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07-008 (2) , The Commonwealth of Massachusetts o ..., •-- Department of Industrial Accidents .. rrx ---=- Office of Investigations „, 600 Washington Street �„ .._ Boston, MA 02111 - .), www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /PIumbers Applicant Information Please Print Legibly Name (Business /Organizatio n(I ividuaI t i■.w- , Ljc _.._ _ Address: 1.1.y. /,--( City /State /Zip: UP-cd-S /vet" O ) Phone #: ) 3 2 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 6. ❑ New construction e es (full and/or part- time).* have hired the sub- contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub- contractors have ship and have no employees 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 lo.❑ Electrical repairs or additions officers have their Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ave exerc r 11. ❑ myself. o workers' comp. right of exemption per MGL y [N p 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: 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 co py 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 and penalties of perjury that the information provided above is true and correct. Slg nattti/ Date: 7 — 2 �— _/ Phone #: 4 / 7 3 7 �t Official use only. Do not write in this area, to be completed by city or town official ty or Permit/License # Is suing C i Authority Town: (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: . t Versionl.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 tj SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING. PERMIT I, G k , a cC.e.... VQ - .... - -- .._ yl. . N .. „, as Owner of the subject property hereby authorize . l ?_. � _ . V. . Le......� _ a� . w .a_� _ _ n _.._.. �.' to act on my behalf, in all matters relative to work authorized by this building permit application. ___ _ _ _ _ _ _ Signature of Owner Date I, (N_.-__........ _. _C_._ ____�....�_._._.�.._.._.__� ..�___.�._....._....m.,.._.__.. as Owner /Authorized Agent hereby d f are 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 andjenalties of per yry e __ s -- Print Name __ _ _ _. _ _ ._ _... �� wn ) 7 /f _..,_ Signature of 0 gent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ._. I � "'`' � -- --,— ,M ..w.�. -�.r., .,_. /(205 V !. .... License Number __ :.__. ____ __ . __ _ ___�_ 5._ _.____ 1 s m _ .� .. Address Expiration Date Signature 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 building permit. rC” Signed Affidavit Attached Yes No • Version1.7 Commercial. Building Permit May 15, 2000 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 ENSLOSE© SPACE) 9.1 Registered Architect: ._._.._..___.. _ 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, _ _ _ ,^_m__._. 1 n.�x..www .... E Signature Telephone Expiration Date Name Area of Responsibility _ _ _ • Address ...__......_._...___....._._. — _. — Registration Number i 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 C e of Construction Address Signatur Telephone , Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed ` Required by Zoning , This column to filled in by Building Department Lot Size __.._. _ _ . _ _.... Frontage "_,.._ _._. __ __,_._.._. _____ ._ _.. Setbacks Front _ Side L :' _.,_........._ R : '� Y_ m L:L. ..._ R: .,, _ Rear M "i Building Height Bldg. Square Footage % t Open Space Footage % . --_. , (Lot area minus bldg & paved „,1 - . parking) ._ .�,� . _ � .... # of Parking Spaces µ--- - -- . `--y — 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 IF YES: enter Book ' Page 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 'I 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 CUBIC FEET OF ENCLOSED SPACE ...! Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Ad ns ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work � r - vim 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 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - r ❑ 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 ❑ U Utility ❑ Specify: MMixed Use ❑ Specify: ,...._...._. .,...- .__...._..._�..- ..,�... ...J�...N._ _..��..._._ -... -_ .___. S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOINGRENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: .._______ ___ ____ ...._. Proposed Use Group: Existing Hazard Index 780 CMR 34): __ , . __, _ Proposed Hazard Index 780 CMR 34): '.__....,., ______ _ ... __M SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1 s t 2nd 2 i 41h 4� ___-__ _. ______._. _ _ i Total Area (sf) Total Proposed New Construction (sf)_ 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❑ • • Versionl.7 Commercial Building Permit May 15, 2000 e Depaum elit Use # only vrsrs P i -� - -- City of Northampton Stag! h rs , °' � Building Department .yrbE ..prim, ' Y e , s � f ` 212 Main Street Sevrierl e � atfa tlity � v rt , : � � i lfl Room 100 ¢ater elf atla i. � Northampton, MA 01060 , Tw'�� e t ctCt a ,Il ,� x,� , . 1 '' NORTHAMF . P �A 01 0 Pie i a � , ne 413- 587 -1240 Fax 413 - 587 -1272 PloflScte Plansn� � � � � Ottfer pec�� F �� 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 5 16.0 ,, t {� l . Map Lot Unit � ' �/, i Zone Overlay District EIm'St: District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZEDAGENT 2.1 Owner of Record: Name (Print) _ Current Mailing Address: Signature , 4 11/.., ,' �� 'II Telephone 5'£i, t/ ,,/ O G 7 JiU 4 2 2.2 Authorized Agent: I : fl--- ...) - .1,—(,):_..... ____...._ ! -- Pi° 13 ___24e,4 Name (Print) Current Mail( Address Signatu Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS • Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (tr.) i i (a) Building Permit Fee ._.,..,� ..._ 2. Electrical i _.'.__. j (b) Estimated Total Cost of Construction from (6) _ ....._...... _. __. __._.w,. . r 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) ..__.— ._..,..__. ____.._ _ „.. 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) ^ I%” Check Number 1 i - i. I! This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 460 NORTH FARMS RD BP- 2013 -0091 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 07 - 008 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP-2013-0091 Project # JS- 2013 - 000140 Est. Cost: $20000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY J LUCE 100515 Lot Size(sq. ft.): Owner: VOLLINGER JOHN J & GRACE F Zoning: RR(100)/WSP(100)/WP(22)/ Applicant: TIMOTHY J LUCE AT: 460 NORTH FARMS RD Applicant Address: Phone: Insurance: P 0 BOX 14 (413) 387 -9800 LEEDSMA01053 ISSUED ON:7/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL METAL ROOF ON BARN 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 7/24/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner