32C-260 (36) The Commonwealth of Massathusetts •
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): _
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. Q I am a employer with 4. Q I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. ['Remodeling
ship and have no employees These sub contractors have 8. Q Demolition
working for me in aci employees and have workers'
g any capacity. n 9. ❑ Building addition
[No workers' comp. insurance p. insurance.
required.] 5. We are a corporation and its 10.E Electrical repairs or additions
3. Q I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions
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' 13.0 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 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 hereby certify nder the pains and penalties of perjury that the information provided above is true and correct.
Sisnature• , � �� Date: ,� l
Phone #: SL:/(75
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 #:
r .
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 0 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /—/A11.,Z ___ / 1 . ... ...... __ .._ .__ __... _ as Owner of the subject property
hereby authorize ✓g j.. .1 ._. to
act on my behalf, in all matters re tive to work authorized by this building permit application.
7_, — -- - - -- __+ /// ..-"e
Signature of Owner y Date
1, i , ey,..___...Fe: ! ..._ ._.._.,__ ._.___..___...._._.,._,___.. .__....__ , as 5iiviwar /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 perdu
A / Y . ' , 't_ . 0 .. _ ... ..s..
Print Na • -
/
ignature -r/Agent Date
SECTIO 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: dge4 ' 7 r, ,.L . T / . /... Wirer.- •.,.. __. . ;./. 7 .&
License Number
/
Address Expirati Date
Signature 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 .
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
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
/ / f ... %
Address
- Telephone
Version1.7 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 m
Frontage
Setbacks Front
Side L. ____._. R:— ... L., __.... R. _
Rear ._ _____
Building Height
Bldg. Square Footage
Open Space Footage ___. __,. % µ,_ __ . __
(Lot area minus bldg & paved m _.,.
parking)
# of Parking Spaces _____
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO 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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO G----
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, excavatio r 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 •
•
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 I
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 ❑ Othert] t ".
Brief Description Enter a brief description here.
Of Proposed Work:
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 ❑ 1 2B i
❑
F Factory ❑ F -1 ❑ F -2 ❑ 1 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 ❑ J 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
,...W
S Special Use ❑ Specify�
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _ _ ,, . _. ..__._ Proposed Use Group ,_m._..
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
1st st
2
2nd nd
rd.. _..
3
4th 4tn
Total Area (sf) Total Proposed New Constructionisf)_
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 Zoneo Municipal ❑ On site disposal system
• f •
• RECEIVED Version1.7 Commercial Buildin& Permit May 15, 2000
� � De Eaten #use vnl
City of Northampton S #atG►af er,��
111/11 I 52011 am' o�
212 Main Street
Building Department curb Cgt4rtufrw�I Pertf
e,er�5ep #acrar a itlttj
Room 100 vlia #erltilt/ U A all�r ttit
l �tI A 1�� Kamm'
nonntnu PTON.w►otaeo Northampton, MA 01060 Teo Sets o Structural PJans
phone 413 - 587 -1240 Fax 413 - 587 -1272 PiaUSrte 1?lans
Othet Spef�r '�
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
Map Lot Unit
Zone Overlay District
— .A. �. ., �_ , a. , 'EImSt.`District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Signature �"'- -- ' Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Address
Signature 6 . y - Telephone /4//)7 .� ` y7-'
SECTION 3 - ES f ED 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
Construction from (6) ....
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) _....,
5. Fire Protection
c ) 1 30
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
1
dune 6, 2011
Louis Hasbrouck, Building Commissioner
Office of the Building Commissioner
Puchalski Municipal Building
212 Main Street
Northampton, MA 01060
41.3 587 -1240
RED:: PC)MI ROY I IANCOCK CONDOMINIUMS, 90 Pomeroy Terrace
Change of General Contractors - 1_'nit #5
Dear Mt. Hasbrouck,
This letter serves to notify you of a change in status pertaining to construction on Unit #5 at Pomeroy
Hancock Condominiums, 90 Pomeroy Terrace, Northarnpton MA 01060.
General Contractor Al Martinbeault currently holds the building permit for improvements to this unit. Due
to changes in his personal circumstances he is now unavailable to perform the work. A new general
contractor, Harry Nett of BSI' Construction, has been hired to complete the work and with this letter will be
submitting an application requesting this change to the building permit.
Please on't hesitate to call if you have any questions regarding this matter.
Sine ely, /
titifi /
Linda S. Muerle
File it BP- 2011 -1052
APPLICANT /CONTACT PERSON BSF CONSTRUCTION INC
ADDRESS/PHONE 18 GLENDALE VIEW DR HAMPDEN (413) 530 -9055
PROPERTY LOCATION 90 POMEROY TER
MAP 32C PARCEL 260 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out l
Fee Paid /��'� ✓vgJ�
Typeof Construction: RENOVATE 3RD FLR UNIT 5
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 70668
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$MATION 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.
90 POMEROY TER BP- 2011 -1052
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 260 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 # BP- 2011 -1052
Project # JS- 2011- 001696
Est. Cost:
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BSF CONSTRUCTION INC 70668
Lot Size(sq. ft.): 23304.60 Owner: MUERLE LINDA & BURT EWART
Zoning: URC(100)/ Applicant: BSF CONSTRUCTION INC
AT: 90 POMEROY TER
Applicant Address: Phone: Insurance:
18 GLENDALE VIEW DR (413) 530 -9055
HAMPDENMA01036 ISSUED ON:6/30/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE 3RD FLR UNIT 5
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 6/30/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner