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YVY Hri>.11-01 \-/ ‘(1 'r o1.1.4da'
The Commonwealth of Massachusetts
D epartment of Industrial Accidents
' , Office of Investigations
r ' 600 Washington Street
1 Boston, MA 02111
°� - „' wwx . mass gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): IR 0 (9ert b d4444. e _
Address: (3 � ,
' 2 d - Lt
\ C ity /State /Zip: tjl'GZ, Phone #: �'(� Q � I
Are you an employer? Check the appr to box: Type of project (required):
1. ❑ I am a employer . to er with 4 ❑ I am a general contractor and I
Y 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. El I am a sole proprietor or partner-
ship and have no employees These sub- contractors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
working Y P tY• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or officers have exercised their 11. additions
"'AI offi hised thei Plumbing repairs or additions
I am a homeowner doing all work ❑
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' 13.E1 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.
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:
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 h eby cer Ander e p zns and penalties of perjury that the information provided above i true and correct.
Sienature: 4 4 1/4„..4,--4. 4 1/4„..4,--4. Date: 7 L/ / 1
#: 4 -f( 3 i ``{'12
Phone #:
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
f
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
w
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
I, _.`.. d._.....__ __ �... _ - �_ _ ,...._ ___....._. _ , as Owner of the subject property
hereby authorize __..4._ _ to
act on my behalf, in all matters relative to work authorized by this building permit application. _ _____ ____ _
N ______
Signature of Owner Date
- I e� _ _.._....._.__ „_._. , 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.
Signec u er the a' and penalties of e_rlurlr
1
Signature of Owner /Agent ate
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :_.
��_��� ������ w ������������ License Number
Address Expiration Date
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 No
Version1.7 Commercial Building Permit May 15, 2000
J
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 Ef LOSED SPACE)
9.1 Registered Architect:
__._ r Not Applicable ❑
Name (Registrant): ? _ ____ ._._.__,,._..._..
Registration Number
. _ ..,_ ..__.___ ._. _._.. ______ _
Address
_ ' Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
_
Name _ .._. w______.._,..__ _. . - -... Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
_____
Address .... ____ _..__ _, Registration Number __ w _A__
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
Company Name: _..,....� ._ ......__...,__.,_.�....._..._._ ._.,...._._._
.__._ __ ..______m Not Applicable ❑
Responsible In Charge of Construction
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON.ZONING
Existing Proposed Required by Zoning .
This column Mr; filled in by
462/ C I _ J Building Department
Lot Size ._. _t_..._. pp _. . �__
Frontage l. �..l .... /;a __. 1 . _ _a___- _ _ _ ._
Setbacks Front
Side L :_._— ........ R:_ TJ . L.L. ; R.'_._
Rear .__0 / - - �
Building Height
Bldg. Square Footage % "�'°'
Open Space Footage -_ % 7.---7. - --
(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 a 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 contain a brook, body of water or wetlands? NO '40 DONT KNOW (3 YES 0
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 0
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 i
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 ii
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
x
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 "
CUBIC FEET OF ENCLOSED SPACE lli 1A 0 '
Interior Alterations ❑ Existing. Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Acce so , Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ . •th ❑
Brief Description Enter brief description here. ( Of Proposed Work ' l„r r/t�/ , it, ex1 ; - t1 - A • bo'r ii) de(„1 y
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 0
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ , 38 ❑
M Mercantile ❑ n 4 ❑
R Residential R -1 ❑ (/ �4 (' -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: _..__. �__y_.. __ _ Proposed Use Group: .w ___ _.. _ _
Existing Hazard Index 780 CMR 34): ;_.._., „_ „_ Proposed Hazard Index 780 CMR 34): _ _. _______ _ _._. _ w _ _,
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1 st i
1 ---..j
2
2
3rd _ 3rd ---
4 4 _. _.._. _ _ _ _ __
Total Areas Total Proposed New Construction s
Total Height (ft)
Total Height ft w .._ , ,, ,.:.. �_
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
•
i ,
iVl2 ommer ial Building Permit Ma 15, 2000
•
De art e t ese''o [ Z 4:'g V 3,
C.• _ ,. ampton sa . - . - , �.
B ding De . _ . e M0 1 F
2 l in %Me . t ` ,� ' � ,
Room 1 e t pE CT∎oss a tet•. ' ;atia , -, l w ` v a : a .0 4. e . ,r tm,
phone 413 .. • ax 413- 587 -1272 Piaf a, lari . , � f F =if
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
1 , A `�i''41.-A Map Lot Unit
Zone Overlay District
I
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: a1� ..
Name ( n i � Current Mailing Addre
Signatu� 1 � Kr�^ -^ Telep 3 5 � ._ _ T l ate• ._.._ .__ .__
2.2 Authorized Agent:
Name (Print) Current Maili�Address
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 4 a p r ..� (a) Building Permit Fee
2. Electrical ' (b)' Estimated Total ; Cost of
`+ Construction from (6) _, ________ ..._._....
3. Plumbing I Building Permit Fee
4. Mechanical (HVAC) ______ . ,___..._. », ,._. .._.V._ % gl 1
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) *4, &p0. - Check Number
This Section For Official Use Only
Building Permit Number Date
. Issued
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2012 -0063
APPLICANT /CONTACT PERSON GOODMAN ROBERT & LEVIN STEPHAN
ADDRESS/PHONE 133 FRANKLIN ST UNIT A NORTHAMPTON \ n rl`
, \\
PROPERTY LOCATION 133 FRANKLIN ST (5-91
1
MAP 24D PARCEL 336 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
F9e Paid
Q�BuujIding Permit Filled out
1P ePaid Jr? Jo
Tvpeof Construction:_Deck Addition
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9KMATION 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
7,J 7/ 11
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.
133 FRANKLIN ST BP- 2012 -0063
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 336 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck Addition BUILDING PERMIT
Permit # BP- 2012 -0063
Project # JS- 2012- 000095
Est. Cost: $4800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: GOODMAN ROBERT & LEVIN STEPHAN
Zoning: Applicant: GOODMAN ROBERT & LEVIN STEPHAN
AT: 133 FRANKLIN ST
Applicant Address: Phone: Insurance:
133A FRANKLIN ST (413) 584 -4122 0
NORTHAMPTONMA01060 ISSUED ON: 7/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT DECK TO UNIT A
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 7/26/2011 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner