32C-182 (2) 4
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"' The Commonwealth ofMassachusetts
.-. -.. Department of Industrial Accidents
F Office of Investigations
ti ._ . , r 6 00 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): s L C A. 4 y , _
Address: U l S' - \AkIN ua-
City /State /Zip: ,S v *zvc. Lbw --f) Phone #: to CP 1 ' 1 `7
Are you an employer? Check the appropriate box: Type of project (required):
i
1. E r
I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ 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. El Electrical repairs or additions
q ]
officers exercised their 11. have thei repairs or additions
J. 1:11 I am a homeowner doing all work ❑ Plumbing P.
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: 'NI
Policy # or Self -ins. Lic. #: Expiration Date: t 7--
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 co py o f this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi nder tl • , ains and pen ties of perjury that the information provided a • ove is true and correct.
Si •nature: ' L Date: ?'0 r --L ' — r --L ' —
Phone #: l
Official use only. Do not write in this are', 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
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) "
.. 0 Independent Yes 0 No t Structural Engineering Structural Peer Review Required • U
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED .WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
•, . _ .., -
. _ , as Owner of the subject property
hereby authorize . _
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, , 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_penaltiessf,peilury._ _ __ .,,,, _„„ _
— ,
Print Name
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : tA 0 Vi14 O
License Number
o
0
_ ____
_ -
Addrei -
i
Expiration Date
NI•4111111111, ''', ___ ____„___ ____ ___
....`fil...-......... 5._..',.._.`11,1 _(.7_ __
Signat r-- Telephone
I
SECTION 13 4WORKERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida 't must be completed and submitted with this application. Failure to provide this affidavit will result
lf
i
in the denial of the issuance of the b ' ing permit.
Signed Affidavit Attached Yes No 0
t,t,y4
t
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION - FOR BUILDINGS -AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF E F SPACE)
9.1 Registered Architect: _
f __. _. .__ -- Not Applicable ❑
Name (Registrant)
Registration Number
Address
C___ \ Expiration Date
i£«- 1v- E�Ufn-- AP RA.. Litt c.14b�l ._. µ_____ __i
Signatu Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Ristration 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
S r ` e) .,_..._ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address All 1(31'(0/-'1,1,117‘'.--.,
Signature r Telephone
1
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Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning r
This column tore filled in by
Building Department
Lot Size __. _ ......._ ._.. ..,._
Frontage
Setbacks Front
Side L '__ R.?.._ L. _..._ R
Rear _ 1
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces i
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 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 0 DONT 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 , 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) over 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 t
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition 0 Repairs ❑ Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 13.
Brief Description Enter a brief description here. {ZE4)j( t.,1) 0u.- t•G,NALS _� ------
Of Proposed Work t � D /Z 6, "Cc. O t O ,
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 E 2A ❑
E Educational ❑ 2B { ❑
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 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify: .,'-- -. _.__,___._._..� _ _ ___..
M Mixed Use ❑ Specify:
__ _ �
_ ,
... _
S Special Use ❑ Specify: .. .�.o.,. -.... ..�... �..„... . . . . ..� _-,. _wu __,- _,..
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _,_._._ __._,_._,_. _ _ Proposed Use Group: _____ ..., __,.___.. - .._ ...__,_..__,___._.,_.
Existing Hazard Index 780 CMR 34): _,._..._____ �_w. _._ 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)
t
151 1
2nd 2 nd
_ . __..
4th 4v
Total Area (sf) Total Proposed New Construction
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 ZoneD Municipal ❑ On site disposal system El
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Version1.7 Commercial Buildin Permit May 15, 2000
R GCEk : - - o use
GV • ty of Northampton sttsat�erit' 4 S r'
B ilding Department Cu Ctit/o ueway Perrrttt y * F
App 3 u e 02 ' 12 Main Street SeweltSep cAvatlal frty
Room 100 Waterll altabllitj�i
ofeuur GN • - 0 • • mpton, MA 01060 Twa Sets o etura Rlans t a
PAA "' ' " • one 413 -587 -1240 Fax 413 -587 -1272 plaslt Plans
Other Specify
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
to - 1)Locs .Map Lot Unit
6 yt t �{ , Zone Overlay District
�T
-._ m `Etm St District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- 43 kr/ASkrt.t.6-- ItY44
Name (Print) Current Mailing Address: •
X13 5__ _._ . __._.__
Signature Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing !Address:• Cv S _ _ __ _l:19 _. _._.__
Signature .,,`� Telephone
SECTION 3 - E' IMATED CONSTRUC ION COSTS'' •
Item Estimated Cost (Dollars) to be Official Use Only
completed by_permit applicant
1. Building I, CUD (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Z i Construct from (6)
3. Plumbing
5. Cub Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection ��
6. Total= (1 +2 +3 +4 +5) - lZ Cf3 Check Number /
This. Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2012 -0444
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 0
PROPERTY LOCATION 376 PLEASANT ST
MAP 32C PARCEL 182 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /o-6 (#/ 3
Fee Paid
Typeof Construction: REMOVE COLLAPSING ROOF STRUCTURE,NEW TRUSSES,MASONRY
REPAIRS,NEW ROOF & SLAB, I bL,D OWNER'S STUDIO,RENO BATH & ADD
1 /2BATH TOSTUDIO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 040714
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOyI'IATION 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
De s olition Delay
"oroie
S �
Signature of :uilding Official Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
376 PLEASANT ST BP- 2012 -0444
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 182 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 -0444
Project # JS- 2012- 000715
Est. Cost: $59000.00
Fee: $354.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 7361.64 Owner: SZLOSEK STEFFIE AND OTHERS CIO 6 CRAFTS AVENUE LLC
Zoning: GB(100)/ Applicant: SACKREY CONSTRUCTION
AT: 376 PLEASANT ST
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 0 Workers
Compensation
SUNDERLANDMA01375 ISSUED ON:11/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE COLLAPSING ROOF
STRUCTURE,NEW TRUSSES,MASONRY REPAIRS,NEW ROOF & SLAB, AMENDED
5/1/12- REBUILD OWNER'S STUDIO,RENO BATH & ADD 1 /2BATH TOSTUDIO
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:
/1 /7/0 135`
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner