32C-182 n I
Yl �i
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0 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investig ,
t '� 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Leaibl
Name ( Business /Organizadon/Individual): a * S W
Address: g 3 $ . *A-A"A .
City /State /Zip: 't. Phone #: 'A 1 b'6 (o `r • 4 19 '15
Are you an employer? Check the appropriate box: Type of project (required):
1. E7 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.,❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees Thesesub-contractors have g. 50 Demolition
working for me in any capacity. employees and have workers' 9.' ❑ Building addition
[No workers' comp. insurance comp. insurance. --
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3. ❑ I am a homeowner doing all work exemption myself. [No workers' comp. right of p lion p er MGL 12.F% 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 11 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: A.T.
Policy # or Self- -ins. Lic. #: U lt&6 W, 4- &At i. J9jt Expiration Date: 2 �• Z.
Job Site Address: 3 7` S C, City /State /Zip: t
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 DIA for insurance coverage verification.
I do hereby certi nder t p ns and es ofperjury that the information provided a ove is true and correct.
Signature: Date: j h I
Phone #:
FOthe only. Do not write in this area, to be completed by city or town offcciaL
n: Permit/License #
thority (circle one):
Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
rson: Phone #:
Versionl.7 Commercial Building Permit May 15, 2000
J
f
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION - TOBE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING. PERMIT
.
as Owner of the subject property
hereby authorize �� °�
act on my behalf, in all matters relative to work authorized by this building permit applicatio
Signatdre of Xwner L Date
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 andenalties ofserj _. a..w _. .._,-
Print N--P—
Signatur wner /Ag Date
SECTIO 12 - CON TRUCTIO . SERVICES
10.1 Licensed Construction Supervisor Not Appli cable
Name of License Holder
License Nurhber
•._..�fW!!r�
Address Expiration Date
0i 1�,� I k
Signatu Telephone
SECTION; 13 - WORKERS' C MPENSATION INSURANCE AFFIDAVIT (MG.L. c. 152, § 25C(6))
Workers Compensation Insurance afficLavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the b ding 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
AN IVI
CONSTRUCTION CONTROL. PURSUANT TO 780 CR 116 (C' I ONTAINING MORE T000 N
I TH 35, C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑ iv P Y\j C_
Name (Registrant):
........ ......
Registration Number
Address
Expiration Date
SignatL*6 Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
. . . .......... ... ......... . .. ...... . .......... .... . . . . ..... . ............ . .... .....
.......... .. ........ ....... . ...........
Address Registration Number
Signature Telephone Expiration Date
.... ............ . ...... ........... . .....
Name Area of Responsibility
.....r._. ----
Address Reg istration
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
'A
L Not Applicable ❑
Company Name:
5 wt4
Responsible In Charge of Construction
s) 1-044AH- WA-
Address
Signature Telephone
t
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON" ONTNG C. G�AA't
Existing Proposed ` Required by Zoning .
This column to 1 e 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
p arkin g)
# of Parking Spaces ---
Fill:
(volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON KNO YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DO KNOW 1 YES 0
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? MM _
Needs to be obtained Obtained , Date Issue
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 Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex avation, 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 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOS SPA ,.�/
Interior Alterations Existing Wall Signs ❑ Demolition 1.� Repairs Ef Additions ❑ Acck onvoir.0 , Building,[]
Exterior Alteration E3 Existing Ground Sign [I New Signs ❑ Roofing [Change of Use E3 . .
Brief Descri ption 'Enter a brief description here. 904601 Co L4,AP5*tkr 4.CO I S Coty c� Cv Ks
Of Proposed Work t-AP►' 0.401 RW o VILS. SKS�w � �'F 'G�Ss►�s SKl�tik��' ��
te a uK, M: w a..ra-
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 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ _ __- - -, 3A ❑
Institutional ❑ 1-1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 1 4 ❑
R Residential ❑ I R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 513 ❑
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)
a
151 St r
2nd __ 2 nd
_ .... _.._ . _...
rd ,...._..w,__..__ ...,_ ...._.....,_..,,.._.,....,....,
3` 3
4`" _ _ _ _ 4 th
Total Area (so Total Proposed New Construction s
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 E?f On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
Pon �� � a
Ci of Northampton Sttrtc� t '
`•� Bui ing Department� #Sp�
2 Main Street SewelepttAvilaExtlify
oom 100 iltE�� iA�ati ! I[i i � iad" 31
per• orthamptOn, MA 01060
phone 413 - 587 -1240 Fax 413 -587 -1272 „ 1I�aitPns �p
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
This section to be completed by office
1.1 Property Address
Map Lot Unit
Zone Overlay District
-- 'El
m St: District CB District
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Cu rrent Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name (Print) Current �Mailinc Address _
._.....�.1.,�..'._._.� eft.- •�� -�-� �.��._ _ �......_�. _. ".__�_... _� .
Signature nature Telephone
SECTION 3 -'ESTI ATED CONSTRUCTION COSTS''
Item Estimated Cost (Dollars) to be Official Use Only
com pleted b y ermit a m
1. Building (a) Building Permit Fee
3 Z
2. Electrical O ..__ b Estimated Total Cost of
Z, Construction from 6 _ ._..__.
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _ .
6. Total = 0 + 2 + 3 + 4 + 5) 6 a Check Number
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0444
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 Q
PROPERTY LOCATION 376 PLEASANT ST
MAP 32C PARCEL 182 001 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 . 42 n 1
Fee Paid
Typeof Construction: REMOVE COLLAPSING ROOF STRUCTURE NEW TRUSSES MASONRY
REPAIRS NEW ROOF & SLAB NA or 2 E- e rcj f'jc
New Construction
Non Structural interior renovations
Addition to Existin
Accessoly Structure
Building Plans Included:
Owner/ Statement or License 040714
3 sets of Plans / Plot Plan
THE F LLOWING 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
11 Y7 !I
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.
376 PLEASANT ST BP- 2012 -0444
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 32C - 182 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 -0444
Protect # JS- 2012 - 000715
Est. Cost: $37000.00
Fee: $222.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 7361.64 Owner: SZLOSEK STEFFIE AND OTHERS C/O 6 CRAFTS AVENUE LLC
Zoning: Gg B(100)/ Applicant: SACKREY CONSTRUCTION
AT. 376 PLEASANT ST
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 O Worke
Compensation
SUNDERLANDMA01375 ISSUED ON :11/7/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- REMOVE COLLAPSING ROOF
STRUCTURE,NEW TRUSSESNASONRY REPAIRS,NEW ROOF & SLAB
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 11/7/20110:00:00 $222.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner