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The Commonwealth ofMassachusetts
Department of Industrial Accidents • '
Office of Investigations •
; 600 Washin Street r
.% Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): G - .'et- C L,C7 - • a ' 4c, i 41 , tv s r to - llt..y
Address: ( 3 C k ..tc(clei <<,. /
City /State /Zip: ` " t 'i - I L'‘ • . 0 ' Phone #: G/3) C 55 /33 ,
Are you an employer? Check the appr'IPiat box: Type of project (required):
1. I am a employer with 4. J I am a general contractor and I
employees (full and/or part- time }.* have hired the sub - contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7: ❑ Remodeling
ship and have no employees These sub- contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
g Y P h'• 9. 0 Building addition
[No workers' comp. insurance comp. > nsurance.$,
required.] ] . 5. 0 We are a corporation and its 10.® Electrical repairs or additions
officers have exercised their 11.0 Plumbing repairs or additions
3. ❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL
Y P 12.0 Roof repairs
2
c. 152, §1(4), and we have no
insurance required.] t 13. IQ] Other sd 6 t' F'LopyLJ
employees. [No workers'
comp. insurance required.] SKEET' R exec
*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: L 1 toe' - M...'-k0./ i as G ,
Policy # or Self -ins. Lic. #: (k) (_ ( 3/,\-., 7 3 sa-- Pr // Expiration Date: '] -(0. Z
Job Site Address: /4 i ( �' E�3 City /State /Zip: f , 7e S / lck.
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 u der the ains and pen [ties of perjury that the information provided above is true and correct.
Signature: ` ' T 41jge Jo / i t/ Date: 5-=7 —/ Z
Phone #: (w C 5 . 3 e.) _ ✓
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
4
,
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
)
M4 CI,t, 1
.• ,
I, .. tA,000,......1 _ .\-_--._ _ _Et.) ...„ _ LAK:Ls y , -.._ , aS Owner of the subject property
......._
hereby authorize .. C.'ff Bokyy
act on my . . f, in I m tters relay ' authorized by this building permit application.
-.
Ak ‘\ " '''\---■
_.:D _- l 0 -
.„....._,_ ....._, ..,....... ___....
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 thepains and jaenafties_of Rerlyiy
Print Name
. _ .... _ _ _ ..,....._ ......._ ..„., ... _
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder :1_ — _< 0 V.C.L1 __?.0+„..„(1.,„COA _-- - __ - ..........
License Number
— _ ......,_
... .....,
----I 3 - ---S---C-e-il 4 _L2:dtiaAtskvu
Address Expiration Date
21 -/
( 7 / 1
__ 3-6, f57 ._ )--- - L_
, 34411e*4 i','% -1.,
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 V., No
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGNAND CONSTRUCTION! SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 1,16 (CONTAINING MORE THAN 35,000 C.F. OF EILOSED SPACE)
9.1 Registered Architect:
_________ _ _. . _ Not Applicable ❑
Name (Registrant):
�. "�
Registration Number
Address
_. ' ----- Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name ...._. ..._._.._ _ _ _...M Area of Responsibility
1
Address Registration Number
Signature Telephone Expiration Date
i
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
L ___.._ _
t �: � -�Q_.�.�,`�pp�'� ...: C�.� .. L _ _. _.. � Not Applicable ❑
Company Name: CS L.
_ ______ .._ _ _____._._.._ ____._ __ _
Li _5 C vkCe % 1Y7 s 27 � /L
Responsible In Charge of Construction
(-1rC41 it) 3 Li 5 04
Address t 3 / S- ( . ,i 4 I ,, W t t t r 4Lf s �✓�'� _
Signature i 0 Telephone
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON, ZONING
Existing Proposed Required by Zoning ,
This column tot"; filled in by
Building Department
Lot Size�s. - . '� A !'`
Frontage...a._ .._ ..._. .___._.._. I.._......_. .._..____.._._ _.___.__..__,._
Setbacks Front
Side L:- R _ L R::
Rear
Building Height L fe - „^
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces F - —
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW SO YES
IF YES: enter Book ' Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 4E?
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
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc.vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO /80
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 ,
CUBIC FEET OF ENCLOSED SPACE 1 "
Interior Alterations ❑ Existing. Wall Signs ❑ Demolition N. Repair Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description ;Enter a brief description here.iAc1-1/460 4.3owo FLOOIIS 13 - t.TV_ TAJJTxsLL. Asek.,"
Of Proposed Work. 'Rgr‘ovt cvonp pAAJE4 -1M6 C, ICIT. =STALL 3“ CCtRoCKC. V& (6.3 I1L 9 ftniz co0E
.L P C .5) w e l l * p ± N T , A P ?LY._. "[ � 9 ME blE 4.JEEO 13E.• _ _._......_ .__.
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A-4 ❑ A -5 ❑ 1B
B Business ❑ 2A ❑
E Educational ❑ 2B f ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 jk 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: _.____ _.__________._ _µ...__,..._.. ._ ' Proposed Use Group: L __ __w.._.._ m__________._....__ _____ ..
Existing Hazard Index 780 CMR 34): _, _. ._V ... _ __. ' 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 1 st ; L ._,..0._
2nd 521,. 2 _. _._
4' 4
O
Total Area (sf) 3 73$ _ Total Proposed New Constructionisf) _ __
...
Total Height (ft) ,3 p _ ..__ .__ _ _, ,,. ,, ._ .
Total Height ft 3_,C?
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewa e Disposal System:
Public( Private ❑ Zone _ _ „ Outside Flood Zone❑ Municipal llPl On site disposal system 0
Versionl.7 Commercial Building Permit May 15 2000
raa # tit e ii Depa( 9 uss
City of Northampton � Pa ',IN,* # �� - � � � only r:i U �
�
1���
2 � � � Building Department �� u f7 �ri rr ea Perms ,� � ��
212 Main Street • Sewer /Sep " vaila ttkt �`� g N
T. OF BUILDING INSPECTIONS
Room 100 , lWWat�er e A3 aa ii p
� �� `' � ��£�" "v a �
�, � � � �`� �,, u � w .
NORTHAMPTON MA 01060 ► 1 rtharnpton, MA 01060 Tw6S lctura Plan 0aM� s s '
phone 413- 587 -1240 Fax 413-587-1272 Plot/ P -
S�t '
`.Other Specify t ,
�,� :,,, ...,ate_. ... . :.. . .t+ ... i4>_ 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 INFORMATI
1.1 Property Addres
1 This section to be completed by office
` � : Map Lot Unit
. A. i '� N1 C1 i iN S t e t4- Zone Overlay District
0 IoS
— ... _ Elm St. District` CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
c ,3.3__- __.�: - PS.:Y1___3 k , } ..._..c -C P 0 tO a( ,V13 Jr_ e , M 6 01 2.3
Name (Print) Current Mailing Address:
Signature l '� - ��✓ \-% r -^q -..\., Telephone
2.2 Authorized Agent:
' - 3 - CF/c- nc2 _ _.. _ _m __.. • 1 no rbor- c.vt1l - . 2C? ,St) vt fmw .l'�',1 K
Name (Print) Current Mailing Address. 010
Signature j/e6 C [mot Telephone y /J -s r - / g 6s
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building -(a) Building Permit Fee
S�c)VO
W.
2. Electrical 'i (b) Estimated Total Cost of
000 . Construction from (6) _... ,..__....M ......... ..._
3. Plumbing �...._ ` Building Permit Fee
4. Mechanical (HVAC) __.M._...•.
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 0 61000.0e, Check Number Oh,/
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0987
APPLICANT /CONTACT PERSON GEOFFERY GOUGEON
ADDRESS /PHONE 13 S CHESTERFIELD RD WILLIAMSBURG (413) 695 -1335
PROPERTY LOCATION 237 MAIN ST - UNIT 1
MAP 10B PARCEL 086 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE BEDRM /LV RM FLOORS,SHEETROCK BEDRM/KITCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 96151
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
V 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
l " -Nj 5 11311 'Z
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.
237 MAIN ST - UNIT 1 BP- 2012 -0987
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 086 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- 2012 -0987
Project # JS- 2012- 001711
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GEOFFERY GOUGEON 96151
Lot Size(sq. ft.): 12632.40 Owner: APRIL REALTY INVESTMENT LLC C/O 237 -239 MAIN ST LLC
Zoning: URB(100)/ Applicant: GEOFFERY GOUGEON
AT: 237 MAIN ST - UNIT 1
Applicant Address: Phone: Insurance:
13 S CHESTERFIELD RD (413) 695 - 1335 WC
WILLIAMSBURGMA01096 ISSUED ON:5/16/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE BEDRM /LV RM FLOORS,SHEETROCK
BEDRM /KITCH
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 5/16/2012 0:00 :00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner