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23A-111 -Z 146vi-( /11/1° _ WI I • 5 g ,t0! 4 ,- 1 6 / 7- 7` CA041 i 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 0 =� - ,..` Boston, M4 02111 www nwss.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Si W &Nu-el i- L4 Mtt t i L Address: \'\o NI i 4 VA/ (o PkAux 40 City /State /Zip: S. 11034 po, fry O[cl'% Phone #: L A - (o+pS . OA Are you an employer? Check the appropriate box: Type of project (required): 1. Ut I am a employer with 1,0 4. ❑ I am a general contractor and I 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. XRemodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y P h $ 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. ❑ 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 13. ❑Other 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. 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. ,� n K1/411‘11\( Insurance Company Name: l i t I MUM . (o. Policy # or Self -ins. Lic. #: %%00S tb LIO il(-)11 Expiration Date: 1P ) Z5 1 Job Site Address: Iv kfr- ,)T', City/State /Zip: ft frvz - I vo- Oik.V1 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 fo • . uran e coverage verification. I do hereby certi er the . # % . # penalties of perjury that the information provided above is true and correct. Signature: Date: 9)/1))) Phone #: 1 -11c5 (Y ni %(, 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 #: . Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No �'!I SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT V PV I, as Owner of the subject property Wit Q9 `q �.+t,� hereby authorize I to act on my alf, i all m rs relative to work authorized by this building permit application. i " 9) 6 ii Signat re of 0 ner Date v iticx4fitst7 1r " ; L,1� , 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. \611.5 in L, ‘.() s ' "ilk C Maw4v 1 Print Name 1 ( 9 lc t( Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: e 1 Not Applicable ❑ Name of License Holder V L c rc 111 J►,, ! li 1 ' W License Number to N � I ti sift h S, it he �1, 0,3 )'Z ) )ti Address It 1 Expiration Date Signature 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 b tiding permit. Signed Affidavit Attached Yes No 0 Versionl.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 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 Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Version!.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning 1—(PC v ) This column to be filled in by Building Department Lot Size Frontage Setbacks Front (j Side L: a R: 0 L: R: Rear 1a Building Height + Bldg. Square Footage Open Space Footage v (Lot area minus bldg & paved v �/0 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES o IF YES: enter Book 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 Q , Date Issued: C. Do any signs exist on the property? YES lei NO IF YES, describe size, type and location: \ Ili- VJi_t�(-� S � 1 l`' j°�fi�� PS D. Are there any proposed changes to or additions of signs intended for the property ? YES 1 NO ti IF YES, describe size, type and location: kroAF , E. Will the construction activity disturb (clearing, grading, exc- ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO Ito IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations grExisting Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs El Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. tii Of Proposed Work: j (Armor �) �^dN1tiI1:t ti of (1- ¶p... - @i10- SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 CI A-2 ❑ A -3 CI 1A I CI A-4 ❑ A -5 ❑ 1B El B Business K. 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -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 L ❑ 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: �)0 .)INC`5� Proposed Use Group: 1 : Existing Hazard Index 780 CMR 34): Tit Proposed Hazard Index 780 CMR 34): g SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1st 4�� 1st 100 2n �IV0 2 900 3rd q t )TIL 3 �UC� 1?C7<;2L 4 4 th 4 th Total Area (sf) 100 Total Proposed New Construction (sf) 77 Total Height (ft) 73' 9 (-110,014 ..) QUil Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewa a isposal System: Public Private ❑ Zone Outside Flood Zone Municipal On site disposal system El L., �' ,r. `i..... .. s •+M+, wry F f .. Versionl.7 Commercial Building Permit Mal 15, 2000 �♦O use only Department G ity of Northampton Status of Permit;. • , ` : uilding Department Curb Cut/Driveway Permit - 6 12 Main Street Sewer /Septic Availability' Room 100 WaterNVell Availability • c o► = ampton, MA 01060 Two Sets of Structural Plans e 413 - 587 -1240 Fax 413 - 587 -1272 Plot/SitePlans Other Specify APP ATION 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 Map Lot Unit M n<) AJ ST , r 1M br Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Pa/4ltry t° )or� l'Ci. ,k �6 Name (Print) Current Mailing Address: , Signature Telephone 2.2 Authorized Agent: tlIM LNwr -Ll 11() t illtote s N 5, D CPCa0,f Name (Print) c 4 Current Mailing Address: HI GUS Oaicc Signature \t Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 0() (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of �,1 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) q3d19 3 5. Fire Protection 4 Qw J 6. Total = (1 + 2 + 3 + 4 + 5) ©o v Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0263 APPLICANT /CONTACT PERSON SCAPES BUILDERS & LANDSCAPING LLC ADDRESS/PHONE P 0 BOX 469 DEERFIELD (413) 665 -0185 0 PROPERTY LOCATION 2 MAIN ST MAP 23A PARCEL 111 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out J v' / �3 6 Fee Paid eh Typeof Construction: RENOVATE 1ST FLR INTERIOR TO OFFICE SPACE l fir j r-S New Construction P ,(', Non Structural interior renovations j eaC)/ Addition to Existing rivt Accessory Structure Building Plans Included: Owner/ Statement or License 091302 3 sets of Plans / Plot Plan THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 :. : I Delay r ZX /� Si: of B u ild g 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. . . 2 MAIN ST BP- 2012 -0263 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 111 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 -0263 Project # JS- 2012- 000421 Est. Cost: $55000.00 Fee: $330.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCAPES BUILDERS & LANDSCAPING LLC 091302 Lot Size(sq. ft.): 9888.12 Owner: PLOTKIN DANIEL L & Zoning: GB(100)/ Applicant: SCAPES BUILDERS & LANDSCAPING LLC AT: 2 MAIN ST Applicant Address: Phone: Insurance: P O BOX 469 (413) 665 -0185 0 WC DEERFI ELDMA01373 ISSUED ON: 9/22/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE 1ST FLR INTERIOR TO OFFICE SPACE - EMERGENCY & EXIT LIGHTS REQUIRED 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 $330.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner t t \ r , I I 4 ' rs C fir