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31D-146
ris■r► // --oe_ 2/ 07 ,v2$ -- . . _,,,,,c,,,,, zjr /6 ilij 1 '� - yr - –�— _- - 1 I 1 ,________----- , wl ' ! crn i A‘ a s ' �-._ � _� --��,, s ._ ));)--, _ H Q ....,... \2„--: ______. i 1 ;iV- ________________ ____ , __________ _g vgl__K rocii I 3 1/ pi / i / Y f 1 ° l ..r � ' .:: c5 ,- T 1 c _ \, \ , ,, 0 k i i . \ ' ( ' ____ ---.^-'''''-- ' ' "-' 1- --- 7 _ r-2n0-41/ a te/ . k _ • The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations u � 600 Washington Street "' !. =� f� Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): i A M 67c _ Address: C! � G�. City /State /Zip: A14 Alta Q ( 00 2 -Phone #: "T " 2 '53 76 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. J I am a general contractor and I employees (full and/or part - time). * have hired the sub - contractors 6. New construction 2:0 I am a sole proprietor or partner- listed on the attached sheet. 7. ' \ Remodeling hip and have no employees These sub - contractors have 8. [Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. El 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 employees. [No workers' 13. ❑ Other 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 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /e 7-0 — /1 Phone #: 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 #: I -a - Versionl.7 Commercial Building Permit May 15, 2000 ---I SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �pT ► t K J IM 1 j Lw L� , as Owner of the subject property hereby authorize to act o ehalf, in all matters relative to work authorized by this building permit application. /a/f/ �_ I Signatu f 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 unde I), . , .: nd penalties of perjury. Print Name i l0 /1 Signature of Owner /A nt Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Su ervisor: � Not Applicable ❑ Name of License Holder : j ■ p© r Pict i t a ,,> .. License Number Address f 1 e 1 . 14, Expiration Date Signature ' Telephone S 0 / Z-- 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 AO No 0 st • 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 • B Versionl .7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage t . Setbacks Front / V i V Side L: 1 0 R: L: i 0 R: 5' ' Rear Building Height Bldg. Square Footage ,G fit„ % p Open Space Footage (Lot area minus bldg &paved Svia /> van parking) # of Parking Spaces -e Fill: 6 (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW s O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW CO YES 0 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained o , Date Issued: C. Do any signs exist on the property? YES NO 0 IF YES, describe size, type and location: 2 ' .41 4 K.A. s' r d 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. .. . ' . - • , � ..^ �.. ^ ^ .' ' ' ^ ~ , ^ . � ' ' .. � ' * . ^ ' Version!.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 C O) C'u FV _ CUBIC FEET OF ENCLOSED SPACE I Interior Alterations ❑ Existing Wall Signs ❑ DemolitionA Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a br descr here. RQ r/0 14 T IQ e '' 03 " ^ '� Of Proposed Work: PST h/1 ,..1 "LA/ el/ Drr 5. t LAI J4 rI A.A(.- a dot"f'4 /'4 44.1 -, SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A -4 ❑ A -5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ 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 ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use Specify: , T 1(R I A ^'� E 4 ' S Special Use ❑ Specify: �" - COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Cxisting 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 / 1st / ` ra 2 °d t SU 2nd iS D 3 d s„ 3rd S 4 4 tn Total Area (sf) ,) S"'p ti) Total Proposed New Construction (sf) Total Height (ft) 3r Total Height ft t 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public A Private ❑ Zone Outside Flood Zone Municipaal On site disposal system[] w 1 ati fi �� , .. .. � ... .. a 7 7,. .. • Versionl.7 Commercial Building Permit May 15, 2000 ED Department use only Ci , of i • C .. C Status of Permit: B !din! D rtment Curb Cut/Driveway Permit - ' 12 a f- 1tr2fs@ 2011 Sewer /Septic Availability • om 100 Water/Well Availability No , a t 4 1 4 " T :_, Dols Two Sets of Structural Plans phone 413- ; - ' i ce . . - _ - Plot/Site Plans Other Specify 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 i / J a k i f, J-Tt /� Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /)01" ,t. % i 6 'h E C.elt f l o i< i ra' Jr Name (Print) Current Mailing Address: Signature T elephone _91 \----- 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 3 , (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing TN) V b Building Permit Fee /� 4. Mechanical (HVAC) (_ J 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) L i 0 FD IV Check Number T r x6 This Section For Official Use Only Building Permit Number Date Issued Signature ' // —2G-- / Building Commissioner nspector of 9'' Buildings Date . . 110 KING ST BP- 2012 -0411 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 146 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 -0411 Project # JS- 2012- 000656 Est. Cost: $4000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NORMAN COE 60524 Lot Size(sq. ft.): 7927.92 Owner: MELNIK PATRICK J & ALICE E TRUSTEES Zoning: GB(100)/ Applicant: NORMAN COE AT: 110 KING ST Applicant Address: Phone: Insurance: 374 MIDDLE ST (413) 253 -3078 AMHERSTMA01002 ISSUED ON:10/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM & WINTERIZE UPSTAIRS PORCH 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 10/24/2011 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner