31B-198 (2) 1 j
:A "' The Commonwealth of Massachusetts
Department of Industrial Accidents
7, Office of Investigations
..... 't 600 Washington Street
**l~ Boston, MA 02111
�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ov... t'"- ra , 1).A. 1 i tE, �/' & LNI
Address: 7 3. o f'b Terat t°
City /State /Zip: 0#1 Cc,, /eT3 AO 0A lc., Phone #: 40,- ,66:: " ,-" S
Are you an employer? Checl( the appropriate box: Type of project (required):
1. ❑ lam a employer with 4. I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. am a sole proprietor or partner- listed on the attached sheet. 7. ED Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. fl We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3. ❑ lam a homeowner doing all work g P.
myself. [No workers' comp. right of exemption per MGL 12.r'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.
;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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ., ``"_ 7 ,.0 Date: ( 2 / 6
Phone #: ( 41( 3) (....6 3 — S ' Alpo(
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
4
Version1.7 Commercial Building Permit May 15, 2000 ,
SECTION 10 STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _._. . ._..,....__... __ , __.... , as Owner of the subject property
act on my behalf, in all matters relative to work authorized by this building permit application_
Signature of Owner Date
I, K /14 C:: .._ r_ ,.,.i:�... t v __ ._... , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
an�c'Selief.
cir Signed undef the pains and penalties of pe!
Print Name
K4,CC f rE c N , 9, pRic 2c /0 ____ _ _._ _. _..__ . ...
Signature of Owner /Agent Date
1 SECTION 12 - CONSTRUCTION SERVICES
f
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : _ ...__._ j '4
License Number
Address Expiration Date
1 � -. 7 F'c IJC� 4/3. , . .1 - ,tf,�..$
S ...
— ignature 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 0 No 0
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
1 _
Signature Telephone Expiration Date
I i
P
Name Area of Responsibility
Address Rtoistration 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
... Ihiwe . ..ThieL`.v~`"a J Not Applicable ❑
Company Name:
Re sponsible In Charge of Construction
Address
- 7. 443 33 =1
Signature Telephone
1 ,
.,
, 1.
Version1.7 Commercial Building Permit May 15, 2000
1 S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
• Building Department
Lot Size ...__ "___. _ ._ .__ M
Frontage
Setbacks Front — ,_
Side L:t R fp L:L__ R:._ 1
Rear _.._._..._ / -L,_ "
Building Height
Bldg. Square Footage % ;� "" ,.
Open Space Footage _. % __ ___ .
(Lot area minus bldg & paved L 1
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 perm'i>< recorded at the Registry of Deeds?
NO 0 f,ONT KNOW 0. YES
IF YES: enter Book ! Page. / and /or Document #
B. Does the site contain a brook, body of water or wetlan s? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtainedrfrom the Conservation Commission?
Needs to be obtained 0 Obta"ine,.d 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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) ove 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 ,
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 Description !Enter a brief description here.
Of Proposed Work:1
fLE F L r», Ct C4A1J ; R,12-0 Cd c Tt'( L ((t MA lE 64 Ac.,,,5_,_
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 ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 44 R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ea.
U Utility ❑ Specify r
M Mixed Use ❑ Specify :1 �_._..,,._..�.ti..__ _.._,�...�...N._.....n_.,._..e_ _...�_ —M__.e.. _......_._._.
S Special Use ❑ Specify: f ___._.__ _____
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _,. _.._ .. __ .__., __.-._ _w,_ __ Proposed Use Group: r___ . ___.._w . ._.-..._.....____....__.-__ ...._._--- _
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) €
1st 3
st
1
2nd _,.__ -__ _ ___... _ 2 nd
3 3 �
_. _ , - 4 th
4th
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❑
Versionl.7 Commercial Building Permit Ma 15, 2000
I
°
Building Department
212 Main Street V . L
{ � X0'0 Room 100 e . tom
Northampton, MA 01060 - � � �
phone 413-587-1240 Fax 413 - 587 -1272 e 5 ; 3
_..' ,,,^ h 5 ... ,r"xmma ;;;:e -it. ,.,,, 8 1 3 ,, N,. fe ,+, ,
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
/0 ? b2,/ ST: ;4'_i7 y 070A) it/4 Map I Lot ` c?
Unit
•
>! C ' /a2 r' ' Zone • Overlay District
t 7 i
I Elfin St District` CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
t/ ", ._..5 , -'Es .. <' -_ . 'f 1 �H ___C. t:.4E �.... _ sr ° % N /-� + . 1 e i O 4
Name (Print) Current Mailing Address:
'j/ /3 ... : _ 2 Yo a
Signature (:---- '9►� 7 Telephone _______ ______ _.__.___..___.___.,_ __�....... _ ___..._._... _.._.
2.2 Authorized nt:
Name (Print) Current Mailing Address: ' - '-- : Signature - 1 Telephone
SECTION 3 - ES E D CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
co dieted by permit applicant
f 1. Building 7/3 -- 0 - 00 ------ ti' - c -,--- 1 (a) Building Permit Fee
f 2. Electrical .__ -- (b) Estimated Total Cost of
Construction from (6) . ..__. _. _.. __ _ .
3. Plumbing Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number ii9l la9 `�
This Section For Official Use Only ///
Building Permit Number Date
Issued
Signature
Building Commissioner /Inspector of Buildings Date
w g -AItt .` BP- 2010 -0956
GIS #: COMMONWEALTH OF MASSACHUSETTS
i;mate.aidek:3114- 198 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0956
Project # JS- 2010- 001417
Est. Cost: $10000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KARL FERGUSON 60171
Lot Size(sq. ft.): 7535.88 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: URC(100) / /EU Applicant: KARL FERGUSON
AT: 109 ELM ST - SESSIONS HOUSE
Applicant Address: Phone: Insurance:
92 BEAUREGARD TERR (413) 563 -3355 0
CHICOPEEMA01020 ISSUED ON:4/29/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE MANSARD ROOF W /LIKE
MATERIALS
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 4/29/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo