31B-180 The Commonwealth of Massachusetts
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A -� Department of Industrial Accidents •
�-_, Office of Investigations •
- 600 Washington Street •
�. �� zt Boston, MA 02111
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' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ` l S A RNPO c
Address: f s 7 CA U 6 H I L- Rip
City /State /Zip: L6 V E 11 Phone #:
Are you 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. ❑ New construction
2. [ 4 am a sole proprietor or partner- listed on the attached sheet. 7. E Remodeling
.J 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
i
h
d i
have ave exercse their 11.
3. ❑ I am a homeowner doing all work ❑ 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.] I 1
*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 under th . pains and penalties of perjury that the information provided above is true and correct
Sienature: _ .„---1.--- / Date: Ai
Phone #:
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 #:
,-
Version1.7 Commercial Building Permit May 15, 2000
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SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required • Yes 0 - No 0
SECTION 11 - OWNER AUTHOR ' TION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONT . TOR APPLIES� BUILDING PERMIT
I, .._.. .,, "..�5 '' ._ .., _ _r.. _ _, as Owner of the subject property
CG 4111 111111111. y
ti
hereby authorize `.._ ��....�� _.e.?y ✓V 6 �e �. �.v .. .__�_..... .._.. ._ to
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act on my beehh If in all matters re 've to ork authorized by this building permit application. __ _ _ µ
x Signature of Owner Date
I C._i.;..I ___. __._��_A. G _._.... - _,_... _. -___ _ .- _.. -__.. 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 ofser ury,_ _,... _ � .._
' -
Print Name _,
v f f, S 0)4 r/ v� ct (,
Signature of Owner /Agent T Date /12_ / l z.--
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
.� -
C g_.41/2._ ._.__ / n...,.. � _.. _. ._ s... ... .
Name of License Holder . _,� .. , �.�.t2
- --� —��— License Number
Address Expiration Date
Signature Telephone
SECTION 13 - WORKERS'; COMPENSATION INSURAN 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
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 ENI LOSED SPACE)
9.1 Registered Architect:
Not Applicable
Name (Registrant): ._.____ ___...__._._.._._M_._._..___.. .
Registration Number
Address
,._. Expiration Date
•
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
P
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
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON, ZONING
Existing Proposed Required by Zoning
This column tb Ee filled in by
Building Department
Lot Size _ , F - . __ .....__._
Frontage
Setbacks Front
Side • L:. — : R ::__ _....... - L: =., .__.. R:'" _.M.._ _ ..__.
Rear
Building Height __
Bldg. Square Footage _. ,__.. __._. % ----- _.., ..".__,
Open Space Footage % __ v~Y ��
(Lot area minus bldg & paved ;,.......
parking)
F
# of Parking Spaces _ , u..
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: s
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 .ONT K oW 0 YES 0
IF YES, has a permit been or t ' to be obtained from the C. - ervation Commission?
N.
Needs to be obtained • • .ined , 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 T. additions of signs intended for e property ? YES 0 NO
IF YES, describe size, type . d location:
E. Will the construction a . ity disturb (clearing, grading, excavation, or filling) over 1 acre or is it p- • of a common plan
that will disturb ove 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 ❑ isting Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessoryg ❑ '
Exterior Alteration Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work ._ 6141106 A o p Sd f f I TS _....,_.. _ _.____
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A � ❑
A-4 ❑ A -5 ❑ 1 B ❑
B Business ❑ ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F-1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 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 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify _. _ . _ _
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGO( ∎ G RENOVATION ADDITIONS AND /OR (CHANGE IN USE
Existing Use Group: __ _.____ .. Proposed Use Group:
Existing Hazard Index 780 CMR 34): ,w _ M _ .___ Proposed Hazard Index 780 C - 34): .. _ ____ __... __..
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPO D NEW CONSTRUCTION 0 CE USE ONLY
Floor Area per Floor (sf)
1st M
d
2 ,
' .
4th —
Total Area (sf) Total Proposed New Construction (sf) r „
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 0 On site disposal system
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Version1.7 Commercial Buildin& Permit May 15, 2000
" x% g �Departmefit aol
REC C
C. Y o f N orthampton $tatrts1b I t to r
' <1 � c f`l i r e :
Bu Idin • Department t Ct�t/Driveway a IA��
12 ain Street • S� r p yatlabtwgr �, �
R om 100 to er eliArat(abdi MI` t �� _
mpton, MA 01060 T� • t aura �>±?l t � , " �
DEPT. of BLit' 3 "ee4 Ec - ' , :7 - 1240 Fax 413 -587 -1272 PI aflSrt t Pl ans` . ..
NORTH
Other S ec j
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 �j �� ��
- t ., -.0 x. 4.-- T section to be completed by office
1.1 Property Address:
'1' Pr0",ptc- f h + /46 I -t (- . ( Map Lot Unit
Zone Overlay District
0tv U I
- -- ------------ - - ----.- -- ---- -• -- - -- -- Elm'St District` CB District`
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
..... ................... ...
• f�
i 2.2 Aut. • • rized . ent: _
Name (Print) Current Mailin9_Address
�_,/ 44‘:5-. Signature K^�_/ (v•,�, , J/ �') Telephone
� ' SECTION 3 - ESTIMATED CONSTRUCTION OSTS
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) . _.,.... _. ,..,w, _........
3. Plumbing Buildi Permit Fee
4. Mechanical (HVAC) _______________ . ______
5. Fire Protection / ab tq ! _. __ _ __ ._..,___. ...._.........
6. Total = (1 + 2 + 3 + 4 + 5) Check Number if 06_5
This, Section For Official Use Only
Building Permit Number Date
Issued
Signature: /L-6—(:)1 7 I I - Z,
Building Commissioner /Inspector of Buildings Date
•
45 PROSPECT ST BP- 2013 -0055
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 180 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP-2013-0055
Project # JS- 2013- 000082
Est. Cost: $9000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CURTIS A BARNABY 99366
Lot Size(sq. ft.): 17598.24 Owner: LOCOCO ENACE J & JUDITH R
Zoning: URC(100)/ Applicant: CURTIS A BARNABY
AT: 45 PROSPECT ST
Applicant Address: Phone: Insurance:
157 Cave Hill Road (413) 687 - 8876 0
LEVERETTMA01054 ISSUED ON: 7/16/2012 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL GUTTERS & SOFFITS
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 7/16/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner