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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): / // 1 , I P I ,e-
Address: 2 a , 30 X aqj
Y p: 6h f t e / -/e/ mU. ��� P h
City/State/Zip: (J one #: ` /3— ?' "I -- 5 •
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with Q 4. ❑ I am a general contractor and I
_ (full and/or part- time).* have hired the sub - contractors 6. ❑ N w construction
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 10.0 Electrical repairs or additions
3. ❑ am a homeowner doing all work
officers have exercised their 11. Plumbing repairs or additions
I right of exemption per MGL
myself. [No workers' comp. p 12.0 Roof repairs
insurance required.] t • c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ 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. /- // L
Insurance Company Name: A h iP/ZTy
Policy # or Self -ins. Lic. #: WG 2 - ,j )5 - 366 t' (i - (2 / Expiration Date: tY tit y -16 p)O IT)
Job Site Address: 6121 1 J ±4►On ' V I - - r , " ity /State /Zip: 0/1 � h7)17jy(/
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 and pen ies if perjury that the information provided above is true and correct.
,/
Signature: // � // ✓. / Date: U 4, /do 0
s
Phone #: / 5- 2' 7' 5/ 7D L (
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
Contact Person: Phone #:
or 1
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 �� /y �'1.. /2 _. , as Owner of the subject property
hereby authorize ✓ 71,3 ?DOA 0qA . venettax an )10mt0 to
act on my be. 'n all matter tive to w. ' authorized by this building permit application
._ 4 /
� l /UT /t�
Signature of Owner - , Date
I, /.Qfl� _../s/ir... �.,._�_.., . �.. , 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 anc penalties of penury, „_,� �......._� ..,.....
Print Name
B- GY06
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: N ot Applicable ❑
Name of License Holder : _._..
License 31,
s,w
d,_ _. pox._.. ..,q7..,_ _ hio.�. i� I- eid. _ ea.,. DJvI,2 _..,, _. /a_ Gld' - as /i
Address Expiration Date
a �
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT I(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 0
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 ENCLOSED 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
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name ... A , _ ......._
rea 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
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Spa Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
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 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 NO
IF YES, describe size, type and location: 1'
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 (3 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i ,
� y
Versionl.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 Additions ❑ Accessory Building ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. ', e YV1O i p 1V44 0 h w 4,11 S 61 'tot.' 1
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ,- f ❑
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: ,
M Mixed Use ❑ Specify:
S Special Use ❑ Specify: _ _ n .._. __ „
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing 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)
1s 1st
2nd 2 nd
3
4th 4 th
Total Area (sf) Total Proposed New Construction Lsf)
Total Height (ft)
Total Height ft ._.. e
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zoe Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone _ Outside Flood Zone❑ Municipal ❑ On site disposal system❑
1
Version1.7 Commercial Building Permit May 15, e 2000
Department use anly
City of Northampton Status pfPe
�� Building Department Curb Cut/Dpveway Permtt
�� 212 Main Street Seaver /Septic
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural `Plans
phone 413 =587 -1240 Fax 413- 587 -1272 Plot/Site
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
19 S v O n 5 /9V e-47 L)C_ Map Lot Unit
N0 v Gt
i-3-7/0
Zone Overlay District
a .. _ ,.... - Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
62 b rc f% / vt it/or-itia n/7
Name (Print) Current Mailing Address:
-�. 1 7 1 7 52s 33
Signature �i✓t Telephone
2.2 Authorized Agent:
To i oA nN. Gsentootral ?e. 501 K917 6,h44
Name (Print) Current Mailing Address.
. . `1 5 .. /6Y.. __ (1),
Signature /�L_ Telephone
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 Building Permit Fee
4. Mechanical (HVAC) .,_ _ _..... _.
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 1 O1/ O) Check Number 6
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0793
APPLICANT /CONTACT PERSON THOMAS DOLAN
ADDRESS/PHONE P 0 BOX 297 CHESTERFIELD (413) 585 -0612 Q
PROPERTY LOCATION 19 STRONG AVE
MAP 32A PARCEL 150 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin l Permit Filled out •
Fee Paid ' '
Typeof Construction: REMOVE PANELING ON WALL,INSTALL FRP SHEATING,RUBBER BASE BOARD
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/ Statement or License 039281
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
C� 3/1-2 iU
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.
19 STRONG AVE BP -2010 -0793
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 150 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTYFUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP -2010 -0793
Project # JS- 2010- 001178
Est. Cost: $2167.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS DOLAN 039281
Lot Size(sq. ft.): 5314.32 Owner: FLYNN DEBRA
Zoning: CB(100)/ Applicant: THOMAS DOLAN_
AT: 19 STRONG AVE
Applicant Address: Phone: Insurance:
P 0 BOX 297 (413) 585 -0612 O Workers
Compensation
CHESTERFIELDMA01012 ISSUED ON:3/12/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE PANELING ON WALL,INSTALL FRP
SHEATING,RUBBER BASE BOARD
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 De9artment Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: (--■ 5/ Le' iS
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
�- r".ate
Certificate of Occupanc Signature:
FeeType: Date Paid: Amount:
Building 3/12/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo