32A-182 •
.4 1., The Commonwealth of Massachusetts *
Department of Industrial Accidents
„, a �, -' Office of Investigations
�
600 Washington Street
z Boston, MA 02111
`"` www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): L1' . , e' , '7/"
Address: /// /,r/f7 7 , S/ sf ',,,-- / A/ /2)
City /State /Zip: 46'x'69 5 4/1- D /pc? Phone #: //� - S --E/. y757]
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. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. Ej Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q ] oficers have exercised their 11. Plumbing repairs . ❑ I am a homeowner doing all work officers ❑ or additions Plumbing 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 13. ® Other (
employees. [No workers' L z
comp. insurance required.] pi d AS
*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
i f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
S ignature: ; -12t1 (� 3,..A, c� Date: 57q/
Phone #: 1.7) 5 _ � / `j 5l z/- Q ,7
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 Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , • / 46 . f _. /4/ 0,4/..._ . .. .. __ - ... _. - _ r as Owner of the subject property
hereby authorize 2 �' ._. _ ) ' rT
act on my behalf, in all matters relative to work authorized by this building permit application _
Signa of 4 Owner Date
I, .... _M__ ..... ......... _,_ _ _._ ___. .. , 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 of perEury. . _
Print Name
Signature of Owner /Agent Date
S CTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : __ n -- y.. _J.. _... Ye-...47064/ ._
License Number
/// GtkQ._ /. . _6:..___R.& 4,,a1C ...,/ . f)_.. 4,e6:05,.. . ?'1_. /o. .. __....„_.., .. ,,_‘. 4 . ...... _ „ .
Address Expiration Date
i — 11.,4, . /.`2 5 - -
e ... ?„rte 57/ 2 / /Z-
Signature / / / Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE 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 0
r
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):
...,....,_.. a .._..a. .e Registration Number
Address
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 ❑
ompany Name:
Responsible In Charge of Construction
Address
at- 9 3 75-z)
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 L. µ~ R _. µ _ L =..r.__.. _.. R:' _ ..?
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 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 0
IF YES: enter Book ' Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 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 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 ENCL SED SPACE
Interior Alterations Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Acces i hiding Ly
Exterior Alteration Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use 0 Othe
• Brief Descripti Enter a brief description here. a 0 P/4 4 4 P/ n/f/0 G? ,C -.47: ,~ FPS d
Of Proposed W : 4-jvil v Gp9,L°6.G; df *n'Ljh. f E
/,7'fif 9 /!44 Gd/✓F6G'OMyl7o%.�rt'j 4.0 o/--
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE °
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly El A -1 ❑ A -2 ❑ A -3 ❑ � IA I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business A, 2A r ❑
E Educational ❑ 2B - C ❑
F Factory ❑ F -1 ❑ F -2 ❑ i 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 I ❑
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): __ _ .!I
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
f
1 st
1 st
2nd 2nd
___. _._ ,.,.,_ .. __,,,_- 3 rd
3
4 in
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 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system
Versionl.7 Commercial Buildin& Permit May 15, 2000
�o �g g g , Departmen use on ly
� , City of Northampton 'Stet l of P,errn�ts , tO Ag .
iuilding Department CttrbCut/D u a tPer o �! 1 `'
tiii
X1 2 Main Street Sewer(Septtcratlaerltt z
R �� Room 100 ;1 R *attabili rV i
Northampton, MA 01060 'T wo e s ofiStructural Plans _-� -
z one 413- 587 -1240 Fax 413 - 587 -1272 ' Pl a ttSxte F s ' a
cf Other Specify 4 : w
,.r
AP ICA 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 Property Address: This section to be completed by office
_
Map Lot Unit
69 6 Rio j� sr 24-:_:4--- p
4 /-i-/b A4 6` O6 D Zone Overlay District
_� ._ _..._. _ _____..„ve. _ . ....._� .. _ Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
7 ./ �.. � / �_..__ a _._ _ .._��._i _ a) . �� �, —, di-
Name (Print) Current Mailing Address
Si natur d / Telephone
2.2 Authorized Agent:
2I /2, 7.. y4.2 -. _�_. W ,' �ng j ` . � 0 sf m �/
Na (Print) Current Mailing Address
Signature i �, 4 Te lephone
SECTION 3 - ESTIMAT D C • N / RUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
.Building D v (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6) . ____ ,.,, ,. _ , . _
3. Plumbing ..._._... - Building Permit Fee
4. Mechanical (HVAC) w....,__ ._, ,....._...__...
5. Fire Protection "' ��
6. Total = (1 +2 +3 +4 + 5) A 2 y 6 p Check Number j 3 v t
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
69 BRIDGE ST BP- 2011 -0921
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 182 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2011 -0921
Project # JS- 2011- 001503
Est. Cost: $2900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LARRY YENTCH 048666
Lot Size(sq. ft.): 20386.08 Owner: ALL SMILES LLC
Zoning: URC(100)/ Applicant: LARRY YENTCH
AT: 69 BRIDGE ST
Applicant Address: Phone: Insurance:
P 0 BOX 120 (413) 584 -4750
LEEDSMA01053 ISSUED ON:5/9/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT DOORS
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 5/9/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner