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24B-069
.' The Commonwealth ofMassachusetts ..1,— ,. .9 `fir ,,"7; Department of Industrial Accidents .' ,' k, F Office of Investigations , , w � 0,,,' :' 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): .44,A.t -tS i- P.A)) l K.) � :.,.1.„c"i' . CO � _ Address: GOO U t.t l t S , City /State /Zip: -le, r S i Ni 6-i`lt l 1.-1 y i Phone #: it 43 - 73 4 -2 0 f3 Are ou an employer? Check the appropriate box: Type of project (required): 1. [ I am a e to er with ZS 4 ❑ I am a general contractor and I mP Y 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors Lr`!I 2. El I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling 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. El 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' 13.0 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. 1 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: 'f e€ (2 ,Ess iris Cv .. Policy # or Self -ins. Lic. #: i..1 C. 81S 8 2_42- Expiration Date: 12- (S l 1 1 -2 -- Job Site Address: '2_.R7 V, ■ N• �tss �T. City /State /Zip: p MBA fit t'�["D )--.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 $250.00 a day against the violator. Be advised that a co py o f this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the , , 'r and penalties of perjury that the information provided above is true and correct. Siznature: v Date: 4- ?1/7-. Phone #: 40,.- 73 23 i , 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 #: N . 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, - PATttA Ct IS CRA . -4 -.) - A..... ...(,,ES II!) . . , as Owner of the subject property hereby authorize . A bA,,I-NS 4.4_13'4 VI ...... .. C2:t...N.t. _ CO...J.__ . , to act on my ) be alf, in all m ers relati e to work authorized by this building permit application. • _ j______ . /62...c.,..(-......"..... Sigpfature of Owner Date - - - ---- I, Abii.l & + .gyAcrb: )0 Co&i, . Q: ,./AtiliTz.e.:,— -- tic -, -) eiro, _ •• _ .,_, , 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 periEL _______ ._ , _ .._____ __ , _ AL.) D l 1.() P I _ .-,. _ .__. •_ . __ ..._._ , ,.. _ _ _ ... , Print Name ------:, , "..„,,,,..._...........-- (4„......-4.) 4 •• ____ , _ _ _ ... .., ... . .. . .... - ignature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES / 10.1 Licensed Construction Supervisor: Not Applicable 0 . .R.-.e Name of License Holder : _ 1 .- ) —\-- c- -t- 3' •' 0 7/ C'S7 _1 _ .... _ _ . ... , C._ _ . License Number 0../ 0 8 i__ , Address Expiration Date -, ...., nature 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 ilding permit. Signed Affidavit Attached Yes No 0 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 EWCLOSEDSPACE) 9.1 Registered Architect: .._. Not Applicable ❑ Name (Registrant) 4 G r , F itm- 0/04 Registration Number Aa Address " 4/3 151 • Oivl Expiration Date Signat e Telephone 9.2 R: gist red 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. �o_. _ .. Area of Responsibiiity� Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor .._.... twist,.. _.+ __..__ _._ _. Not Applicable B Company Name: �tb!w_., ( Responsible In Charge of Construction Address ignature Telephone • Version1.7 Commercial Building Permit May 15, 2000 S. NORTHAMPTON, ZONING • Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size �� ...._ _.. __�_ _ .:_..: �.:�:?'1,�,._. �..�.�_._........�___ __.____ ... _..__ _._. F rontage _..{_...._.._ : _ S A'�.. _......... ._......___ ., _.._ Setbacks Front Side _. � R: 3 L '. R:._ Rear ATE' Building Height 5AR �C Bldg. Square Footage j jj _-SA t ______ Open Space Footage % (Lot area minus bldg & paved AS14.� parking) # of Parking Spaces = c Ate- °• —. Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ( 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 DONT 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 NO 0 IF YES, describe size, type and location: ' St &- (a k 12r bi, Stc.z D. Are there any proposed changes to or additions of signs intended for the property ? YES NO 0 IF YES, describe size, type and location: i(' ,,x .0 C ataTt , FL ,Z, .J E. Will the construction activity disturb (clearing, grading, ex vation, 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 t SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 4 t e!e CUBIC FEET OF ENCLOSED SPACE - Interior Alterations Existing Wall Signs ❑ Demolition El Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. I3eL C+• i .4`1`1` Of Proposed Work vl SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B r F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 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 ( ❑ U Utility ❑ Specify M Mixed Use ❑ Specify S Special Use ❑ Specify ._�.._,...-.m._ .,_._,- �M�,.o.... ,� -,._w ___ _ . _..- _ ___ ._ COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING:' RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: _. Qv, NC _____ _.__ Proposed Use Group: ' ...._. A._M,,e— . __..., _,_._.. _____,........ 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 ET 2 .. _ .. , _ 2nd 2 3rd 3 4 4 th .._.._.__________.__._._:._... _____. 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 l Private ❑ Zone Outside Flood Zone] Municipal ID On site disposal system ❑ / \\ Version1.7 Commercial Building Permit May 15 2000 Q _ , ag i n g t ` '� ©ep artmefit u orfl �, City of Northampton stak4 ;®f • e } � � 7 �`�4� � � ` � ' Building Department rn urb et�t/ © nye ay t=e 5 *� n.'- - Q," tV ! � � er s ,, y 212 Main Street Sewer A ralfa - nty y • c ROOM 100 �lllateitorell ACiailabillt " ,4 Q , 4 / Northampton MA 01060 Tu r $e 7 a to ett4r, 'laps t" ' d� y� m / phone 413 -587 -1240 Fax 413 - 587 -1272 Pla S it e Prans F J �` ' ` Other Speetfy AP C ATION 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 Map c) "[ Lot (pq Unit *L I ST ) Zone Overlay District E. (' vA + 1 - N : V 1 - 0 � - S A ` ACA a'A cJ i ` Elin St: District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: EA St W alt- A-1"tb1- SisSi_ ..L . - � ._.....__. ...._ .. .______.._..__.__...._ ._ _ _ _. _._� ------ _ __. _ -_ __ _ - . - Name (Print) Current Mailing Address: _„--------------------- X /� 4l 3 - .SZ . 4 i t _t ._ Signature X . ..4—.... —. ,/ • Telephone 2.2 Authorized Agent: Name (Print) Current Address: �1.,DR� 1 eov 41 7.u� Signature ._ - Telephone ,a '2 3 ESTIMATED CONSTRUCTION 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 3 t So'Q I Construction from (6) .... _ ... ........ ...... 3. Plumbing _._ _..._...._-...__._._ -_ ._m..�. _ , Building Permit Fee 4. Mechanical (HVAC) ........._._........_...__ _..._..._:._.. .__..._.„ 5. Fire Protection 0 _ •- - -• -- - -•• - - ,� �� - a 6 7 6. Total= (1 +2 +3 +4 +5) 34 i -C Check Number - This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector.of Buildings Date File # BP- 2012 -0876 APPLICANT /CONTACT PERSON ADAMS & RUXTON CONSTRUCTION CO., INC. OUP ADDRESS /PHONE 600 UNION ST WEST SPRINGFIELD (413) 734 -2138 �s e-yV! 0 PROPERTY LOCATION 297 KING ST - EASTHAMPTON SAVINGS BANK l �� MAP 24B PARCEL 069 001 ZONE HB(100)/ i ��'' ( V"2' L` O F THIS SECTION FOR OFFICIAL USE ONLY: rt �� P� PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out —�� Fee Paid Typeof Construction: RELOCATE ATM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 071951 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: .4pproved 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 421 7.--• 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. 297 KING ST - EASTHAMPTON SAVINGS BANK BP- 2012 -0876 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24B - 069 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 # B P- 2012 -0876 Project # JS- 2012- 001542 Est. Cost: $34500.00 Fee: $207.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ADAMS & RUXTON CONSTRUCTION CO., INC. 071951 Lot Size(sq. ft.): 35980.56 Owner: ANDRUS FLOYD TRUSTEE C/O EASTHAMPTON SAVINGS BANK Zoning: HB(100)/ Applicant: ADAMS & RUXTON CONSTRUCTION CO., INC. AT: 297 KING ST - EASTHAMPTON SAVINGS BANK Applicant Address: Phone: Insurance: 600 UNION ST (413) 734 -2138 Workers Compensation WEST SPRINGFIELDMA01089 ISSUED ON:4/23/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: RELOCATE ATM 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 4/23/2012 0:00:00 $207.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner