44-035 (2) zne c.ommonwea[th of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
uv� Boston,MA 02111
www.massgovldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letziblv
Name(Business iorganization4ndividual):
Address:
City/State/Zip: D l Phone.#: -2
Ar�e you an employer?Check the appropriate box: Type of project(required):.
1.0 I am a employer with 4. 0 1 am a general contractor and I T New jest(required):
6.employees(full andlor part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the'attached sheet. 7. OR=odeling
ship and have no employees Thy sub-contractors have g• []Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.
insurance._ 9. Building addition
1equire] 5. ❑ We are a corpomdon.and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself-[No workers'comp. right Of exemption per MOL 12toof repairs
insurance required.]t c. 152,11(4),and we have no
employees.(No workers' 13.❑Other
comp.insurance raiutral.]
*Any applicant that checks box 91 m ot-shw fig out the soetion below showing dwir wodm'eampeumhon pokey tnformatm.
t Hommwom who submit Qua dMavit indicting they are doing all wo&and then hire outside cmftdm meat submit a new affidavit indkoWg such,
tCwftwtas that check this box saint ausched as additional shoot showing the name ofdu aibcaaracWm and state whether or not those cantles Bove
employo x. 1f 8u sub-contnctas have aMloyas,they must provide dwk wvrkne emw 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: _e,
Policy#or Self-ins.Lic.M t� Ue _Y qO� 7 2 Expiration Date:
Job Site Address:L15� 20WJ6 L JV I Citylstatelzip: ,4
Attach a copy of the workers'compensation policy declaration page,(showing the policy number and expiration date).
Faiilure.to secure coverage as required under Section 25A ofMOL c.152 can lead to the•irrnpo ution of criminal penalties of a
fine lip to$1,500.00 sad/ar one-year impd8owndit,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against thr violator. Be advised that a copy-of this statement'may be fotovarded to the Office of
Im►estitations of the bIA for insurance eoveta¢e verification.
I do hereby eerxfy under lire pains and peaddes of perjury that the Infonnadon provided above is true acid corm
Phone#:
Official use only. Do not write this area,to be CONPAW4 by dty or town offidal
City or Town: PermitfUeense#
Issulag Authority(circle one):
`1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: • Phone M
Version 1'7 Commercial Building Permit May 15,2000
SECTION W STRUCTURAL PEER REVIEW(780 CUR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to
act on 72',77to work authorized by this building permit application.
SignatWa Date
1, ti"l`I/ �✓ � �lr as Owner/Authorized
r
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 pen of perjury.
Print
Of J Date
S Ti0 12-CONSTRUCTION SERVICES
10.1 Licensed Construction SuDervisor Not Applicable ❑
Name of License Holder: kei.) t f'2— 5-,3(
Ucense Number
Address Bp anion Date
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 No 0
Version 1.7 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
Eviration Date
Signah" Tekvtw e
9.2 Registered Professional Engineer(s)=
Name Area of ResponsibW
Address Registration Number
Signature Telephone E*ration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of ResponsibW
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Nunber
Signature Teteplwne Expiration Date
9.3 General Contractor
S pbly J 6 �
Not Applicable ❑
Company Name= y /
�
xwl
Responsible In Charge of Co io
/nsbWnw
4e
Address
Signature Telephone
Version]-7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
a �4
Interior Alterations jP Existing Wall Signs ❑ DernolitionEl Repairs El Additions ❑ Accessory Budding[]
Exterior Alteration ❑ Existing Ground Sign❑ Now Signs❑ Roofing of Use❑ Other❑
Brief Description Enter a brief description here.
12 e-
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 11 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
8 Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B 0
U Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U utility 11 Specify:
N Mixed Use ❑ Specify:
S Special Use r] Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA I
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(st)
ist 1 St
4 2nd
2�
P 3fd
4th 0
Total Area(st) Total Proposed New Construction(sf)
Total Height(ft)
Total Height It
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information:Zone Outside Flood Zoneo Municipal Sewage Disposal System:
Public ❑ Private E] 0 On site disposal systern❑
F
Version l_7 Commercial Building Permit May 15,2000
Deparbrient use only
ity of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Lectnc'AUG " 4 2015 Room 100 Water/Well Availability
i No hampto n, MA 01060 Two Sets of Structural Plans
F Phone 587-1240 Fax 413-587-1272 Plot/Site Plans
v�r,� .,,,.; �,oioso
Other Spwk
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 7 Kf"M 14,
1.1 Property Address: MTh/is section to be cornp�lote�d by office
Co` V� ��� S)I" Map /�y'� Lot (2 8 l> Unit
Zone Overlay District
Q
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2
Name(Prit) Current Marling Address:
�; /C��%u�,��l✓" ter```
Sgnab a T elephone
2.2 Au tonze A
Name(Pmt) Current Malirg Address.
Signature Telephone
SECTION 3-ESTIMATED CONSTRUC COSTS
Item Estimated Cost(Dollars)to be Official Use Only
d by it applicant
1. Building / n J��f o (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) edd. e> Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Budding Commissioner/Inspector of Bukirgs Date
File#BP-2016-0146
APPLICANT/CONTACT PERSON STEPHEN CAMP
ADDRESS/PHONE 46 EAST ST EASTHAMPTON01027(413)527-7124 Q
PROPERTY LOCATION 215A LOVEFIELD ST
MAP 44 PARCEL 035 001 ZONE
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: STRIP&SHINGLE ROOF&INSTALL 19 REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 082531
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolit'
Sign e of Building fficial 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.
215A LOVEFIELD ST BP-2016-0146
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV:Block:44-035 CITY OF NORTHAMPTON
Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOFING/REPLACE WINDOWS BUILDING PERMIT
Permit# BP-2016-0146
Project# JS-2016-000242
Est.Cost: $15000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN CAMP 082531
Lot Size(sq. ft.): 36416.16 Owner: CAMP JESSE
zoning: Applicant: STEPHEN CAMP
AT. 215A LOVEFIELD ST
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527-7124 O WC
EASTHAMPTON MA01 027 ISSUED ON.81612015 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF & INSTALL 19
REPLACEMENT WINDOWS
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 8/6/2015 0:00:00 $105.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner