22B-067 • 4
"`' The Commonwealth of Massachusetts
D epartment of Industrial Accidents
Office of Investigations
600 Washington Street
�_ 4y
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): AMA ik
Address:2 - 3 5 ) S
Cit /State /Zip: ( - US 0/0c3 Phone #: F/ 9 2 Z - 7 Gi 1
Are you an employer? Check the appropriate box: 4. Type of project (required): 1
. general contractor and I yp re p ( q )
I. ❑ I am a employer with ❑ I am a g 6. ❑ New construction
employees (full and/or part- time). * have hired the sub - contractors
listed on the attached sheet. 7. ❑Remodeling
2. �'�am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.0 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' comp. right of exemption per MGL 12. ❑ 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.
r 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 nacre 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 thepolicy 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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sisnature: 41116.. Date:
Phone #:
3 22/--
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 #:
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 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ' V _G[� .. / �(..c�_ c .. �.._ ..�� _. _ ...._ _ ..._... s Owner .f the subject property
act on my behalf, in all ters relative to work authorized by this building permit application
Signature of Owner Date
, as Owner uthorized
Agen -ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
d b- ef.
Signed under the pains and penalties_of perluryr
P ame
l l .....(.0 20// ,
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
License Number
Address Expiration Date
/— ( M /4- (Y1013
Signatu Telephone 51/2
SECTION 13 WORKERS' CO AFFIDAVIT, (M. G. L. c. 152, § 25C(6))
Workers Compensation Insurance affid vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the b ding permit.
Signed Affidavit Attached Yes No 0
k.
Version1.7 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 ❑
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
9
Address
Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
KA .1....... -_.. /A p . ,!. . -...1 :ir , r _. _,. . _,, _ Not Applicable ❑
Comp y Name: •
esponsible In Charge of Construction
2_2_3 K4 . w c7 Ltd 6S 0/03 3'
Address
f 5 - 2
Sig Lure Telephone
•
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
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 0 YES 0
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 conta a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit be or need to be obtained from Commission?
Needs to be obtained Obtained
, Date Issued:
C. Do any signs exist on the property? YES,„ (3 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
a
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 .,I 4
CUBIC FEET OF ENCLOSED SPACE t
Interior Alterations ❑ E isting Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use 0, Other ❑ -t-t_.._,62 'w
Brief Description Enter a brief description here �� S V L f ` / b S /2r3p
Of Proposed Work: 0 \ j • -c-0 e e - - T - 1, � 0 F R " .5Ft E /'� / N G- J jA b - cog -v o� ,�f'� F t
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A l ❑ 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 ❑ 1 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A 0
S Storage ❑ S -1 ❑ S -2 ❑ 5B
U Utility )4" Specify:
M Mixed Use ❑ Specify
S Special Use ❑ Specify: . _ .....___ ..,._.__. . F.. ___ ..__ _._._ .__.. __.___._..__ _ . ___.._._.,� ___ _.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing 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 s t
1
2 nd
2
. _
_ .
3rd . _ . ..__ _ . _.� -___.. .. ., ._...,
. 3 , d
__ ... .. ...,_ .. __ ____ 4 th
4
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 0 On site disposal system
•
Versionl.7 Commercial Building Permit May 15, 2000
Department use only!
__ City Df Northampton =Statris,af (ern t x
IVED
uilc ing Department Curb Cut/Dnueway Perrrlk
2011 212 Main Street Se wer /Septic Averlability
Room 100 1/uaterft(IfellSAyailabiirty
NI rthe mpton, MA 01060 T'wo Set's of Str eturaf Mans
DEPT. BULD'�j 58' -1240 Fax 413- 587 -1272 Flat/Site Plans
NOR7HAWiPTON' 0 1060
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� by office
(0 re`e? /4111 Ma p at 113 Lot Unit
c9/ 06 a Zone Overlay District
. w_- EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
( F c L A k _ . . . _ P .. r 3 . . Co 6Q6 f ,ti ..44 OE)
Name (Print) /d
�I l rry s Current Mailing Address
JV `� C X13_..._ ?. .. qly, ........ _.
Signature Telephone
2.2 Authorized Agent
K ietRa) 1 .1k) CT- 4e
Name (Print) Current Mailing Address:
Signature Telephone
/ 22 _ 7 L
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3 (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 id 0515--
This Section For Official Use Only
Building Permit Number Date
Issued
Signature
(// 0 11
Building Commissioner /Inspector of Buildings Date
215 SPRING ST BP- 2011 -1038
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22B - 067 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -1038
Proiect # JS- 2011- 001676
Est. Cost: $4500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KAREN CARTER 070008
Lot Size(sq. ft.): 4250628.36 Owner: GROW FOOD NORTHAMPTON
Zoning: URA(100) //WP/WSP Applicant: KAREN CARTER
AI 215 SPRING ST
Applicant Address: Phone: Insurance:
223 Main Street (413) 221 -7419 0
LeedsMA01053 ISSUED ON:6/13/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:ROOF STRUCTURAL REPAIR,SHEATHING &
METAL CORRUGATED ROOF
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: 0,1: Insulation:
Final: Smoke: Final: Vk ‘_ / / /CIVir
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OE
ANY OF ITS RULES AND ' ' 1 1 - 1
1 44.44.111 AL 4
Certificate of Occupan � 'n
FeeType: Date Paid: Amount:
Building 6/13/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner