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32A-271 (19) / � � . y . d \. �. : � , � < � � , f � . Z � ` \ � % � � � � \ \ �. �� � �% k % � � � \ . . . � >�� � . � � � � � 8 r J@9AjS 96pug 351-011 LO t V/ � } O Z 1I�b M341S o .V/ V l a N u IL 6-.l z o `�. w wr m — < r �I w CD i III a � L�� ii I Q- i C� N u co L40 z i 'I w M- w cu 5 Al co w w \ 0 w 14- o o Ij bo m w I Y j Nw°m a m O 41 a� I N L) c j N Q m m Y i E � � II p 1 II (V i j � M I Lr) �I M M III M j The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , 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): 1C� ' ►� y Address: City/State/Zip: Phone#: �< Are you an employer?Check the appropriate bo . Type of project(required): 1.P I am a employer with 100 _ 4. ❑ I am a general contractor and 1 ❑ employees(full and/or part-time). have hired the sub-contractors 6 New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition and have workers'working for me in any capacity. employees 9. F-1 Building addition [No workers'comp.insurance comp.insurance.# required.] 5• ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.F-1 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 13ther T employees. [No workers'. 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 thepolicy and job site information. Insurance Company Name: J Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: �f t City/State/Zip: Attach a copy of the workers' compensation 4licy 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 Si afore: Date: Phone#: L Official use only. Do not write in this area,to be completed by city or town o I aL ---- — 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 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 OWNER AUTHORIZATION-TO;BE COMPLETED:!WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR>BUILDImPERMIT _._..,as Owner of the subject property hereby authorize act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date — I, 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 pa1w1ndAR naltits Print Name Signature of Owner/Agent Dat SECTION 12-CONSTRUCTION.SERVICES 10.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder `_ w � 1�� - License Number Add ess Expiration Date Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L. 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 Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL.:PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF E?,f LOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ 3 Name(Registrant): _ I 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 r R�q stration Number Signature Telephone Expiration Date f NameH Area of Responsibility I , 3 Address Registration Number Signature Telephone Expiration Date _....... . Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor 07 Not Applicable ❑ Company Name: _ Responsible In dharge of Construction i Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 8. NURTHAMFTUN-ZONING Existing Proposed` Required by Zoning . This column tb fie filled in by Building Department Lot Size Frontage - Setbacks Front Side L:i-� R:'•:_..____ L: __.._J R: Rear Building Height Bldg. Square Footage % � Open Space Footage 1 __ �__ 3 % _ (Lot area minus bldg&paved J L_ i I~_ _? I� a&in #of Parking Spaces ` Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW Q YES 0 IF.:YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES Q IF YES: enter Book '< Page° and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 401� NO 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 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial Building Permit May 15,2000 J SECTION 4-CONSTRUCTION SERVICES FOR PRQ.IECTS LESS THAN 35,000 a t 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 Enter a brief description here. / Of Proposed Work:I A x �Q f SECTION 5 USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B B Business ❑ 2A ❑ E Educational ❑ 26 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ : _ -_ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑ 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 __ _ ` Proposed Use Group.- _ m _.•_ ._ 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) t 1 sc St i 2ntl _ 2°° _ _._................... 3 r 3rd 4th _ __ _ _ 4"' Total Area(so Total Proposed New Construction(sue Total Height(ft) _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[:] Versionl.7 onun Re 't May 15,2000 ao City of Northampton \ Building Departme it 1 2 pCCACAW Iv 212 Main Street 1 Room 100 DEPT.OF BUILD AG P Northampton, MA 01 NORTHAMPTON. phone 413-587-1240 Fax 413-587-1272 4E USE OR QCGUPA F. oR naij I G O Y DWELLING SECTION 1 SITE INFORMATION' 1.1 Property Address: This section to be completed by office Map Lot Unit Nom , will Dlo!�-v i I _Zone Overlay District "Elnt"St:"Distr(ct CB District SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailii Address: Signature Telephone SECTION 3-'ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official''Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of _�.�. .�.._ Construction from 6 3. Plumbing ElUltflfttg�F'erni4fiee 4. Mechanical(HVAC) "` Q 0 5.Fire Protection ____...__ __...._._.___..._..... _._.. i' 6. Total=(1 +2+3+4+5) Check Number This Section:For Official Use Only Building Permit Number Date :Issued -Signature:_ Building Commissioner/Inspector of Buildings Date File#MP-2013-0109 �K� LD APPLICANT/CONTACT PERSON GUERRA CLAUDIO i ADDRESS/PHONE 675 NORTH FARMS RD (413) 586-6323 PROPERTY LOCATION 1 BRIDGE ST MAP 32A PARCEL 271 001 ZONE NB(52)/CB(48)/ 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: ZPA-ADD 20 X 50 DECK New Construction Non Structural interior renovations Addition to Existing Accesso1y 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 INFORMATION 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 fb[t 3 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 the Office of Planning&Development for more information.