39A-036 The Commonwealth of Massachusetts
., ,; Department of Industrial Accidents
.,:l; : ,: << Office of Investigations ,�
-:' 600 Washington Street
w i=t Boston, MA 02111
° '`y www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Le6ibly
Name ( Business /Organization/Individual): k J 4 - (? i b C St - (`,D
Address: 600 U Kt tb,..) S'i -
City /State /Zip: (.7. S - pi2,1 os. tel.. Phone #: 734. Z 13
Are you an employer? Check the appropriate box: Type of project (required):
1. ' I am a employer with L' 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. Ell New construction
listed on the attached sheet. 7. ❑ Remodeling
2. [1] I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. y f Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. o workers' comp. right of exemption per MGL
y [N p 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no hJ{
employees. [No workers' 13. Other �Z t,- covC�A
comp. insurance required.] K, 0.1K— ,
*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: `pe�32L.Z1S .i,-
Policy # or Self -ins. Lic. #: j 58242 Expiration Date: 12- 3 ( L 12-
Job Site Address: I b3 CIO 1-i. , S City /State /Zip: ■ktRTN A.)--k- ►:C
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_atidjenalties of perjury that the information provided above is true and correct
Signature: Date:
Phone #: 413.734 -2-12 $
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
II Contact Person: Phone #: __ --I
Version 1.7 Commercial Building Permit May 15, 2000
,
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
. c ,‘
w
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, _ _ _ -- _ _ _. _T. .... _.._.._ . , as Owner of the subject property
hereby authorize A �F .,�.�.1 . ?i ! . `4..,e- . to
act on my beh , all matters re tive to work authorized by this building permit application
Signature f Owner Date
I, A A?�?4 _ . l. il._/ . . = .. wµ. _.., ___„__.. , 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 penalties, of perms, e o � ,....m _ „ __.__ .,..._��
Print Name ___ .___..___.._.._..__.._._ _.._ . _.._. _.
h
� _ 10. _....._.,... __....... ..—..._.. ...,.._.J.,. ,,. .M. ......
S - ure of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder .......w ,22 tvit '`: L. ri 6 .? C.`.R,( �..._�. tl_� _ .._.r r
License Number
__ _ _ "sp_ Q_!' lam . ._ .3.,..... _. - tin,. FF. .. .-{A....._. _ . _....81`-12-_ ( ....._.....
Address ., Expiration Date
S' ature 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 th b ilding permit.
Signed Affidavit Attached Yes 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 EILOSED SPACE) .
9.1 Registered Architect:
_._._._______.__ _ �, _ _.. _ . .. .`.° Not Applicable
_.
Name (Registrant): T ._..__.�._ w.___.._._._..__... _ ..__.__,_._...._.._.__ .
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
I
Name Area of Responsibility
Address _.__ ._ Registration Number - __„__....__ .
Signature Telephone Expiration Date
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date W.. M_ ..._....._ _.
9.3 General Contractor
-
A AA? -44_._ __._� 1tTQ ?__..COt`rc�i , _ -.¢`) .-._. _.. ._..._______,._.__.__.______.__ Not Applicable ❑
Company_ Name:
/.? .v? µ SS _.__ ,... ____.__.
Responsible In Charge of Construction
GOD 0-11 aim S ea St ,,,,i F (e. r l. 0la51
Address__ _- .m. .m . _. .__._. _.
S' re Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to • b a filled in by
0' p,atd.c.0 1 & Building Department
Lot Size
Frontage ........ _.. _.,_.. _ .
Setbacks Front
Side L. R..._ L:r R:._3 3 . •
Rear __ . ...
Building Height
Bldg. Square Footage _.._ ; M_ _...._
Open Space Footage , %
(Lot area minus bldg & paved
parking) �� .�.,.Q..�....b .. _
# of Parking Spaces W._ F
(volume & Location) .n
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO (3 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES
IF YES: enter Book ' Paget and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ( DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
Do any signs exist on the property? YES g NO 0
IF YES, describe size, type and location: 5 r t 4 ��c 7tr+ St 64.4 To 'die' ekdt Ue./)
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (S4
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, or 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.
t ,
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 t
CUBIC FEET OF ENCLOSED SPACE 11
Interior Alterations ❑ Existing Wall Signs 151 Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ®a ;?,l
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. (ZRr -toVE= V./2,C- f :ABFZC(AT b ATt-A K,aS; k. Arab
Of Proposed Work : JE,lk..4o ( 1'4 ?AT (,,,k4 \J1TH 'IS (_Ac- K
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 U 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 0 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:.____ , - .. __ - ......_..,.- �.., .__. ..__..�.._._.
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): .___ __,._..... _ 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--.1 t �.
1st 1 s ,
IO0
2nd 2nd -
3ro _ . _.. 3- , , _ .
.» ------
4 m
4
Total Area (sf) t 00 Total Proposed New Construction jsf),__ _ __w,
Total Height (ft) , -
1 Z.
Total Height ft _.:.._ a..:y:,.
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone information: 7.3 Sewage Disposal System: t'4 o '-E
Public ❑ Private ❑ Kl D,Qt: Zone _. _ , Outside Flood Zone Municipal ❑ On site disposal system
c
Version1.7 Commercial Building Permit May 15, 2000
�Departem lt use orti �a
_ t if "�-e �' a .. �' . . ' ` l' % . ` �� { '
- Ci ty of Northampton Status pf P* � §
• Balilding Department Curl ` ti ett ue �P� � me h , - .
212 Main Street S4utierf e # A' c at 4 t#1 t 4 . .
- 62012 p H �,�
I Room 100 W afe e ailaix 1 d,7 �
Nor hampton, MA 01060 Twa §eft of�4 cturaf,PCans ' �
...,.,
o r T eu' 0064,413_587_1240 Fax 413- 587 -1272 Pot/S to Pfans _
NORTHN\ , .€ i
Oth ec,
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
This section to be completed by office
1.1 Property Address:
Map Lot Unit
i CD Nt 1 Jl , Zone Overlay District
_ - - __ _.... ... Elm St. District' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
�Pr t-1 � Toi NA C )1 ° .1----7 .._.__...
Signature ��, C -�'yr� Telephone 9-1 3 .517 — f' / / 7
2.2 Authorized Agent:
Name (Print) ,t l 6 ,) c.N en Current Mailing Address
Signature Telephone 4( 3, ?3 4_ Liss
SECTI 3 ESTIMATED CONSTRUCTION CO `'
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building : (a) B uilding Permit Fee
2. Electrical ; (b) Estimated' Total Cost of
( ` 20£� Construction from (6)
3. Plumbing Building Permit Fee
....._ _ ____ _____ ____ . 9 .--°
4, Mechanical (HVAC) ,...-_.__....__...... ._._..__..._.....__..._.._..,._ _.....
5. Fire Protection ."---
6. Total= (1 +2 +3 +4 +5) tO Check Number YO
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2012 -1076
APPLICANT /CONTACT PERSON ADAMS & RUXTON CONSTRUCTION CO., INC.
ADDRESS/PHONE 600 UNION ST WEST SPRINGFIELD (413) 734 -2138
PROPERTY LOCATION 163 CONZ ST
MAP 39A PARCEL 036 001 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
V � / � -� ^
Fee Paid Y 420
Typeof Construction: PE-Ibiebigil ATM KIOSK KC/Av. c
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 071951
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJRMATION 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
77 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.
163 CONZ ST BP- 2012 -1076
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A - 036 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -1076
Project # JS- 2012- 001858
Est. Cost: $10500.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ADAMS & RUXTON CONSTRUCTION CO., INC. 071951
Lot Size(sq. ft.): 40249.44 Owner: LEVEE LLC
Zoning: GB(100)/ Applicant: ADAMS & RUXTON CONSTRUCTION CO., INC.
AT: 163 CONZ ST
Applicant Address: Phone: Insurance:
600 UNION ST (413) 734 -2138 Workers Compensation
WEST SPRINGFIELDMA01089 ISSUED ON:6/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE ATM KIOSK
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 6/7/2012 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner