17C-129 (2) HRO
INSURANCE
GROUP ,ems
MASSACHUSETTS WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY
INSURANCE CERTIFICATE INFORMATION PAGE
ITEM 1.
PARTICIPANT NAME AND MAILING ADDRESS: CERTIFICATE NO: WCMN0110
Northampton Housing Authority
49 Old South Street FEIN: 046003578
Northampton, MA 01060 ENTITY: Non - profit, public employer
ITEM 2.
CERTIFICATE EFFECTIVE FROM: 06/01/11 TO: 06/01/12
Effective 12:01 A.M. Eastern Standard Time at the Participant's mailing address.
ITEM 3.
COVERAGE:
A. Workers' Compensation Insurance: Part One of this certificate applies to the Workers' Compensation Law
of the Commonwealth of Massachusetts.
B. Employers' Liability Insurance: Part Two of this certificate applies to work in the Commonwealth of
Massachusetts. The limits of liability under Part Two are:
Bodily Injury by Accident: $1,000,000 each accident
Bodily Injury by Disease: $1,000,000 certificate limit
Bodily Injury by Disease: $1,000,000 each employee
C. Other States Insurance: Massachusetts Limited Other States Insurance
D. This certificate includes these endorsements and schedules:
WCNG0000 Insurance Certificate
WCNGTERR Terrorism Risk Insurance Act Endorsement
ITEM 4,
The premium for this certificate will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE
i iiroutft. „ 44.04.er
This certificate is hereby countersigned by on 5/13/2011
Authorized Signature Date
. The Commonwealth ofMassachusetts ,
Department of Industrial Accidents
'
4 ,- . 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/Individual): �C ." C\\,.., \y `� N a./ CSC\ J
Address: Lrt. C 1 5 1 S\
�J /
City/State/Zip: r3 ,\ 6 Phone #: L { (S 1 — Y L O ?Cal l
Are you an employer? Check the appropriate box: Type of project (required):
1. [2'1 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 a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub- contractors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
working Y P tY• 9. 0 Building addition
$
[No workers' comp. insurance comp. insurance.
required.] 10. 5. ❑ We are a corporation and its ❑ Electrical repairs or additions
d i
officers have exercised their 11.
3. ❑ I am a homeowner doing all work ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof 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.
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:1Vv-- t, k) ftWRO - �-vvcO c v.ce C•r- i7', .A C-
Policy # or Self -ins. Lic. #: V..)Crt\N61 \ C Expiration Date: 6 Il 1 i Z
Job Site Address: 137 ■)ti\ -St -B 1 j AA - F (0'-ACC City/State /Zip: d 1 z 2
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 certify uncl the pain • and ennal ties of perjury that the information provided '- iv:, 's true and correct.
Si • nature .// �' -fix- �� Date: yi
Phone #: / L i' VO30 1((
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 #:
~ t
Version1.7 Commercial Building Permit May 15, 2000
J
,
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
1, _ _ ...., as Owner of the subject property
hereby authorize _ _ _.__ r. _._...d..___ __ m _'to
act on my behalf, in all matters relative to work authorized by this building permit application. _
t _
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 pai 4 1.nd .e alties of .e 'u ,
IC
Print Name .._ _ _, _ __ ___ _ ...
Signature of Owner /Agent = Date
SECTION 12 - CONSTRUCTION. SERVICES
1 (1 0.1 Licensed Construction Supervisor: Not Applicable 0 u.
Name of License Holder . `. _. .c G -7 - .-.... --- 3,
License Number . ._
���� ^ ^ � ^ � u �__ _.
Address Expiration Date
1135 cY-YU3Gi -71
Signature °lam Telephone
SECTION! 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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
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 EILOSED SPACE)
9.1 Registered Architect:
. Not Applicable ❑
Name (Registrant): •— a.
Registration Number
Address
Expiration Date
__I
Signature Telephone
9.2 Registered Professional Engineer(s):
. }
Name Area of Responsibility
Address Registration Number
f
Signature Telephone Expiration Date
i
Name Area of Responsibility
I
Address Registration Number
,
Signature Telephone Expiration Date
i
Name Area of Responsibility
Address Registration Number
g
Signature Telephone Expiration Date
i
Name Area of Responsibility
Address ___.... ____. __ Registration Number
Signature Telephone Expiration Date .., _ .._...x
9.3 General Contractor
_ • . Not Applicable g
Company Name: ________ . _____. _ a jir- sin '6 4 ,1 Ite.
. ______ _ _ . _..____.,_._._ �, , C r
Responsible In Charge of Construction
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed ` Required by Zoning -,
This column to 1 e filled in by
Building Department
Lot Size _ ..: ,
Frontage _... _ ._
Setbacks Front
Side L:
r____, R i L :_ ....,. R !7.
Rear ..___....
Building Height jµ
Bldg. Square Footage % i "'"
`v _ ._
Open Space Footage %
(Lot area minus bldg & paved la __... _
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 Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Books '< Page` . and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 1g DONT KNOW (3 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO
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 0 NO ON
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
-
f
• a .0. ' t e, I.
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Version 1.7 Commercial Building Permit May 15, 2000 „.
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs 0 Demolition 0 Repairs ID Additions 0 Accessory Building 0 t
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing III of Use 0 Other El t ;
........___ ......... _
Brief Description ',Enter a brief description here. frvV ( 'e C L 'k .'s4- cr4 - 1 - '"' - 't ''' ` 1.1; 0
Of Proposed Work:
......_
- .
SECTION 5- USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly
El A-1 0 A-2 0 A-3 0 IA I CI
A-4 0 A-5 0 18 0
B Business CI 2A 0
E Educational 0 2B " r 0
F Factory 0 F-1 0 F-2 0 2C 1:1
H High Hazard CI 3A 0
I Institutional 1:1 1-1 El 1-2 ID 1-3 0 3B El
M Mercantile 0 . 4 0
R Residential 0 R-1 0 R-2 0 R-3 1:1 5A 1:1
S Storage CI s-i El S-2 0 5B
CI
U Utility
0 Specfy: —
M Mixed Use 0 , Specify:1
S Special Use 0 Specify:1
1 ,_ 1
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: , 1 Proposed Use Group: I _
Existing Hazard Index 780 CMR 34): _ ,. , ' Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
- .OFFICE-USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ,,, "
Floor Area per Floor (sf)
,
1 st .,,, __ __ st
1 [ ,
2nd 2
i
..:
3rd 3
th
4 i
4th ,
,
___.__•_______
Total Area (sf) 1 Total Proposed New Construction (sf)
-- ..
Total Height (ft)
Total Height ft ,...„ _ ,,. _ j
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone ., Outside Flood Zone0 Municipal 0 On site disposal system0
S 711( L4.c .G•' l b !2
C 7
F r Version1.7 Commercial Buildin Permit Ma 15, 2000
Qeoai-trne rd§Kersl
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City of Northampton 7 ��
i JAN I
O � 0t2 • B u il d i ng Department ,' • e_ s r � IR: :- ''A
212 Main Street e a i l w ag1► �A a�� r
auicv r vo ws Room 100 e i g4 .
MPTON �+ao °A 4 Northampton, MA 01060 • 2 @ t k P � �
p o 13- 587 -1240 Fax 413 - 587 -1272 I' fr,' l 5 " �plai�sn<� 2 ! fm d �
.„ c;€A< ltHI.>.:. .!..M.: . " tr ikC 5A `..' ..nom.: ,.
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
I f) S 4 _ 13 i N\ Map Lot Unit
- - to - � I � Zone Overlay District
__..__.�..._ _.. .,_.w....: ______---2 E1rn St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
w
Name (Print) Current Mailing Address:
/V -` 00,k ∎ . 1M 1�� _. __._ .M"
Signature Telephone -- 0/ - vo 3 0
2.2 Authoriz• • A•ent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f ! 00 C . (a) Building Permit Fee
(U 00
._N_ _
2. Electrical i (b) EstimatedTotal Cost of
I Construction from (6)
3. Plumbing i Building Permit Fee
4. Mechanical (HVAC) _.__.__.____. _. -
5. Fire Protection _. _. _ _ �___.__ __ .__ ......
6. Total = (1 + 2 + 3 + 4 + 5) ._ 0 Check Number / w/ 7
This, Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0645 l G� rL (1144,60:(V%
APPLICANT /CONTACT PERSON DAVID GOUR lam'' / .r '7
ADDRESS/PHONE 68 MEADOWBROOK RD EAST NGEADOW (413) 525 -4622 . �r f� J G�
PROPERTY LOCATION 137 HIGH ST - BLDG M
MAP 17C PARCEL 129 001 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 —
Tvpeof Construction: EMERGENCY REOOF REPAIR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 032053
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
Demolition Delay
I 17 Ira_
Signature of Building 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.
137 HIGH ST - BLDG M BP -2012 -0645
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 129 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0645
Project # JS- 2012- 001109
Est. Cost: $1600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID GOUR 032053
Lot Size(sq. ft.): 125452.80 Owner: NORTHAMPTON CITY OF NORTHAMPTON HOUSING AUTHORITY
FORSANDER APARTMENTS
Zoning: URB(100)/ Applicant: DAVID GOUR
AT: 137 HIGH ST - BLDG M
Applicant Address: Phone: Insurance:
68 MEADOWBROOK RD (413) 525 -4622
EAST LONGMEADOWMA01028 ISSUED ON:1/18/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: EMERGENCY REOOF REPAIR
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 1/18/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner