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The Commonwealth of Massachusetts
Department oflndustrial Accidents
°°-
Office Investigations f o nvetiati
f .. _... a
600 Washin atop. Street
.�� ,o Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. Qi 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: D Remodeling
2_ I am sole proprietor or partner- These sub- contractors have
ship and have no employees 8- ❑ Demolition
working for me in any capacity. employees and have workers'
g Y P h' 9- ❑ Building addition
[No workers' comp. insurance ` comp: ansurance # - - -
required.] - 5. 0 We are a corporation and its 104_1 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' co right of exemption per MGL
y [N comp. 12.0 Roof repairs
1
insurance requared.].t _ _. __ c 152, § (4 ) and we have no - - -
1-3- [] 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: 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 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 unde pains and penaltie ' perjury that the information provided above is true and correct.
Si. , ature - - Date:
Phone #: 4 3 — '7 S
1/ A 1
Official use only. Do not write in this area, to be completed by city or town official
— City bi 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 19011)
..
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER. AUTHORIZATION TQ BE COMPLETED _1NHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDIN PERMIT.
as Owner of the subject property
hereby authorize'.._...._. to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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 and penalties of penury.
Print Name
Signature of Owner /Agent Date -
SECTION:12 - CONSTRUCTION: SERVICES
10.1 Licensed Constructi Supervisor: Not Applicable ❑
J / 'p� I C S' ,
l' Y V Y�� I mo, (f i.-�' i.....,...�.. i)
Name of License Holder ..Y....._. - -- ------------ ---- -�
License Number
f) , eA / -(/ ,1,1,, $i " f= ' c o. i iv. -, J`1 I 6
Address Expiration Date
— --- ):c = ,� / °
Signature Telephone
SECTION;1;3 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G. c 152, § 25G(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
Versionl.7 Commercial Building Permit May 15, 2000
J
f ,
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION :SERVICES --FOR BUILDINGS- AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO, 780 CMR 1- 16;(CONTAINING MORE TITAN 35,000 C.F. OF ENSLOSED SPACE)
9.1 Registered Architect: - '
I Not Applicable ❑
Name (Registrant):
— Registration Number
I i _
Address ■ __........__,.,.
i Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
I ,
Name Area of Responsibility
i
i Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
Name Area of Responsibility
i 2
Address Registration Number
1 € i _ _
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number _
Signature Telephone Expiration Date
9.3 General Contractor
:w. =; _.. ._ € Not Applicable ❑
Company Name:
Responsible In Charge of Construction
i
_ Addres
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPT.01`4ZONING -
Existing _ Proposed Required by Zoning i
This column ti:) filled in by
Building Department
=
ii It ,.
Lot Size ,
Frontage 1 i I :
,.......____ ....... i 1 i '..
Setbacks Front = i , i .
,
, i 1
Side L:: 1 R:i i L'F1 R: 1 I
. i ! i
Rear ! i
Building Height '
__i , --7
i i – 1
—
Bldg. Square Footage r -----1 % 1 r {
Open Space Footage %
----7- -- - (Liit area minus bldg & paved 1 fre=t =
parking)
# of Parking Spaces —
Fill:
11 il — ----i
(volume & Location) - i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF 1 .YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 I
,
IF YES: enter Book! i Page I and/or Document #i
t ,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES a
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 0 NO 0
IF YES, describe size, type and location: " i ,
D. Are there any proposed changes to or additions of signs intended for the property ? YES C3 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 0 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
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 . a brief de scription here. A v t S ' r S = r - ON \ r k G 1
Of Proposed Work: / Q S ` 0 U \ `�
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) ' CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ IA I ❑
y . A-4 ❑ A -5 ❑ 1B 1
B Business 2A + ❑
E Educational ❑ 2B r ❑
F Factory ❑ F-1 ❑ F -2 ❑ 2C : ❑
I-1High Hazard ❑ - — == = 3A f ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 El 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S-1 0 S-2 ❑ 5B ( ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETETHIS SECTION IF EXISTING BUILDTh&UNDERGOI REN1.OV.AT1ONS ADDITIONSANDIORCHANGE IN USE
i _
Existing Use Group: . J P roposed Use Group: } ....I
r
Existing Hazard Index 780 CMR 34) i Proposed Hazard Index 780 CMR 34):1 .-_..I
SECTION 6 BUILDING HEIGHT AND AREA
r 0EFIf EaUSE, ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION. 4 _,;
7X
Floor Area per Floor (sf)
1 St
1st I
2n ` i ________
3r° 3 1
m
4d' i
8 4 -
Total Area (sf)� Total Proposed New Construction (sf)
Total Height (ft) !; -
_ Total Height ft.. _ _. - .,,,i
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[]
•
� � P � '
�
V eision l .7 Commercial Bu • Per M a 15, 2000 y
■
RECEIVED City of Northampton $�t a ' 3
Building Department i `r X4,3 ' :
212 Main Street ���'� ��`
�-„.��:� ,��
DEC 3 0 20H
Room 100 £ � i , -.� 4.
mod' :s e --e a'' ':-
Northampton, MA 01060 z v 47
DEPT OP BUILDING INSP ;� ! 413 -587 -1240 Fax 413- 587 -1272 °•�' i ``
NO RTHAMPTON • MA '1060 ,.. v `a y , N s �l "x 3z
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:
3� � 5 / `K I . Lot Unit
N or 7 �P /. r I o i o Zone Overl District
~ _— . ErrttSt Distncf CB District •
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
— ■ /
Name (Print) Current Mailing Add ss:
Signa r�iG (-0 elephone p
2.2 Authorized Agent:
,
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS;'
Item Estimated Cost (Dollars) to be Official Use ,On_ iy
comp leted by permit applicant
1. Building ��i^l ^ t 01 Building Permit _ Fe e _�
J� tIJJ
2. Electrical j (b).Estimate..... 0 lCost_of
Construction from (6) -
3. Plumbing 1 Braiding PerrnitFee
4. Mechanical (HVAC)
5. Fire Protection � vI
6. Total= (1 +2+3+ 4 + 5) Check Number x..17 '/ ( Q e,,,.
This Section For Official Use Only
Building Permit Number Date
- Issued
Signature;
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0608
APPLICANT /CONTACT PERSON RONALD HODGES
ADDRESS/PHONE 60 NORTH MAPLE ST FLORENCE (413) 586 -1150
PROPERTY LOCATION 376 EASTHAMPTON RD
MAP 44 PARCEL 056 001 ZONE GI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,5 7 �j _ r W --
Fee Paid 6
Typeof Construction: MOVE STAIRS FROM HILLSIDE TO SIDE OF BLDG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 003042
3 sets of Plans / Plot Plan
THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO 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
e ela
3 17
Sign... - of :ui dint fficial 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 EASTHAMPTON RD BP- 2012 -0608
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44 - 056 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 -0608
Project # JS- 2012- 000903
Est. Cost: $5000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
' Const. Class: Contractor: License:
Use Group: RONALD HODGES 003042
Lot Size(sq. ft.): 21300.84 Owner: FOURNIER FRANK N III TRUSTEE
Zoning: GI(100)/ Applicant: RONALD HODGES
AT: 376 EASTHAMPTON RD
Applicant Address: Phone: Insurance:
60 NORTH MAPLE ST (413) 586 -1150
FLORENCEMA01062 ISSUED ON:1/4/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:MOVE STAIRS FROM HILLSIDE TO SIDE OF
BLDG
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 1/4/2012 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner