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18D-004 (2) The Commonwealth of Massachusetts Department of Industrial Accidents . - tea r 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 Name ( Business /Organization/Individua1): R01/ Ytv' lap Isj Address: 1 L pkc S 1-he; OT City /State /Zip: i Phone #: 0 Are you an employer? Check the appropriate box: Type of project (required): 0 4. I am a general contractor and I 1C-Er I am a employer with ❑ employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I 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' Y P h'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. 3. ❑ I am a homeowner doing all work ffi h d h ❑ 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' li. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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: T kk 1 ��1 Policy # or Self -ins. Lic. #: 65 6 GU 6 - 9-1 , 0 r ) g6 ` 'O� Expiration Date: 06 16 C) Job Site Address: F O N pc) City /State /Zip: ['icg `'1 MiptoI / 11p Attach a copy of the workers' compensation policy declaration page (showing the policy number and expitation 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 tr and correct. Signature: Date: Phone #: Official use only. Du nut 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 #: - 1 , -. � e Version 1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CN1R110.11) Independent Stru �� �� c�una|EnQineeringStruntuoa|PeerRevimwRoquined Yes \~� No v_/ SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ("\r). - - �� |. __-_el �/ ____ Owner of the subject property . hereby authohze� to act behaff, in aU matters relative to work authorized by this building permit appflcation. -`���r�. / . �� -~ '/ s/^'am� mowno, \�/ Date |.-___v . Agent hereby declare that the statements and nform the and mo��� knowledge 6 , and belief. Signed under the pains arid penallies of perjury. , R13 to-cl r'4 JA4.uo N\ . .. .. - SliglsoP) _ _ , _ ,....,......, _ _ „ Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Constru Su Not Applicable [] Name v, License Holder : _ / \ 0515147 License Numb ___ ___ �_-___[[ - /_/(-� __-______'--� Address a / Exp�auvnoa� - fp -�� Signature Telephone SECTION 13 -WORKERS' COMPENSATION uRANCE (M.G.L. c. 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 buiWingpormit. _ �I'd �_�-- �_� G�nodAffidavhA�ached Yes No v_/ t 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): .w, 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 g p Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone t 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 Setbacks Front ' Side L L :' 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 CO DONT KNOW 0 YES 0 IF YES, date issued: ' IF YES: Was the permit recorded at the Registry of Deeds? NO (s.,,,) DONT KNOW Q YES C 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Date Issued: C. Do any signs exist on the property? YES Q NO 39 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 9 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t v. r 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 0 Demolition ❑ Repairs ❑ Additions Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. - g f , 1 Of Proposed Work: IN\ AU U t y 5 tc t w G\ SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 0 A -3 ❑ 1A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B I ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 0 R -2 ❑ 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): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P r o p o s e d Hazard Index 780 CMR 34): _.m_.__.__ __________ ._ SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 st 1 st 2 nd 2 „d 3rd 3rd _..._.._ . 4t 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 0 On site disposal system E] t Versionl.7 Commercial Building Permit May 15, 2000 3 Departmept use only City of Northampton Status of ger. rlit 1 Building Department Ciirb"CutUDi veway P _ __ _ 212 Main Street seterlSeptic9fluailal5tlity Room 100 WaterlllleltAvallabillty AUG 1 9 2009 Northampton, MA 01060 Two Se of S tructu r al , Plan ,:' phone 413;- 587 -;1240 Fax 413- 587 -1272 Plot/Sit Plan . Othe Specify APPLICATION TO CONSTR&CTTREPAIR, 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: 1 C)% Map Lot Unit r .,) ('‘(Y)101.\) R /�,i\l) Zone Overlay District _.._..__ q - `�.,._. _ I Q 0 \ ROT1U, • i Elm. St District CB District N SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 001 u m mK : tall: �.m.:C ( - __. ________,A,,,,, �� ? - . . Name (Print) Ai Current Mails Address: N - � . . . C?. IV Signatu e d',... 2. _ Telephone 1' �o75 2.2 Aut • rized A. ent " 4 ' itk Al Name (Print) Current Mailing Address , 1- .. .� „c),,\5, '41,,,._,. _ .. Signature � I i �d Telephone q I3 531 'u 6`4 k SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only - completed hypermit applicant 1. Building �� " ( a ) Buildin Permit Fee 2. Electrical ;b) Estimated' Total Cost of Construction from (6) ._.._,,..„ ..... 3. Plumbing 'wilding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) ,eckNumber — This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date ) : BP- 2010 -0194 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0194 Project # JS- 2010 - 000237 Est. Cost: $7000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARDIZZONI 051547 Lot Size(sq. ft.): 87120.00 Owner: MOCK WILLIAM D & EVELYN F Zoning: GB(100) /GI/ Applicant: ROBERT ARDIZZONI AT: 108 DAMON RD Applicant Address: Phone: Insurance: 7 LAKESHORE DR (413) 531 -4841 WC HOLLANDMA01521 ISSUED ON:8/19/2009 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 8/19/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo