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The Commonwealth of Massachusetts
" Department of Industrial Accidents •
Office of Investigations
600 Washington Street
Boston, MA 02111 •
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information / Please Print Legibly
Nanle ( Business /Organization/Individual): ON Ai' " 4- (c
Address: 'j 4 ' N (4.-Cr Al - 12,: AtZ> F-1FI6-L.f- l4)4 --
City /State /Zip: dt &=> Phone #: III e j 53Zc
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
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2. 0-1 am a sole proprietor or partner-
ship 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. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 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' 13.0 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 u r he gins a d pe lties of perjury that the information provided above is true and correct.
Signature: Date: h&j 4
Phone #: q i3 e 3
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 0 No ®*
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
act on my behalf, all matters relative to work authorized by this building permit application.
57/G∎ ,3or/
Sig ture)f Owner ( / Date
. 41 _..tt4.iffrat? , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best cif my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print e
51161 t
Signatu a O wner /Age t Dat
SECT ON 12 - CON TRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : .t�"1Gi1!!.y
License Number
.__.,. . ?. Pi.-Li)._ A' ,._..
Addre Expir ton Date
Sign u - Telephone
SECTION 13 -W RKERS' COMP SATION 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 0
Version1.7 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
V NA - 17 - 4 ..... Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addres A.01 l'73.b.rm
Sigrtat
e „„ ..„„
4 1/Z eNt
Telephone
•
•
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
NC7 C 4 This ccolumn to be filled in by
B uilding Department
Lot Size
Frontage
Setbacks Front
Side L. .. -_.._ R. ....,__._. L...... ... R.i .._,_. - _
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 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,Date Issued:
C. Do any signs exist on the property? YES NO 0
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 0
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 C NO
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
«` a,
Interior Alterations Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accesso , .. uilding 0 '�u
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other • ,; ""
Brief Description Enter a brief description here. , .. r''•
Of Proposed Work:
- 1 - 6 * T / /-_.__ e _ACC S _ f _ € ! v s ) . / - 1 • / 4 0 : 4 1 V / -
/ *
—
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE 54 S( re Y \aN lArtteaA 111+ 543.A
USE GROUP (Check as applicable) (Jl-. eRft cf S CONSTRUCTION TYPE
A Assembly CI A -1 ❑ A -2 ❑ A -3 ❑ , 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B . r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ i 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 0 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify: _._...._. ... _.w_ �_ _ ...
M Mixed Use ❑ Specify: ,
..
S Special Use ❑ Specify:
......�m.w.....�___________ a.,____ _, -._ _____ ,w. ,_._. .. .
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) CMArL
( .
1 st
1
2nd 2 nd
,
3rd .. _� .._._ ,_.._,.. _ — __
.. ...., 3 rd
4 th
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❑
,` 0 • Version 1.7 Commercial Building Permit May 15, 2000
�V ,i„ Department,t oniy
��G �0\` ity of Northampton St c a��r
�� riding Department Curb Pe I� � ° : °
!t' ,
212 Main Street Sew � m � � �
�;� ,v "Y 3 0 y N.4 s. , 'r
`' Room 10 0 uvaferlVtCelk.Avdflabgtr-
�r Northampton, MA 01060 T wo S et s " o Stf uc t ural P t. }
' . •� " p hone 413- 587 -1240 Fax 413- 587 -1272 P l a t/Si t e P lans
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
Li LL („ i Frek . Map Lot Unit
1' VYL I '1-- Zone Overlay District
._..... ,._.... EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) C urrent Mai Ad
fQ Signature r+-) r—� Telephone
2.2 Authorized Agent:
, ^.► },l�/1 !kl� .. (.. "'' ,.. . �,...—_ _. . .. . . M ....[Z
Name (Printr1,� j7' � ` _ Current Mailing Address ., .
z Fib .. 1-. ,.E)3
it 1� f �W ... ►
Signature / Te L h
SECTION 3 - STIMATE 1 CONSTRUC ION COSTS
Item timated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical ..__. (b) Estimated Total Cost of
Construction from (6) ..... ...... _._,_._..... „_
3. Plumbing .�...._ ...----- __._ _ ..__ Building Perm Fee
4. Mechanical (HVAC)
5. Fire Protection ' "° ,. ,...
6. Total = (1 + 2 + 3 + 4 + 5) i Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
.
.
File # BP- 2011 -0946
o oy �' t 1 ,
APPLICANT /CONTACT PERSON JAMES VAN NATTA C l
ADDRESS/PHONE 403 SOUTH MOUNTAIN RD NORTHFIELD (413) 834 -5329 Q I�
PROPERTY LOCATION 19 MEADOW ST I t tQ
MAP 17C PARCEL 278 001 ZONE URB(100)/ hO P` Ek
THIS SECTION FOR OFFICIAL USE ONLY: 6 )) 14
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out atti
Fee Paid
Typeof Construction: INSTALL INTERIOR STAINED GLASS WINDOW SASH S�
New Construction C ��) ( 6e_
Non Structural interior renovations �Q w t �` S � C�%� �� �N
Addition to Existing •
C'Q l01
Accessory Structure
Building Plans Included:
Owner/ Statement or License 040620
3 sets of Plans / Plot Plan
THE FOLLOWING 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 Peiinit 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
emolition Delay
5
• : r- of Buil ing 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.
.
,
19 MEADOW ST BP-2011-0946
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 278 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit# BP- 2011 -0946
Project # JS- 2011- 001545
Est. Cost: $3400.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES VAN NATTA 040620
Lot Size(sq. ft.): 29185.20 Owner: NORTHAMPTON CITY OF
Zoning: URB(100)/ Applicant: JAMES VAN NATTA
AT: 19 MEADOW ST
Applicant Address: Phone: Insurance:
403 SOUTH MOUNTAIN RD (413) 834 -5329 0
NORTHFIELDMA01360 ISSUED ON:5/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL INTERIOR STAINED GLASS WINDOW
SASH- SASH WILL BE SCURELY FASTENED IN PLACE
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 5/19/2011 0:00:00 $0.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner