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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): ?Pc M E L* - A-615 V
Address: 2)-{$ 2-0(41 St ,
City /State /Zip: _ ! A Phone #: 413 a° % 6 — SIX
Are you an employer? Check the appropriate box: el0l2.... Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2.�Lam a sole proprietor or partner- listed on the attached sheet. 7. 461.2.emodelina
ship and have no employees These sub - contractors have 8. El Demolition.
working for me in any capacity. employees and have workers' g ❑ 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
y [N p 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other ;
comp. insurance required.]
•
*Any applicant that checks box #1 must also fill out the section below thowi$g thhir.workers' compensation policy infdrmation.
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 the policy and job site
information. •
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration`Date:
Job Site Address: ' s City /State /Zip:
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 co py o f this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce i 1 under the pains an , enalties of perjury that the information provided above is true and correct.
_ �. Si .nature: _ � �` Date:
Phone #: t. ( 3- a-c ` - q �b
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
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
k.
r
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
I, •,0 c.. .. D �►�! . _._ � . 1. _. 17)e..627)/1 as Owner of the subject property
hereby authorize :....... 14' a ._ _.. !....1 _. M. .._ to
act on my behalf, in all matters relative to work authorized by this building pprmitapplication.
A
Signature of Owner Date
I,. / ' . 1,. e ______ _.....__._____._.____ .., ... ___ __.......__: , 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 un the pains and penalties_of penry. N
u
Print Name
?Ci"1 -- L.a� e nti
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION. SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : > —PAM- e_4sd '.. N ..6 ,. r.. ■5 C.4 ..L..S ._...
License Number
µ 2..& 3Pt-tUlt" .S ��. L___.._________._' _. _2� ( 2__... _ ... '.
Address Expiration Date _____
Signature e / ��' _ ) ....4. Telephone
SECTION 13 - WORKERS': COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 a, No 0
•
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS AND STRUCT SUBJECT TO
CONSTRUCTION CONTROL. PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EI!1„LOSEDSPACE)
9.1 Registered Architect:
. _.._______ __. Not Applicable 0
Name (Registrant):
Registration Number
Address .__
`"� __ Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
t
Name Area of Responsibility
Address Re istration Number __ µ _rr __ mm' ___
9.
Signature Telephone Expiration Date
Name _ __._._�..._ _ ___ _.._.__ �,._W Area of Responsibility _ M _ w _ Mw
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address _._. ". _..___._... _.._._._.._..._._.____ Registration Number __
umber ""
__.
Signature Telephone Expiration Date
9.3 General Contractor
.**1 3 .__ " ".W_...0 E ' . _ __...._._.__ ____. _.,_ _ __. ` Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addr
id tgA,c_Qe... ...e6.02.41 kAt3!,-. 741.-!...4W4): ,
Signature Telephone
• y
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON. ZONING
Existing Proposed Required by Zoning ,
This column to re filled in by
Building Department
Lot Size __...__....,_____
Frontage. _ .... . _ .__....�...._.._ . "_. "._ .__.....__.._. �._.._.._.._..,. .__ ..._._.. _ __ "____.__ __....
Setbacks Front
Side L: _.., R:-- L i._ _.._ 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 Special Permit /Variance /Finding ever been issued for /on the site?
NO (k DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES ___...,
IF YES: enter Book ' Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW (") YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained (3 , Date Issued:
C. Do any signs exist on the property? YES 0 NO C
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?. (3 . NO ®4 ,
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, cavation, or.filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO ` ' j ``~ ' '
IF YES, then a Northampton Storm Water ManapefneMt,Permit from the DPW is required.
, •
Version1.7 Commercial Building Permit May 15, 2000
.1 7 s
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 °.
CUBIC FEET OF ENCLOSED SPACE "r j �
Interior Alterations fzi. Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ - 4 r7 ;
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 0 Change of Use ❑ Other ❑ -
Brief Description Enter a brief description here. 0 P 6r 'b' e-A - 46r - a 141* O # f
Of Proposed Work : /..c) Doo & L6tiere. tocx. 1 6 -3 (12.
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A-4 ❑ A -5 ❑ 1B ❑
B Business , , ,2A ' ❑
E Educational ❑ - 2B , r AL, "
F Factory ❑ F -1 0 F -2 ❑ ` ' , ` ' 2C ' b. . •
H High Hazard ❑ 3A ❑
I 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 El Specify: ' 2.D4c l ^ !� / 9 eat,. i
M Mixed ed Use " �' � . S pecify 1) .b . / .'$l +beJ1.@'.d
S Special Use ❑ Specify ::
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR AND/OR IN USE
ExisttngUse•Group _ ` _ ..___ __.:_' . • " ' ` • •• Proposed Use Group: . , _ ,.,._.___._ ._..__...._ _._._.., .__..
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)
e .
1 st ,
1st
2 nd
2 nd '
_. ro ,__.._,_ - _.. .-. ..._...,�...
4'"
Total Area (sf) Total Proposed New Construction (sf) __
Total Height (ft) .... ........_, ._...__
Total Height ft _ w _ wq , „
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 4, Private 0 Zone Outside Flood Zone Municipal g On site disposal system 0
•
I REC
Version1.7 Commercial Building Permit May 15, 2000
Departn use only
SiP 201i ity of Northampton ;statttstopeplitt.t:+
sic
uilding Department ''.i;burrpriv.,_‘yteay„Term
,
212 Main Street -:SewetispptqA11,0044VARidg
OF BUiU)ma iNspEco6TiooNs
Room 100
• j/ORDWAPTom, ma oi
Northampton, MA 01060
phone 413-5874240 Fax 413-587-1W? .
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
/A0 - DA enc::. R 0A7) Map Lot Unit
N0g11401 Pftita 144. I 06C) Zone Overlay District
EtmSt:District CS District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
k6Ri0C- "P(202zict.c., 1 7 )1026 1 9 -( --
Name (Print) • • , : Curreil Mailing Address:
/ _.
ft Si a ur Telephonet 0.5‘ 33 ,.•
2.2 Authorized Agent:
-V/4 . CA-BOAC)* .
_ --
Name (Print) Current Mailing Address:
Signature Olga oetiALAtf_61.,*
Telephone q!3 -2gi, urO4,, /
SECTION 3- ESTIMATED CONSTRUCTION COSTS •
Item Estimated Cost (Dollars) to be . Official Use Only
completed by permit applicant
1. Building
(a) Building Permit Fee
_ .
2. Electrical 4 ---- (b). Estimated Total Cost of
/ 0 0 Construction from (6)
3. Plumbing 'Building Permit Fee
5( 500
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 4 aoo Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP-2012-02'74
APPLICANT /CONTACT PERSON PAMELA LEBEAU
ADDRESS/PHONE 248 Bryant St CHESTERFIELD (413) 296 -4506
PROPERTY LOCATION 120 DAMON RD
MAP 18D PARCEL 007 001 ZONE GB /GI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /Q p ��i
(p 7 d �JJ
Fee Paid
Typeof Construction: UPGRADE EXISTING BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 064756
3 sets of Plans / Plot Plan
THE FOLLOWING 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
0
Signature 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.
120 DAMON RD B P- 2012 -0274
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 007 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- 2012 -0274
Project # JS- 2012- 000441
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAMELA LEBEAU 064756
Lot Size(sq. ft.): 102366.00 Owner: DROZDAL EDWARD A & KAROL W & MARIE DROZDAL
Zoning: GB /GI(100)/ Applicant: PAMELA LEBEAU
AT: 120 DAMON RD
Applicant Address: Phone: Insurance:
248 Bryant St (413) 296 -4506
CHESTERFIELDMA01012 ISSUED ON:9/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: UPGRADE EXISTING BATHROOM
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 9/22/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner