32C-100 The Commonwealth of Massachusetts
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): ' t; 1` 1�f312V 01�1�) � � kir Cikkt
Address:
City/ tate /Zip: G4,4Wt4 01-0 4"'\ 4 Phone #: ( 7 6 7 -2 122-
Are u an employer? Check the appropriate box: Type of project (required):
1. 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. El 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 10.0 Electrical repairs or additions
officers have their Plumbing repairs or additions
3. ❑ I am a homeowner doing all work ave exerc r 11. ❑
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. ❑ Other Q a p s
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. #: \ /,;—` l' -� ( Expiration Date:
Job Site Address: t : a , City /State /Zip: ' „` =mow h TO N V P j° 1216
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 cerrri�ify under the pains and penalties of perjury that the information provided / ab i ve is true and correct.
Si. /
nature: i 1.. L— �� Date: U • Z
Phone #: 4 ( 3 ) 367 -2_122
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
I Y Contact Person: Phone #:
. Y
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, I ) _) .:.._ D_. A J_!C ;n x.& _._ .. _ v �.. _ as Owner of the subject property
hereby authorize Q ..��_ _ ._,�. �.0_� _..
act o y behalf, in all matters relatiy to work authorized by this building permit application, _
Sig ature 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 perms. n
_ _... ,C_ ._,_ d � �O!X- - ' _ ,., ��. �.
Print Name __..... _ ....
_._
Signature of Owner /Agent Dat
SECTION 12 - CONSTRUCTION' SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.'.......! _...[...1:. ,..._�,.(�.0 /..
License Number
Addre/ Expiration Date
Signa ( i)i ii" {
9 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 the bu ing permit.
Signed Affidavit Attached Yes No
Versionl.7 Commercial Building Permit May 15, 2000
J
SECTION 9- PROFESSIONAL DESIGN -AND CONSTRUCTIONSERVICES - FOR BUILDINGS STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO T80 CMR 116 (CONTAINING MORE THAN 3 C.F. OF EN,LOSED SPACE)
9.1 Registered Architect:
_.._ _______ _. ._._._. M._., 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_ _ "__« __ ___ __„
1 d
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
. - . . ._,.45. ...._.. .._.__.._
33 -. - - -- - 1._
Address
c______B, _. -21,.2
Signature elephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning ,
This column tore filled in by
Building Department
Lot Size _.
Frontage
Setbacks Front
Side L._._ R. _ L. R:
Rear ..w
Building Height
Bldg. Square Footage - -_.
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: ..
(volume & Location)
A. Has a Special Permit /Variance /Findi g ever been issued for /on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the c ( Re of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book ` Page mm and /or Document #:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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, exca ion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 0 ,
CUBIC FEET OF ENCLOSED SPACE
/
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs Fid Additions ❑ Accessory Building ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing • Change of Use ❑ Other ❑ `'
_._.. _.. - --- - -
Brief Description Enter a brief description here. ye / v i - - • ► j r te- C, -4,,---
Of Proposed Work: f'
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE .
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 0 A -2 ❑ A -3 ❑ 1A 1 ❑
A-4 ❑ A -5 ❑ 1B ❑
B Business ❑ I 2A ❑
E Educational ❑ l 2B - r ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ I -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:. _ - , ......'.r..'__ - "_"'. °' ____A...._......` __._.__.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: .__ _4 _ 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)
yr: e:
1st r
1st ___
2nd_. _..._._._.._ _. 2 nd
3rd _ . _ ._ .._ _ _ _ 3 rd ; _._
__...___ ___.,. — 4th -
4 th -.. . _.... .....— _.— __ —_. __ .. ,
Total Area (sf) Total Proposed New Construction (sp_ ,_
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
4 i
Version1.7 Commercial Building Permit May 15, 2000
ePlagtiOr'i*VP0040r1
City of Northampton ,-,..,t,r;.,.--fe
-
i, :P1,4s
Department i
97,7,.94,, J
REas-7:VPD
r 1 1212 Main Street ' ikjgel*M41Itt4NVtliwio
, illin ' Room 100 '‘Air,i4IVA*1.--Nitig...,4,1,At_gaustlkiascag4fipovia41;;;',:
I JUN I 9 tux amp
orlhton, MA 01060
T1 e• S-
i ,.1 t :;. ,,... ,,, -:i;,Z1] - ',::::: --'
L phone 4, M87-1240 Fax 413-587-1272
'',;-,„,,,, lf
DEil. ... , .,
NORTHAMr O ;:-9P, -, 9 1 t t : '
t ....._
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
3 Gov..) c-n : Map 34_6: Lot 1 (7 C Unit
;
KJ 04-1 OTC) kl 14 A
% -, Zone Overlay District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A.m. 1 I .1,
„i
Name (Pnnt) Current Mailing Address:
Signature g,, 1,-. r — Awri..._4111 Telephone Li 13-- ,S 6 - 1 cl t - A --- --
2.2 Authorized Agent:
7 .,,, _. t .... 1 .....,.... ...
Name (Print) y 6.1 tdic k...._ , k../i•-wits..1"6 Cu;entMailingAddress: 3551,71$ ---
..„ ..........
10 . ‘ f A ,,,....4„,
/ / / - th1/4
Signature
_ ....
Telephone (J i 3 3 6 ? --- 2 122„
SECTION 3 - ESTIMATED 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 i Building Perrnit.Fee
4. Mechanical (HVAC) ---
6 Total = (1 + 2 + 3 + 4 + 5) _ ( cro Check Number /6/3
or Official Use Only
Building Permit Number Date
. Issued
Signatur‘le g fi
-- /,...._
Building Commissioner/Inspector of Buildings Date
File # BP- 2012 -1141
APPLICANT /CONTACT PERSON PETER UNDERDOWN
ADDRESS/PHONE 33 PHILLIPS ST GREENFIELD (413) 367 -2122 Q
PROPERTY LOCATION 32 Conz Street
MAP.* PARCELS ZONE SR/WSPII
2G it
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 1 =F !Ol
Building Permit Filled out
Fee Paid
Typeof Construction: Rebuild Front Porch Canopy
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 96600
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F ATION 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
Peiiiut from Elm Street Commission _ Permit DPW Storm Water Management
- • olitio j y
Sig - 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.
32 CONZ ST BP- 2012 -1146
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 100 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- 2012 -1146
Project # JS- 2012- 001962
Est. Cost: $1000.00
Fee: $150.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 28096.20 Owner: ROUNDHOUSE LLC
Zoning: URC(100)/ Applicant: ROUNDHOUSE LLC
AT: 32 CONZ ST
Applicant Address: Phone: Insurance:
49 BEACON ST
FLORENCEMA01062 ISSUED ON: 6/20/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: Rebuild Front Porch Canopy
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 6/20/2012 0:00:00 $150.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner