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24C-019 (2) , The Commonwealth of Massachusetts Department of Industrial Accidents 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): Soak l Ia L)fr3 r flC Address: 22- 2 xi 1■611 S Cit /State /Zip: Nit) (-ha ivtp-4O n , NIA Phone #: 413-59-4 a3 I G Are you an employer? Check the appropriate box: Type of project (required): 1. 1 a employer with 2.C.1 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction listed on the attached sheet. 7. n Remodeling 2. E] I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ 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 officers have their 11. Plumbing repairs or additions 3. El am a homeowner doing all work ave exercised 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' 136ther 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 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 the policy and job site information. n Insurance Company Name: A l M M ihtoj /i u,raro _ Policy # or Self -ins. Lic. #: HCC 2OOC. (J"1 30 1 Expiration Date: �"{ 1 i /2 Cro Job Site Address: 2 -' (' T(9.ve Cit /Zip: Af t d-hafO rn 1 ( 1 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 5250.00 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. Signature: Date: /ii 1 2ct Phone #: 1i4 -1 3/0 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): rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector t 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 O No O SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize _ _ to 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 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 : ,fl 1113. _ A _ � .l li vac.{ (7`u License Number Address Expiration Date Signature Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVITI(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 0 4,, , N, 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 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 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 2>Z ? f\Jbd -h S+. I\ir+h �np r� ..N l .LLtL2C), Adds Signature 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 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 Q DONT KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book `i Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q 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 Q NO Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4 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 ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Descrip on Enter a brief description here. Of Propo d or : „See_ jV4 r )/ 1ve SECTION 5 - USE ROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 0 A -2 ❑ A -3 0 1A I 0 A -4 ❑ A -5 ❑ 0 B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard 0 3A ❑ I 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 I ❑ 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 l 2 nd 2 nd 3 3 rd 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 ❑ On site disposal system • It. . , .,. Versionl.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 This section to be completed by office 1.1 Property Address: t32(0 coS()e( S 4 r-e-el- Map Lot Unit t\)oiz-k-AiNap-c ./\k/\ c )i o(,.0 Zone Overlay District 1 k*e._.' tReq,. \o /1\ ik Elm St. Di CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 0 ner of 1 Record: (41V; 11 l 14 .. L Name Pr Current int) j i i hi, 'vA14.1tz)4-g C__e._ C, 7- Cu Mailing Address: tor), ( Signature , Telephone (LI I '7 5 --ey-'70e6 ( .._..st 2.2 Authorized Agent: Name (Print) ?2/41/ V I AA 01- ) 4 t ' t 4 ' Signature /I , i4t/t (i 4" CTION 3 - ESTIMATED CONSTRUCTION COSTS Telephone Current Mailing Address: Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building see. ..;Z. S 0 0 e•v (a) Building Permit Fee A/A A. Rat i've, 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 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date YMCA Building Narrative Construct 12'-4" wide X 11'-1" high two hour fire rated wall at the basement Electrical room. Wall consist of 3 5/8" 20 gauge metal studs 16" on center with two layers of 5/8" sheetrock on each side. Wall has two hour rated metal door and frame swinging out from the room with panic bar and closer per Mass Building Code Revision Seven. f File # BP- 2010 -0290 APPLICANT /CONTACT PERSON D A SULLIVAN & SONS INC ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413) 584 -0310 PROPERTY LOCATION 286 PROSPECT ST MAP 24C PARCEL 019 001 ZONE URA(15)/URB(85)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ?a /65 Fee Paid /3,2/5— J o Typeof Construction: SEE NARRATIVE � � / New Construction • ML /, / . , ■ ' Non Structural interior renovations Addition to Existint , AP_LitfA „�zr , Accessory Structure Building Plans Included: / �f o ?� Owner/ Statement or License 053668 b �� 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 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. 286 PROSPECT ST BP- 2010 -0290 GIS #: COMMONWEALTH OF MASSACHUSETTS Map_Block: 24C - 019 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY- F-- UND4MGL e:14-2-Ai i • ; `1 R T - P Category renovation LDIN ERMI BUI 9 ` Permit # BP- 2010 -0290 v t Project # JS- 2010- 000273 Est. Cost: $2500.00 _ Fee: $55.00 PERMISSION IS HEREBY GRANTEI3TO: Const. Class: Contractor: License: Use Group: D A SULLIVAN & SONS INC 053668 Lot Size(sq. ft.): 190792.80 Owner: HAMPSHIRE REGIONAL YOUNG MEN'S CHRISTIAN ASSOCIATION Zoning: URA(15)/URB(85)/ Applicant: D A SULLIVAN & SONS INC A T: 286 PROSPECT ST Applicant Address: Phone: Insurance: 82 NORTH ST (413) 584 -0310 Workers Compensation NORTHAMPTONMAO1060 ISSUED ON :9/15/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT BASEMENT 2 HOUR FIRE PARTITION FOR NEW ELEC SERVICE ROOM 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 CIT OF NORTHAMPTON UPON VIOLAON OF ANY OF ITS RULES AND REGULATI • Certificate of Occu • anc Signature: FeeType: Date Paid: Amount: Building 9/15/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo