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N The Commonwealth of Massachusetts
? Department of Industrial Accidents .'
� a 0. Office of Investigations , t.
�- 600 Washington Street
7. �= Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑+ I am a general contractor and I
i employees (full and/or part- time).* 6. ❑New construction
gave hired the sub - contractors
1 2 I am a sole proprietor or partner- std on the attached sheet. 7. ❑ Remodeling
!` ship and have no employees ,ese sub - contractors have 8. El Demolition
1 working for me in any capacity. e .loyees and have workers' 9. ❑Building addition
[No workers' comp. insurance ' co ... insurance.-
.
required.] . 5. ❑ W are a corporation and its 10.0 Electrical repairs or additions o icers ave exercised their 11. i have thei Plumbing repairs or additions
,3. ❑ I am a homeowner doing work ❑
myself. [No workers' comp. ght of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers'
13.❑ Other
// comp. insurance required.]
*Any applicant that checks box #1 must also fill out th /sectionbelow 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.
- IContractors 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: 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 of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under thepais and penalties of perjury that the information provided above is true and correct.
l , I ( !. t
Si•.ature: r r ?' ,',` Date: , t 7 : LL
Phone #: l``
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 #:
•
P ••■•
Versionl.7 Commercial Building P ermit r May 15, 20 .,_ 0_ ,,, O .,_
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) .
Independent Structural Engineering Structural Peer Review Required . Yes 0 No C
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING. PERMIT
I, _ \,..0 r' . x,,-)"1 . . ,� '" -. `. � r . i Qa�. ,.,��' _ �� ._�.� u.�,.�.,. — ���_.�ti.. __ _ . , M�, as Owner of the subject property
l�I
hereby authorize . ) -_ _ /''' • _ •t_l. �. ._
act on my behalf, i all matt?rs relativg t work authorized by this building permit application. _ ____, _________
I I
lk'�' � J� �.
Signature of Owner Date
, - . 7-1 -- 7 -----
1, . te ,.. , 4,..,` .l , ____ . - ' _.. , / _ ,,' '. _ „_
, as Owner /Authorized
. _�,,., -� .
t
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 gams and penalties of RerLury.,,
i _1 -r.' 4. N-...e'....I .2 _�,__,_--,.1.—._1_:. ........ ...a...1,.. —4 ,.- - ..,....! .' v...e1 —±,. - :- .,.n.:ma..v.. _. „.: .....,.,.. _ ,.._.,.— .., .. . »....W.._
Print Name , ! _ _ ..... ________ ..__........_..
z
Signature of Owner /Agent w Date
/ SECTION 12 - CONSTRUCTION: SERVICES
/ 10.1 Licensed Construction Supervisor: Not Applicable ❑
'
' �` 1 t L ,.2 .. ?A_ .
Name of License Holder .= --- �,,�- �.- ,��. -«w� W...�. ��., �. �.m.. �._..m� ,�....A.,.�.,, >....�.,�..s ...�_ _ � ri. • . -._. e
} a
License Number
Addra�s _fi - 'r Expiration Date
G 0. t / r — :: ....o.......W :. ... ..e,..�_ � _ i \, +,,,.
Signature Telephone \ j >,
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 15Z § 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 0 No 0
I
PO Mt,
Version1.7 Commercial Building Permit May 15, 2000
J
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EWLOSED SPACE)
9.1 Registered Architect:
__ _ Not Applicable ❑
Name (Registrant): ----- -_- _____ _
Registration Number
Address
" V 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 _ _ _ .___.._ „_.__
t
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
3
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
--- • _, _.._ __..
Signature Telephone Expiration Date
9.3 General Contractor
.._ ...._ ._. .._. ,.._... _._ __ _ ._ ,__. -- ----J Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
,. vh SSE A 116 cab E Purr 1kM'
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON.ZONING
Existing Proposed Required by Zoning .
This column to lie filled in by
Building Department
Lot Size _ __
Frontage
Setbacks Front —
mo w.
1
Side L:---- - R ..__.._._. L:w... R:
Rear _ .� . _
Building Height
Bldg. Square Footage ,._._.__ ,__ % 7 _.._.,
Open Space Footage _.,
(Lot area minus bldg & paved ,_ „.j
parking)
# of Parking Spaces
Fill: ,
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 C DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO
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 \O
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 0 NO 0,.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
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 Wortr } - sr R a , 1c c D£c
SECTION 5 - USE GROUP AND 'CONSTRU• 1014 TYPE
NS J1P(Ch as applicable) CONSTRUCTION TYPE
A Assembly ' A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
Q A-4 ❑' ; A -5 ❑ 1B ❑
B Business 0 2A ❑
E Educational ❑ 2B , r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ,J R -1 ❑ R -2 tz R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I
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: `
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)
1st 1
st r
2nd 2nd
4th ...__- _.._...,..___ __ _.._._.� _. _, 4 tn
Total Area (sf) Total Proposed New Constructionist _...
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
IP'• .11
Version1.7 Commercial Building Permit May 15, 2000
tcf.
t' qt'' VINtAlDeldartriigit iriseiorq,f';',,7
.1
City of Northampton ;stp i,, .,!..tRe..,. ',,!?•i-,!
Building Department
212 Main Street
SeWeitS ::.
Room 100
LvOfet#AtelfA Araby
Northampton, MA 01060 ily,cOpts
phone 413-587-1240 Fax 413-587-1272 !if
Other Spec
,,
- ' ' ' 16 1Z r i l Ui4ilr '
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPAN 1. - - - =-- Y B JILDING
OTHER THAN A ONE OR Two FAMILY DWELL VG
IMP 1 511111
SECTION 1 - SITE INFORMATION
1.1 Property Address: ,
c This sedtionWevinistMENSie
.. ____ ........., NORTHAIAPToN, MA01080
1 - n t i■fific .i.' .) Yc." :, Map 4 ""t8t Unit
, . .
,„, , I , 7 i / ,I / T,
vit. p • .; y's j. '
Zone Overlay District
' - .c' ,, . .. : • .
— --- ------; Elm St.' Distriat CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT . . .
2.1 Owner of Record:
(
;
IA LL 1 - --
-.. :',.! 7
Signature ; (,)....0 ...1 .,,,)::': L . ''-- - - - - — _ Y .1.-2_,, ' \ ...:..--,..; ' 1 _i_L.
Name (Print) Mailing
.„ -------- Atl
EL , c/ D c lior z ir k
Current Address: __
, .,4 : r
1/
Telephone
) .
( 2.2 Authorized Anent:
'
- - '. P„ ..Z. ... ±......).. 1 .,L ,.„.,':,.!...,.._ _
______:: i_..., .P-k
Name (Print) Current Mailing Address:
,
Signature \- ` 1( ./ 1 ,, i T Telephone
,
SECTION 3- ESTIMATED CONSTRUCTION COSTS . •
Item . Estimated Cost (Dollars) to be . . Official Use Only .
completed by permit applicant
1. Building ;,-/ r., ; ;.--, , — (a) Building Permit Fee
1 , ..
2. Electrical I (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) / ‘/00 • 0() Check Number
A('1 r (6)4k1-' This Section For Official Use Only
Building Permit Number . Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2011 -1051
APPLICANT /CONTACT PERSON MICHELE ST PIERRE
ADDRESS /PHONE P 0 BOX 1444 NORTHAMPTON (518) 428 -2402
PROPERTY LOCATION 17 TRUMBULL RD
MAP 31B PARCEL 151 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: FINISH PITCHED ROOF SECTION, CONSTRUCT NEW PITCH & DECK,CONVERT
BEDRM TO BATH/CLOSET,AMEND 9/16/11 EXTEND DECK — PLA iJg 0 w K e IN S p Ea D
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 105558
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO I MATION 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
Demolition Delay
2/2371/
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 Office of
Planning & Development for more information.
NO
.5NVU