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31B-175 itcOM Mot C ra do m s �"�� � vv4of ? �.I r e w %}17b „ 10°c U !i5t A CPI R ,% Jo{ laitrl yr100),A ss1-9 4 - .--� rip' 15 r a 4' \ The Commonwealth of Massachusetts -� Department of Industrial Accidents � 0.--.,,:e, Office of Investigations , `,` 600 Washington Street Boston, MA 02111 *r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): ,..D: cr.; Address: /qh/1 City /State /Zip/k r q 4i& /f Phone #: c/ _c/ 3 _ 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 employees (full and/or part- time). * have hired the sub- contractors 6. ❑New construction 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 n'• 9. p 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, §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: 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 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 DIA for insurance coverage verification. I do hereby rtify unde t pains and p nalties of perjury that the information provided a ove i true and correct. Signatu e: _ --------..--------..—/ "� Date: i / c Phone #: g i '- 3/ 3 `,)- 3 Official use only. Do not write in this area, to be completed by city or town official Cit 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 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, e.. _..a ..._ __ _ . w . .. _,�._.:..w_,., , _ . „„ _.,.. as Owner of the subject property hereby authorize _._ e — .r. 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 andpenalties of periun!; .__ _ __ . w_- ___ .,, __. Print Name _ .__ _._._____._.___ ____ .__.. Signature of Owner/Agent . Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder . , 1.- _�_ r'� _z2_____ . _,.,_.�_. �_..._.�.....A �.0 . (5.. 'J 05. 1.._.. License umbe I 7'7 sf. / . -1-� 1 0 oho £ __. Add _ F�cpiration Date Signature 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 Li / (.....* /c9 .. eA V-a - 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 EIJFLOSE© SPACE) 9.1 Registered Architect: _.___ _______ _ _ Not Applicable El Name (Registrant): _ _ --- _._._ _...___.. Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date I -- Name Area of Responsibility Address Registration Number m Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number I Signature Telephone Expiration Date __._ __ __._... _..._______ Name Area of Responsibility Address Registration Number I Signature Telephone Expiration Date 9.3 General Contractor . ..__ __._., ___ __,_....___, ...... . ...... ............. ____ , _ ___ __ Not Applicable ❑ Company Name: 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 l a filled in by Building Department Lot Size _� �_ ..�...�.. ? �.:.. ....:._ .�,. ._u .�....+. Frontage Setbacks Front Side L. R. = L:i R: 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 0 DONT KNOW !� YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book ' Page. and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0 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 Q 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 1, IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, xcavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 • -_ .. ,:.. , gyp I SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE ' Interior Alterations ❑ Existing. Wall Signs [a Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ j Brief Description ;Enter a brief description here. ,4,JJ bo j(go ct ' evid 0-6 hei /I 6,174 J 4f �✓ a. ..-s Of Proposed Work: 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 ❑ - I Institutional ❑ I - 1 ❑ 1 -2 ❑ 1 -3 ❑ , 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 iel R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: j 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): x. __ _____ .. 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) Si 1 2nd ._ _. __ 2 nd ........__..... ... ,_.. rd ,.M— �..... ... 3rd _ _ 3 ' 4 n __ -.,. 4 m . ,. _ _ _._ , Total Areas Total Proposed New Constructions_ 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 ❑ On site disposal system e. / i ; , , _ -------- _ Version1.7 I 1 : n1•ing Permit May 15, 2000 De' a e i use o ' • ty of Northam on ,st • y fig W �� B Hiding Department _ ; . INn"` ra �Pl wa PE , I Z 2 01 •12 Main Street ;� a® �� Room 100 Ilator * I a � ���� ,: a of Bun-DING INSPEGTIO14o i ampton, MA 01060 A s ` N hone 413 - 587 -1240 Fax 413 - 587 -1272 Fl � t � � , rg eC� e n ; � . . X44:; , . � " � p,. ttgiv, APPLICATION TO CONSTRUCT, REPAIR, RENOVAT , CHA GE TH SE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THA A ONE R FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: . , 5Lci b✓ 4, 'b✓`e , Map { Lot Unit t/o( ) MA OwO ; Zone Overlay District _ _– .- ------ — --- , w Elm St: Dist CB District S ECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) .. J Current Mailing Address: d; 3'111— TY 0 /// Signat (_v, ■ i E ; s- ''' (-.t` ) t Ul Telephone l t 2.2 Authorized Agent: 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 -- 1 - /y, i (a) Building Permit Fee 2. Electrical vVV VV '' (b) Estimated Total Cost of / °C Construction from (6) _ ».._._ _._.,___._ . _. ___ .. 3. Plumbing / 0 00 Building Permit Fee 4. Mechanical (HVAC) °°_._._._-.__- --- --' °---- - 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) / VI 070 Check Number •' J6 fi �O This Section For Official Use Only Building Permit Number Date . Issued Signature: Building Commissioner /Inspector: of Buildings Date File # BP- 2012 -0654 APPLICANT /CONTACT PERSON DANIEL K DACRI ADDRESS/PHONE 76 HAWLEY ST NORTHAMPTON (617) 543 -2843 PROPERTY LOCATION 37 HENSHAW AVE MAP 31B PARCEL 175 001 ZONE URC(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 /3.56) !G� Typeof Construction: ADD 2ND FLR BATHROOM IN EXISTING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 105989 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 /424-"--° 1 7 1 77/ '2-- 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. 37 HENSHAW AVE BP- 2012 -0654 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 175 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 -0654 Proiect # JS- 2012- 001124 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DANIEL K DACRI 105989 Lot Size(sq. ft.): 11543.40 Owner: LESLEY WILLIAM Zoning: URC(100)/ Applicant: DANIEL K DACRI AT: 37 HENSHAW AVE Applicant Address: Phone: Insurance: 76 HAWLEY ST (617) 543 -2843 NORTHAMPTONMA01060 ISSUED ON:1/18/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD 2ND FLR BATHROOM IN EXISTING 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 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner