE�T AND AREA: _ _,. N BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTIONSE Floor Area per Floor(sf) R st — 1st " u ` 2nd 2nd i 4 . 3m i 3`d 40, 4�' ! r i Total Area(so I Total Proposed New Construction(sf) r I Total Height(ft) x Total Height ft .* T.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone i Outside Flood Zone[] Municipal ❑ On site disposal system[] Versionl.7 Commercial Building Permit-May 15,2000 City of Northampton Building Department 212 Main Street r Room'100 ^ Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 T,REPAIR,RENOVA , O 4 A ONE OR TWO FAMILY DWELLING —�-- SECTION S[TE•NEORMATiON� _ _ _: _ _ _ _, s Tinsectron tare copCeted.6ilrof - fi�e< 1-'I-Pr�onerty Addres �� � � � � s ���_�. x + FF , Ck 0%06701 (� C VVk ( oz� � a "D� ►c#a � r��: . IN GEMEE p.. SECTION2` PROPERTY OINNERSi31PfAUTHORIZEDAGENT� 2.1 Owner of Record: (� i P6-V-\ i��1CA 5_w 1 1 Q tco ♦l'�CA, 1t I Name(Print) Current Mailing Address: t Signature Telephone —OG 7 // 2.2 Authorized Agent: Name(Print) Current Mailing Address: ! ` mil -���A ��y. i � y Ctcr1`- Signature \ ' Pre`? Telephone y 1 3 -j SECTION 3-=ESTIMA"TED•CDNSTRUCTfON 15 STS Item Estimated Cost(Dollars)to be iJfic+al;Uset)nly" completed by ermit applicant 1. Building (a);Bu+id+ng'PermitFee I 2. Electrical , (b)Estimated Total''.Cost'"of` g I E Constructron-from 3. Plumbing Building;Perm►t Fee p n go 4.4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) (, -Cheri be „ : _, . ,_..T ►s°Section FocOfficialGse Building Permit�lumter: Date 3 — 2007 1 ' lssued L r Signature_ D1a10t E S �`� , 010_ 660__ Building Commissionefflnspe 6r.of Buildings Date File#BP-2008-0008 APPLICANT/CONTACT PERSON Flannel Construction,Inc ADDRESS/PHONE P. O.Box 933 WILLIAMSBURG (413)320-8177 PROPERTY LOCATION 716 RYAN RD MAP 35 PARCEL 132 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT FeePaid t4uildin2 Permit Filled 2ut L,f�e Paid Typeof Construction: Repair water damage to rear room New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFARMATION 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 p7[1)9 t67 ignature of Buil mg 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. :r BP-2008-0008 GIs#: COMMONWEALTH OF MASSACHUSETTS . � CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: WATER DAMAGE BUILDING PERMIT Permit# BP-2008-0008 Project# JS-2008-000011 Est. Cost: $6278.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin Flannel Construction, Inc Lot Size(sg. ft.): 11412.72 Owner: WILLIAMS PAMELA B Zoning: SR Applicant: Flannel Construction, Inc AT. 716 RYAN RD Applicant Address: Phone: Insurance: P. O. Box 933 (413) 320-8177 WILLIAMSBURGMA01096 ISSUED ON.71912007 0:00:00 TO PERFORM THE FOLLOWING WORK.-Repair water damage to rear room 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 7/9/2007 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo