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,..; The Commonwealth of Massachusetts . •
Department of Industrial Accidents
Office of Investigations
rn � 600 Washing on Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information ] Please Print Legibly
Name (BusinessiOrganization /Individual): )"!17Sf9' kat
Address: a / ./Vjal S1"
City /State /Zip: /jl t 4 / 4-)i a i r Phone #: G 77-.3 c. E
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with It 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling
ship and have no employees These sub contractors have 8. ❑ Demolition
capacity. employees and have workers'
working for me in any P ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
re a
3. ❑ I am a homeowner doing all work h � P.
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
comp. insurance required.] •
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
' 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.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: E ,� C
Policy # or Self-ins. Lic. #: W` 50030 'j y 0 1 o 0 3 Expiration Date: 7/
Job Site Address: R G '-iir t St City /State /Zip: 44 4/ ,3"iif ' -• Cie‘ a
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: � Date: � � e
Phone #: t 2r ? — S G 6 G
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 #:
`` ` ^
`
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Require �� �� d Yes \~* No \_/
SECTION OWNER U ON - T LETBD WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BU!LDING PERMIT
/
--- »1 -------------------------�------�
|. / y *«'t /r1/ _ - _)1 .)?1 . os Owner of the subject property
"
a��ohze| � � �
act on my behalf, � �ho�����b��i�ponn�application.
Signature of ner / Date
r -----� -----�---------------- -���� �
| ����/_-'��,�����_________________-____-_-___________________ . anOwner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowtedge
and belief.
Signed
14Z,12.----3- 27.1/C7 , , , „ , , „ _
Signature of Oier/Agent Date
SECTION 12 - CONSTRUCTION SERV!CES
1O.1 Licensed Construction Suporviyoc Not Applicable []
7J �--- ---------'--------------� ---------|
wumev,u�ovso*vme,�L i --_ o , �_ __--_J
License Number
,\ ' i ()// (4- / ____.__- _ -_-_-'
Address Expiration Date
—7/4(Z}I;)-1.----- ,„, 7 ? — ,5 6 C.
Signature Telephone
~ ' " �� ~" � - `� p'
SECTION 1m
�� -�
Workers Compensation affidavit must be conipleted and submitted with this application. FaUu�8zpmv�o��a�davhw0�mu�
in�aUan� the issuance ebui�ingponn�
y_�
� S�nedAffidav�A�ached Yes (St" ------
��� 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 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 Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
/f'T�S�_.._..,. / 494-1. — S .__� Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
a G�7 S� c6
Signature Telephone
Version1.7 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 L... R:.. ..., .,. L.,_.,,. R: ...., w _.
Rear „„ _..
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 /Finding ever been issued for /on the site?
NO (:) DONT KNOW YES
IF YES, date issued:
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 DONT KNOW 0 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 ( NO e
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, excavation, 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.
, ti
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 f Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work: tee/ o�,c /G ,Af4 it S c'r� Ny
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 0 A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business 2A Er
E Educational ❑ 2B - p'
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 0 S -2 ❑ 5B ❑
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)
1st /a?0 _ :f ... T. 1 s
2 n d
2 Hd
_.....___ _. __
_ .._,___ ______ _
3rd . 3rd
4
Total Area (sf) 3 I 4 v 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 Sewag Disposal System:
Public rar Private ❑ Zone Outside Flood ZoneD Municipal On site disposal system❑
i
Version1.7 Commercial Building Permit May 15, 2000
''Department use only
City of Northampton status of Perariit
v `.-- Bt Department Curb Cut/Drrveway Perrnrt
212 Main Street Sewer /SepticAvailabrlity
Room 100 Water/Well Availability
2.009 Northarr,ipton, MA 01060 Two Sets of Structural Plans =
A■ – phone 413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plan "s
Other.Specrfy
APPLI601ON TO ' CONSTRUC'T,- ,REP1{iit, 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
Address:
0 B (` c) ,- 1 -- Map Lot Unit
'� Zone Overlay District
.. _ ...... _ d._ ,.. _ ...._ . _ . -,..... Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
µ /1fr1 ) o j./ (,v c _ 7 , 6 if t% „t ,t� k oit vim
Name (Print) Current Mailing Address:
Signature _ L c�f i r' �� 1 4,.. T e lephone l o K e -' (c _ _. n �� - -,. , - 0 � `�
2.2 Authorized Agent:
Name (Print) dY '6/4/-4-r4 Cu t Mailing Address:
S 7'" �t o� / 3�
( ) ess
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / COO (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) f vJ Check Number -b7o4 ti
This Section For Official Use Only
Building Permit Number Date •
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0142 `
APPLICANT /CONTACT PERSON ROY OMASTA
ADDRESS/PHONE 21 North St HATFIELD (413) 247 -5666
PROPERTY LOCATION 20 BRIDGE ST
MAP 32A PARCEL 173 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � �
Fee Paid .r/ v ^ l v
Typeof Construction: REMOVE 2 NON - BEARING WALLS & BLOCK WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
..e.- e- 7(------
____41_64_____e-od
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.
20 BRIDGE ST BP- 2010 -0142
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A -173 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- 2010 -0142
Project # JS- 2010- 000173
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sq. ft.): 14026.32 Owner: SINGH HARDEV & PARAMJIT KAUR
Zoning: CB(100)/ __ Applicant: ROY OMASTA
AT: 2\ BR E. 32 v i
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Comp ensation
HATFIELDMA01038 ISSUED ON:8/27/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE 2 NON - BEARING WALLS & BLOCK
WINDOW
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: p' t,at..'
i/13 9- Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Final: Smoke: Final• ,OK //3 Q?'
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL ATIONS.
if te
.''
Certificate of Occu.anc „/ .�,�/ Si • nature:
FeeType: Dat • ' aid: Amount:
Building 8/27/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
.i