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' - , —�-- Department of Industrial Accidents -
t • =j -t ' Office oflnvestigations '
if ir } = a 600 Washington Street
r
w1.77:11*- Boston, MA 02111
www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Indivictnat): . A4 4, - , C r - ' ' /
Address: P . <•, 1 (4 . GI S - S f Y 4 . 4 0 5 1 0 1 / 1 /1t, e i 3 y `7 .
City /State/Zip: Phone. #: `/1.5 - - 77r - '3 i L C
Are you an employer? Check the appropriate box: Type of project (required): i
1. Q I am a employer with 4.. 0 I am a general contractor and I
6. Q New construction
employees (full Vntitor part time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. I. Remodeling
ship and have no employees These sub -contra.ctors have. 8. 0 DenzoMon
working for me in an c aci employees and have workers'
y ap t3' 9 Bud g addition
[No` workers' comp: in-smarm : -'nsi r_a '
required:] • 5. f We are a corporation and its 10.0 Electrical repairs or additions
3. Q 1 am- a- homeowner-doing-all-w.Fk- — -- - .--- 9ff1-0r�l1v xezc*5P� nc�ir 11 -. Q Plumbing repairs or additions
myself [No workers' comp. right ofexemption 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.
IContractors 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.prwide 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
. ormation.
Insurance Company Name: _
Policy # or Self-ins. Lic. #: ' . Expiration Date:
Job Site Address: City /St:de/Zip :'
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Fai1nre to secure coverage as required under`Section'25A of MGL c. 152 can lead to the imposition of crinnnal penalties of a
fine up to 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator: Fie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverase verification
I do hereby. certify under the pains and penalties of perjury : that thk information . provided _above_ittrue.and_correcL_. __ _
Si. . • ture: _ r!! . - . Date: /Z 7 `I
Phone #:
.- Official use only. Do ndt write m this area to bi riff a ed 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 #:
x.
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 t
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I ` eL � , as Owner of the subject property
hereby authorize U_ S 'C-- AN All P11 7i' to
act on my behalf, in all matters relative to work authorized by this building permit application.
/Z /
Signature of Owner Date
rr ✓
I, (1.CyC-(__ �"- U , 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.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: ^/� Not Applicable ❑
Name of License Holder : R J s ' (, „I "...1 A (✓� 1.--- ( J g‘jziO3
License Number
P.6, C ` l am 1 c Ar) \ 0,A MA 0133 ii /z- / Zr��/
Address / Expiration Date
3 7 75 3 1.1.6
Signature //!' 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 ei No 0
M
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 ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable rEjl
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
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
ti
•
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 L: R: L: 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 DON'T KNOW 0 YES
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 ® DON'T 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 ,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
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Er Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Cha a of Use ❑ Other ❑
Brief Description Enter a brief description here. /
Of Proposed Work: fi ��9
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 El A-2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -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 1 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
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): 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)
1 st
1"
2 nd
2 nd
3rd 3rd
4
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 Zone❑ Municipal ❑ On site disposal system
e
Versionl.7 Commercial Building_Permit May 15, 2000
Department use only
City of Northampton Status of Permit.
—` " Building Department Curb Cut/Driveway Permit -
,. LUG 212 Main Street Sewer /Septic Availability
DEC ` Room 100 Water/Well Availability
Northanpton, MA 01060 Two Sets of Structural Plans
ph one:41 - 587 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
L/C I f r, Map Lot Unit
f'76 r , �G MA Zone Overlay District
(� ►
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
( " 7 7 C o o t t
Name (Print) Current Mailing Address:
ST 0106
Signature„ - -- Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
�.- `//3 2,
Signature '' Telephone
SECTION 3 - ESTIMATED 6ONSTRUCTION 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 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection -�
6. Total = (1 + 2 + 3 + 4 + 5) Check Number /Li 36"
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
t '
File # BP- 2010 -0581
APPLICANT /CONTACT PERSON RUSSELL MANZ
ADDRESS /PHONE P 0 BOX 485 BERNARDSTON (413) 775 -3126 Q
PROPERTY LOCATION 40 MAIN ST 3RD FLR FREE PRESS
MAP 23A PARCEL 075 001 ZONE GB(100)/URB/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid it /( ` 2
Typeof Construction: 3RD FLR -'FREE PRESS - CONSTRUCT NON - BEARING WALL W /DOOR
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included: 1 p
Owner/ / Plot Plan 1 t or License 81403
Plans
3 sets of Plans / P W , C,S A ST /JOT f fiZ FEf2 f w'ITH SP21� 14S
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOXVIATION 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
/110 (I 10
Sig re 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.
4
40 MAIN ST - SUITE 206 BP- 2011 -0352
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A - 075 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0352
Project # JS- 2011- 000589
Est. Cost: $21700.00
Fee: $130.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BARRY R COHEN 005639
Lot Size(sct. ft.): 54624.24 Owner: FORTY MAIN STREET INC
Zoning: GB(100)/URB/ Applicant: BARRY R COHEN
AT: 40 MAIN ST - SUITE 206
Applicant Address: Phone: Insurance:
40 O'DONNELL DRIVE (413) 303 - 9092 0
FLORENCEMA01062 - 3525 ISSUED ON :10/21/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: FRAME NEW WALL FOR SUITE 206 -SHOP
DRAWINGS FOR SPRINKLERS PRIOR TO FINAL INSPECTION
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: 7-1O Roughq'j- 41 House # Foundation:
2P h'1 Driveway Final:
Final: 1- :(9jk Final: / 42 6 . p
p v1 Rough Frame: O ' /.6t, / .
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: 71n5T l?tii3n:
Final: Smoke: Final: d
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy
isnature: At6 g a t tetvez . FeeType: Date Paid: Amount:
Building 10/21/2010 0:00:00 $130.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner