Loading...
32A-111 CITY OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: 66 tct%e* ` \ The debris will be transported by: /V hfY\ The debris will be received at: Signature of P rmit Applicant IFJA �� Date 9 7 I f 2 f Building Permit Number: i OF NOTICE .„ NOTICE TO T 1, O e EMPLOYEES EMPLOYEES EMPLOYEES a . The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS One Congress Street, Suite 100, Boston, Massachusetts 02114 -2017 617 - 727 -4900 - http: / /www.state.ma.us /dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above - mentioned chapter by insuring with: Massachusetts NAHRO Insurance Group, Inc. NAME OF INSURANCE COMPANY PO Box 803, West Springfield, MA 01090-0803 ADDRESS OF INSURANCE COMPANY WCMN0110 06/01/12 to 06/01/13 POLICY NUMBER EFFECTIVE DATES Massachusetts NAHRO Insurance Group, Inc. PO Box 803, West Springfield, MA 01090-0803 800-932-3112 NAME OF INSURANCE AGENT ADDRESS PHONE # Northampton Housing Authority 49 Old South Street, Northampton, MA 01060 EMPLOYER ADDRESS EMPLOYER'S WQRKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER i MAS 1 • CH/ SETTS N ,H; O 1 l CE UP MASSACHUSETTS WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE CERTIFICATE INFORMATION PAGE ITEM 1. PARTICIPANT NAME AND MAILING ADDRESS: CERTIFICATE NO: WCMN0110 Northampton Housing Authority 49 Old South Street FEIN: 046003578 Northampton, MA 01060 ENTITY: Non - profit, public employer ITEM 2. CERTIFICATE EFFECTIVE FROM: 06/01/12 TO: 06/01/13 Effective 12:01 A.M. Eastern Standard Time at the Participant's mailing address. ITEM 3. COVERAGE: A. Workers' Compensation Insurance: Part One of this certificate applies to the Workers' Compensation Law of the Commonwealth of Massachusetts. B. Employers' Liability Insurance: Part Two of this certificate applies to work in the Commonwealth of Massachusetts. The limits of liability under Part Two are: Bodily Injury by Accident: $1,000,000 each accident Bodily Injury by Disease: $1,000,000 certificate limit Bodily Injury by Disease: $1,000,000 each employee C. Other States Insurance: Massachusetts Limited Other States Insurance D. This certificate includes these endorsements and schedules: WCNG0000 Insurance Certificate WCNGTERR Terrorism Risk Insurance Act Endorsement ITEM 4. The premium for this certificate will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE P 5CoultowydAssiPr This certificate is hereby countersigned by on 5/4/2012 Authorized Signature Date The Commonwealth of Massachusetts Department of Industrial Accidents `.=r, Office of Investigations = 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information • Please Print Legibly • Name ( Business /Organization/Individual): kic� \� CKWkl� �,f(✓1 �t1G11 1' Address: c( V 6_ q w C* - City /State /Zip: / V , VSO Phone #: Lff3 `7 _ Are you an employer? Check the appropriate box: 1 Type of project (required): 1. ❑ I am a employer with a5- 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part- time).* have hired the sub contractors listed on the attached sheet. 7. n Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.1] Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. 12.g 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ^ k) Insurance Company Name: ' v \ S � /VCk�C'© rte G ■1-01? Policy # or Self -ins. Lic. #: W CAA NO I C7 Expiration Date: 6 (( ' 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 nder the p ins and penalties of perjury that the information provided abov i true and correct. Sicznature: ( Date: 9 / I ��o� 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 Contact Person: Phone #: I 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 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT l �_ _W..._ -. .. _� _.. as Owner of the subject property hereby authorize ! _...... ....... �.�. �.. .w .�_....._.... .... . �_.......__� act on my behalf, in all matters relative to work authorized by this building permit application. _ _. Signature of Owner ____._._._, ,._._.. ,. _. , 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_ofpertury.�, Print Name ..M..__ ___. Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ !O1io 7 ... License Num r -? 77 .._. / 9 /4- /fit) 4 _,... cuXtetAa /01068 .5 ........ Addres Expir tion ate fi 4" _.y.. .w _ Si . nature Telephone SECTION 13 -WORKERS'` COMPENSATION INSURANCE AFFIDAVIT (MG.L. c. 1 52, § 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 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 EKLOSED 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 _.._._ .. ............ Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone j . l 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 Building Height ..... Bldg. Square Footage % ___ _ ....._. Open Space Footage % _ _ (Lot area minus bldg & paved parking) # of Parking Spaces ___ Fill: (volume & Location) .___. ..w_.:. _ . _ ___ ..., _.. ___. _ . A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ( DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW _ _ 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 Obtained (3 , 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 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 (3 NO ir® IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • I. 1, Version 1.7 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 0 Repairs ❑ dditions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofin Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: c p \aC 5kwt rfii SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 0 A -2 0 A -3 0 1A ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - ❑ F Factory ❑ F -1 ❑ F -2 0 2C ❑ H High Hazard ❑ 3A ❑ I Institutional El I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential R -1 0 R -2 0 R -3 El 5A ❑ S Storage ❑ S -i 0 S -2 ❑ 5B I ❑ U Utility ❑ Specify: '! M Mixed Use 0 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) is: 1st 2 nd IOW S 4 . v.- ...,.._... ._ .... . .�,� 2 nd 2 nd __. ....... ......_._... .:..._..,...,..._. 3 d ,.,,_,. �_ <...__ _ _ .- ._,,.._ _ . 3 rd _.... 4 4 Total Area (sf) i 0 eo Total Proposed New Construction ,(sf) Total Height (ft) T/ , _.._...... 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 ZoneD Municipal ❑ On site disposal system i Version 1.7 C ommercial Building Permit May , 2000 Departtneht use City of Northam Status ' afP e rml15t s 17,7 Building Department Curb. CutlDnr txrttt E t iii , , r� 212 Main Street Room 100 V Sewer l Se ptt & A v a i labil it y Water Av it C t P 1 2Q orthampton, MA 01060 Two S s �fi oe 4 3- 587 -1240 Fax 413 - 587 -1272 Plot/Srte Pl DE „ Ot11er S APPL TO O STRU T, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLI ANY BUILDING OTHER THAN A ONE OR TWO F DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office G G V\cA �-t Map Lot Unit ' Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: A � ' I cam.` Name (Print) Current Mailing Address Signature / 1� , (1--?..) Telephone 2.2 Auth.,� ed A.ent: Name (Print) Current Mailing Address Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ----- „ 5 ------- :+-" - .._.____j (a) Building Permit Fee �.,._. _ _.,._..__ ------ ._ 2. Electrical (b) Estimated Total Cost of i Construction from (6) .. ___. _ _ . ___._. .. .._ 3. Plumbing .r__. 'x __ = Building Permit Fee 4. Mechanical (HVAC) _._ _..... 5. Fire Protection �� 6. Total = (1 + 2 + 3 + 4 + 5) Check Number /4 ,K/7 dor5i This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date y OK To 6416.411"6"totift\) File # BP- 2013 -0258 GET D D(sPosa't APPLICANT /CONTACT PERSON PETER DOPPMAN ADDRESS/PHONE 377 RYAN RD FLORENCE (413) 244 -4901 PROPERTY LOCATION 66 MARKET ST (2614-4-6 6 51/7(12, MAP 32A PARCEL 111 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 0 5 Fee Paid ll S�J Typeof Construction: REPLACE SHINGLES New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101657 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF� RMATION PRESENTED: V 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 //7JI 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. 66 MARKET ST BP- 2013 -0258 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 111 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 -0258 Project # JS- 2013- 000421 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PETER DOPPMAN 101657 Lot Size(sq. ft.): 4965.84 Owner: Northampton Housing Authority Zoning: URC(100)/ Applicant: PETER DOPPMAN AT: 66 MARKET ST Applicant Address: Phone: Insurance: 377 RYAN RD (413) 244 -4901 FLORENCEMA01062 ISSUED ON:9/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE SHINGLES 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 9/7/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner