30B-084 �"I 1-�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Inves tigations
�t-fr 600 Washington Street
Boston, MA 02111
T;' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly_
Name ( Business /Organization/Individual): Joiyt. DO 04 6.64 t ' i 4o fool, tog,
Address: 2 ( 7 . v X 0 1 Q7
City /State /Zip: Ch e5 /0r /41/ inz, . 0/pi'2 Phone #: 1 //1 — 217 S16
Are you an employer? Check the appropriate box:
I am a general contractor and I Type of project (required):
4.
1. Yr I am a employer with j ❑
employees (full and/or part-time).* have hired the sub - contractors 6. New construction
listed on the attached sheet. 7. 2 Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. El 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.[ Other /./
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r 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: /4 t'ic 1y v /ti 4 A .1d5_
Policy # or Self-ins. Lic. #: W(, 7 — ?IZ / y9 - 0l/ Expiration Date: /Ylf ,76 ,0,/ 2-
Job Site Address: o tll /.4 D i2 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
Iavestigations_of thehlA -for insurance coverage verification__ -- - _
I do hereby certify under the pains and p ti of perjury that the information provided above above is true and correct.
Siena ,re: its 1 t�li� �. Datc. a.ic. /y 2 L' //
Phone #: / - 2 9 7- 57 L/
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 0
SECTION 11 OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, � /. �/f hailVi -_ as Owner of the subject property
herebyauthorize / ��z G�`�'l%C�r�'�....UG<L >r� 'to
act i my beha F, in all matters relative to work authorized by this building permit application.
. Z ) & . . / .. 2.0/l .. „
Sig ture of ner Date
I , f ,... . ',,.. _ __ . _.,..__ _ _. _ , 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.
7 h .,�Zlr1Z�4 __Z./
Print Name /`
L i/7/4/1/efd - te(ttf,■4 __ 47).e4, ,„/,_,7,2,o/./ ,, ,
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
C, . 31 L*/
License Number
' Po /. _S-04 . q7...__ ,./ esfee..t e : /.���.'. 'ig, ...tz /v /.. / _ .I.-- 20 ia .. .._
Address Expiration Date
C ' ' ' '... v . - 4 it. - ‘r 7 :/f- 7 ,,Z4 c - f - A - 5 7/e - 1 1..... -
Signature Telephone
SECTION 13 = WORKERS' COMPENSATION INSURANCE AFFIDAVIT- (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affid vTt must be completed and submitted with this application. Failure to provide this affidavit will result
in the- denial - of - the- issuanceof- the- ing permit. -- -- ---- -- - _ _ _ _ --- - - - - -- -
Signed Affidavit Attached Yes No 0
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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
Nam (Registrant): 5.1
/L , ��^ � Registration Number
Address
piration Date
/1106111111? --
Signa . agigg�� Telephone
9.2 R � , • - - . • • - sional 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
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
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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
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 Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 C) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 Q 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 comi11011 plat
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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4,
Versionl.7 Commercial Building Permit May 15, 2000 f .- ..�n._. .. ,......
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SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 i
CUBIC FEET OF ENCLOSED SPACE IQ.S E ,,
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accesso ry Buil ling ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs 0 Roofing ❑ Change of Use ❑ Othe it
Brief Description Enter a brief description here. O,i1 / a pwrvrdd( wails rir - 5 A ,4 (..
Of Proposed Work: Z'"v /j/OA 0 559.0. , 64 y /F2 v Alan" f r1 s 1' A rtv.r / /D A,,, wI
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 I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ f 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: ,..� __ �. �. .. .,,,W ,
_�,,.,
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: i 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)
3:
1 st 1st
2nd ...,.... ,. ._..,_.. .
3 3rd
rd
4 w
4 th
Total Area (sf) Total Proposed New Construction Lsf)
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 0 Zone _ _ Outside Flood Zone❑ Municipal 0 On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
RECEIVED Depa use only,.,
City of Northampton Status ef Permit:
- 32012 Building Department Curb Cpt/DnvewayPen - -
212 Main Street
DEPT OF BUILDING INSPECTION1 Room 100 Water/Well AvaiTability
NOR111AMPTON, MA 01060 Northampton, MA 01060 •8ets of Structural
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
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
y /09,://cee // /1100‘ /die Map Lot Unit
.4 Do / -(
Zone Overlay District
/(41 >W4 rktiv 441 gra E
- - hi St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6,gif 4 a .9 PI) 4 e „
Name (Print) Current Mailing Address:
4 J A i/ / // 5 -- 4 / -
Signature' _.410 02,141C/411 e ephone
2.2 Authorized Agent:
70 Ao/ Ave/ M, 'b» Ra g 4P9 • f t ife
Name (Print) Current Mailing Address:
1 -1 - 2er -y
_
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated 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 /fri/evt/44". ,} 049 , Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+ 5) S / 7 S * Check Number 792 V/ §i. 93
This Section ForOfficial - Use Only
Building Permit Number pi - 6 07_ Date
Issued
Signe
/-
:uilding Commissiiner/Inspector of Buildings Date
20 LADD AVE BP- 2012 -0620
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 084 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 -0620
Project # JS- 2012 - 001070
Est. Cost: $19544.00
Fee: $93.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS DOLAN 039281
Lot Size(sq ft.): 304484.40 Owner: GRAHAM JAMES H & JAMES J GRAHAM TRUSTEES
Zoning: SI(100)/URB //WP Applicant: THOMAS DOLAN
AT: 20 LADD AVE
Applicant Address: Phone: Insurance:
P 0 BOX 297 (413) 585 -0612 () Workers Compensation
CHESTERFIELDMA01012 ISSUED ON :1/3/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 2 WALLS IN SHOP AREA TO MAKE
ASSEMBLY ROOM & INSTALL 2 DOORS
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 1/3/2012 0:00:00 $93.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner