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I i !I !), , !!!! ! ---- ;! ---- r -- !--- - i --- --- 1 r i ---I i , [ 1 7 ,----:: I 3 1 3 1 3 3 1 3 , 1 3 3 3 3 3 3 3 • 1 - 1 3 3 r 1 1 3 _1 3 3 _„ , 1 I 1 3 3 I 3 • (-----1 - 3- .3- -- •I T , (:)1 ,. 1 - r . si I i i 1 111 ■ , 1 1 , ' - 1 i L _ 1 1 1 _ 1 1 _iLL, 1 'i -- 1 I 1 I I I 1 ' 1 1 1 n n I M 1 i I I I I 1 I 0 I (0 . --/ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations '�. 600 Washington Street ti = Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): (� c7XdT If-tZ_ -' Ac-r70 Address: AO, pJ ov 51/ ... City /State /Zip: C/ tre F'i Uzi) / ' Phone #: tj/ 3 L - r7 j to l 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 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. ❑ , I am sole proprietor or partner- These sub-contractors have listed on the attached sheet. 7. $4 Remodeling ship and have no employees 8. El] Demolition for me in any capacity. employees and have workers' working Q $ Y p ty. 9. El 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. Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ❑ myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §I(4), and we have no 13. ❑ Other employees. [No workers' 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: 510 oe. � jT City /State /Zip: No ivl^^f) 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 co py of this statement may be forwarded to the Office of Investigations of the D for insurance coy • • - v- • 'cation. I do hereby certify u d the pal nd , ena • s perjury that the information provided above is true and correct Signature:, #' 4104 Date: Dca, 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 #: . 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 0 w No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING. PERMIT \ k cn3 'Ok n-evn Les .-(L I, _.... � � .�. .__ ,.,�. �.:.m..r�,d__ _ � .�..�_� _ _..e_.�..w �..���.�..._,._...,�_m___.. _ .. � , as�2w�rer of the subject property /' eel act on my behalf, in all matters relative to work authorized by this building permit application. _ .__ Signature of 0 er -Wm , date I .. _ T�E�/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 under the pains 41enalties of .,-ju I i r k ______ _ ____ __ Print Name l,) ._ c . ..-- ., '... .-• 1\--t4-11/4.___, _ _______ _ ________ ___ Signature of Owner /Agent Date g c S ECTION 12 - CONSTRUCTION. SERVICES \ r � 10.1 Licensed Construction Supervisor: Not Applicable ❑ / f_ i i Name of License Holder : SL __.. — ----- . U ' %a/ ?- License Number ,_P., _� •'� 5 ' 0 l _ \∎ t32 r � s 1 C_tfib i ec . . N . 9.. M __ _ _ . Address i Expiration Date c:: \ (1 . - 1 . 3 - Signatwe 4 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 0 " No Version1.7 Commercial Building Permit May 15, 2000 J 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 EI!i,CLOSED SPACE) 9.1 Registered Architect: I Not Applicable ❑ _ r Name (Registrant): I __ - ..- - Registration Number Address --- _ .. .__.,..:,._.,.._: Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number 1 E Signature Telephone Expiration Date Name Area of Responsibility Address istration Number _ " M_. _ Re$c 1 Signature Telephone Expiration Date Name Area of Responsibility i F Address Registration Number S j Signature Telephone Expiration Date ._ r_.__...__ _._ I Name Area of Responsibility I Address Yµ^m rvV4n Registration Number Signature Telephone Expiration Date 9.3 General Contractor W .`7'd " � '_ / 90 — 4, Not Applicable ❑ Company Name: i} n __ _ __ _______ Responsible In Charge of Construction Address ______ ,_ Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON. ZONING Existing Proposed Required by Zoning This column to filled in by Building Department ,— — _..__........._..a.._ Lot Size .. I i ,_ :'_ _ ___ _ Frontage i ._.. _____ :.... ._.. i _ ___ _ _...... Setbacks Front Side L _ R:,„ / t R: Rear..._........ .,_._.._._.. Building Height .. Bldg. Square Footage % ? Open Space Footage % ---- - ----• (Lot area minus bldg & paved 1 i :. 2 i ? 4 - -- -a parking) # of Parking Spaces % Fill: i (volume & Location) - A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES Q IF YES, date issued: y t IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES _.._ . _ IF YES: enter Book ! i Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: _ D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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 Q NO 0 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 a t 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 ❑ , = Brief Descriptio E ter a brief description here. ts- yKe-vt. w <'. a t.i 6 1 ' -.° ) l' etl^' 1 rte" Noe,_ •.i Of Proposed VIM. • CA AAA..S i 1 tQsvirtvLisk k ►.t ---v t.,� ti Ta vvkrtIt ''L Stit " &Ft & F (E 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 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ,, r ❑ F Factory ❑ F-1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -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: t M Mixed Use ❑ Specify: - S Special Use ❑ Specify: f . 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) F St 1st 1 .........._ _J 2 nd 2nd _. 2 __ __ ! 3'1 _. . _..m�.______ ...__ 3rd 4 th ___ 4th 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 ZoneD Municipal ❑ On site disposal system _.mill Versionl.7 Commercial Buildin &P May 15, 2000 t 3 .� .I] e � ! ,: .GSEsi'� ,k �a � 'k �� Be GE w City of Northampton Sta - � ' Building Department 9 20 212 Main Street a , -,, g �' Room 100 :,_,-.e, ' -��, 's � orthampton, MA 01060 ;, h �t - � � �� • one 413- 587 -1240 Fax 413 - 587 -1272 a do ` � o , , 4 0 ' ` meet t -e" 4 ' i 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 SY V t e c c1J ;$ r ' Map Lot Unit A,7o P/ "'t itn I Zone Overlay District __..w.—_..._. .—.._._....... .....: ------- ,._ E1rtt St. "District :, CB District SECTION 2 — PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: _. i l V Signature Telephone y 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature ` Telephone Y/3 3 76 — //c2 SECTION 3 - ES ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ' (a) Building Permit Fee ; L eN5 fi1(-4-0 1 ,. _.m __ M .._ .__ _ : 2. Electrical ..., (b) Estimated Total Cost of __. l Construction from (6) _._.. ___._ , ___ .___._.__.. 3. Plumbing i Building Permit Fee 4. Mechanical (HVAC) -- ._ 5. Fire Protection __.. _ ___.._.__ 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 3 6 ,�, 3O/ 1155 This Section For Official Use Only Building Permit Number Date . Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0561 APPLICANT /CONTACT PERSON GARY ROSENTHAL ADDRESS/PHONE P 0 BOX 531 CHESTERFIELD (413) 320 -7961 PROPERTY LOCATION 56 VERNON ST MAP 31A PARCEL 112 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid ,I&S ?6/ )15s Tvpeof Construction: REMOVE 2 NON - BEARING INT WALLS4 CREATE L SHAPE OFFICE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 90936 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 emoli ' • Delay V ///7 — / 7 . e of Buil' ing O icia 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.