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O. The Commonwealth of Massachusetts
VI 14
* i , Department of Industrial Accidents
Office of Investigations
�4I 600 Washington Street
Boston, Mass. 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual) : /Min /(} `' /n /4 4)1.1 ,4.t c' )
Address: °35 ,( ,t �?,.c l
City /State /Zip: Lt.) . - A iP a Phone #: "//3 — 3 '//5 -
Are you an employer? Check the appropriate box: Type of project (required):
1. 1 I am an employer with 4. 11 I am a general contractor and 1 6. [1 New construction
employees (full and /or part time).* have hired the sub - contractors 1 Remodeling
2.X I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 1 Building addition
[No workers' comp. insurance comp. insurance. $
required] 5. ❑ We are a corporation and its 10. Li Electrical repairs or additions
3. 1 I am a homeowner doing all work officers have exercised their 11. 1 Plumbing repairs or additions
myself [No workers' comp. right of exemption perm MGL
insurance required] - c. 152, § 1(4), and we have no 12. 1 Roof repairs
employees. [no workers' 13. 7 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
}Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attach 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 most 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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si: nature: P cz,- 1 . 0 Date: e . " 1 1,-.:)._
PrintNamer 77 -Al4 c M AeLvh,oko Phone #: , 3 _ ` vi3 ° 41i ( 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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #:
Version1.7 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, P, f r t C. k /' ' / ' ' [ U / e_ , as Owner of the subject property
hereby authorize TZ C)i"► /jS /Z Ug ro to
act on my al in all matters relative to rk authorized by this building permit application.
4 2';/ 3 1.2 CY,,Z
Signa ure of Owner Date
I, o !- 1..t A r) , as Qaaaer /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
. —eat.° _3//q /1
Signature Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: /y� Not Applicable ❑
Name of License Holder / /IQYfl S / n� A( ) tL_/i j7 )�' b ca--
License Number
/JNne e l 1v. /. / 1d i 9 3 f /iz
Address Expiration Date
AIWA
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 � No
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 ❑ Existing Wall Signs ❑ Demolition ❑ Repairs 15I Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ ivy Change of Use ❑ Other ❑
Brief Description --) (/0 '` X `7/ 1
; f?in L' cj = X`r -s j'; liRc} ern, �. �,,P s *, u R . . A r,-.* L / ,,,, e: uj r ,, c , t
Of Proposed Work: _ r
-' ) . c� API .) g +,ref. k,� ibi - o f �3�? �-n; 27v�4au Ale�,i i ti' ' kR s
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 `lL R -1 ❑ R -2 jki R -3 ❑ 5A
S Storage ❑ S -1 ❑ S -2 ❑ 5B
[ g
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)
r
1 st ,-
1
2nd
2 nd
3 rd 3rd
/
j
4
4 4 "��•
Total Area (sf) Total Pro used New Construction (sf)
Total Height (ft)
T al Height ft
7. Water upply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private ❑ Zone Outside Flood Zone❑ Municipal A On site disposal system
iNrO
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required b oning
This col to be filled in by
Bui • g Department
Lot Size
Frontage
Setbacks Front
Side L: R: Jz'. R:
P
Rear /
Building Height /
f
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 Q DON'T KNOW Q YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW 0 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 a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO top
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
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
152 -154 Federal St Map Lot Unit
Northampton, MA
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Patrick and Sheryl Malone 167 Audubon Rd p
Name (Print) ,,,,, Current Mailing Address:
. (413) 584 -6679
Signature G�� Telephone
2.2 Authorized Agent:
. /en c -ei ,4 CJ ////7/d , i22
Name (Print) ' / ryi Current Mailing Address:
Signature (AAA -ti- Telephone
SECTION 3 - ESTIM D CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $4,300.00 (a) Building Permit Fee
2. Electrical $1,500.00 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing $2,700.00 Building Permit Fee
4. Mechanical (HVAC) $0.00
5. Fire Protection ,}.
6. Total = (1 + 2 + 3 + 4 + 5) 4 es � / 5 A w is/1 Check Number 6
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0747
APPLICANT /CONTACT PERSON THOMAS AQUADRO
ADDRESS/PHONE 38 LINSEED RD WEST HATFIELD (413) 348 -4444
PROPERTY LOCATION 154 FEDERAL ST
MAP 30B PARCEL 074 001 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
Typeof Construction: REMOVE /REINSTALL DRYWALL & SUB FLOOR IN BATH & KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License 083682
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
Demolitio elay
-IC - : -:>°°°°°' -3 /A
Signature of Building O ficial 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.
154 FEDERAL ST BP- 2012 -0747
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 074 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 -0747
Project # JS- 2012- 001319
Est. Cost: $8500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS AQUADRO 083682
Lot Size(sq. ft.): 8494.20 Owner: MALONE PATRICK M & SHERYL A
Zoning: URB(100)1 Applicant: THOMAS AQUADRO
AT: 154 FEDERAL ST
Applicant Address: Phone: Insurance:
38 LINSEED RD (413) 348 -4444
WEST HATFIELDMA01088 ISSUED ON :3/22/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE/REINSTALL DRYWALL & SUB FLOOR
IN BATH & KITCHEN
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 3/22/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner