32C-114 The Commonwealth of Massachusetts
Department of Industrial Accidents
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a. Office of Investigations w •
600 Washington Street
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= " Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): (CF1A-R
"
Address: 12 A/ (A( 5%. / Fire D P4 Oct -e MA- 010 31
City /State /Zip: i 4-Y3 QNt/(u e, AAA oto3q Phone #: 4 ( 3 3 74` 56
-s
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. [] I am a general contractor and I
employees (full and/or part-time).* * have hired the sub - contractors 6. ❑New construction
t
2. I am a sole proprietor or partner- _listed on the attached sheet. _ 7. 0 Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in capacity. employees and have workers'
g any - . 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.: -- --
required.] 5. [J We area 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 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.n Other VINYL- Si Om(
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 contactors 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 certify under the pains and penalties of perjury that the information provided above is true and correct
-- Si 1 e4A.444 ( 1517.47 -
1:7 Date: 1 b 72 Co/ 1
Phone #: 4 (3 3i 4 "5 -00 .5 — .- 0 .
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 #:
A
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 0 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l as Owner of the subject property
hereby authorize ....._..__.... _......._
to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, _.._.. (C 0 IJ .... V/-f 7- , 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.
t C (-1 -A,Q. D...... PA K . 1�
Print Na e
19-2
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
/�
Name of License Holder . 1 ` I C H Ai p D '4 t`Q
. r . 3 5 Th'
License Number
1:Z`t - (,r 5T2e2 H- Ay eNN vat e , m o IZ / /a /
Address Expiration Date
4t 3 7 . 5-
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 building permit.
Signed Affidavit Attached Yes !# No
i
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
R (C(f'AIa D ... Imo- Not Applicable ❑
Company Name:
Responsible In Charge of Construction
... .... ...
R. (3A-1Z, T I -q MA N sT H fi yPeRVitt €,N
Addre 11,��
�V pt- 413 374 - So oS
Signature Telephone
Version1.7 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
Setbacks Front
Side L: R: L: 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 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 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
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.
0
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 1E1
Brief Description Enter a brief description here.
Of Proposed Work. VI MYL SIP //(G
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ( ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing 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 1s
2nd
3rd ..... 3 rd
4th _.._ 4
Total Area (sf) Total Proposed New Construction (sf)
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
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Version l.7 Commercial Building Permit May 15, 2000
• ity of Northampton S #ado
`G �� Deeartrrtent use only ' ,
F elt Pent'
'� `���� B ilding Department Curb ut/Dnve ayPermit
�� 12 Main Street ewerl epticAvailabfhtyr
a
,� Room 100 Water/Welll�v billty ,
Northampton, MA 01060 Two sets of Structural Piers
•��'"� phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot!$$ ans,
Other Sfserfy
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
COIN. STR.e � Map Lot Unit
N 0 Rita*- M . P T 0 k MA Zone Overlay District
Eim St. District CB District'
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
00
I . t C ftterr0 _... fi ... 129 I i 1 ST. I'f D €RvrtLe- ! M/} ..... 0(039
Name (Print) Current Mailing Address:
13. 3 _.
Signature Telep hone
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 it/1,1A 5/01N1_ $ — j 400.
(a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) ._..
3. Plumbing i Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) $ "7 4' 00 . Check Number / � V O
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
51 CONZ ST BP- 2012 -0434
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 114 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0434
Project # JS- 2012- 000692
Est. Cost: $7400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD BART 23568
Lot Size(sq. ft.): 14331.24 Owner: BART RICHARD P
Zoning: URC(100)/ Applicant: RICHARD BART
AT: 51 CONZ ST
Applicant Address: Phone: Insurance:
129 MAIN ST (413) 374 -5005
HAYDENVILLEMA01039 ISSUED ON:10/27/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL VINYL SIDING
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 10/27/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner