32C-012 ` The Commonwealth ofMassachusetts
;— Department of Industrial Accidents .
fra- -= Office of Investigations
--r . , a 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 /Organization/Individual): _
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: 1 Type of project (required): I
1. ❑ I am a employer with 4. ❑ I am a general contractor and I f
6. ❑ New construction
employees (full and/or part- time).* have hired the sub contractors
listed on the attached sheet. 7. ❑ Remodeling
2. [13 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 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11. Plumbing repairs or additions
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.
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.
Signature: Date:
Phone #:
1 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
hereby authorize __..._ . _.
act on my behalf, in all matters relative to work authorized by this building permit application. ___ ...._..
Signature of Owner Date
, 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 perfury _.e�.... .__....„ . w,y._.
Print
X ign r of / er /Agent /Date
SECTION 12 CONSTRUCTION. RVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . '.__ v __ __._.. ,
License Number
Address Expiration Date
. _.. _.e
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.
Signed Affidavit Attached Yes 0 No
A
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 E■FLOSED 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
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
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON, ZONING
Existing Proposed Required by honing
This column to e 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) �_.._.�� . .,,b�... »m ,M �.�,��•.a .,.n,..,....
r rn
# 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 0 , 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 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 E l NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
, 0
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE =` ) ii4.
F
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ s
Exterior Alteration ❑ Existing Ground Sign El New Signs ❑ Roofing ❑ Change of Use ❑ Other 0
Brief Description Enter a brief description here. ,
Of Proposed Work: / ,-1 p
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 ❑ F -2 0 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): __, __ __ _ ...............:__ __.
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
.
___ __
1
st
.... 1 st 3
2nd .___ 2 nd :
,
3`
41h _____. _ 4 __.. ___._______ __. ___,
___.
Total Area (sf) Total Proposed New Construction (s__,„
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
i Version1.7 Commercial Building Permit May 15, 2000
P f Departrnehtuse only
ity of Northampton Statt�`��t��ert�Ft 4
1 : uilding Department c - i � Peitt �� I °�,5 �� , ' � �
0 k 212 Main Street Sewerls ttc1Avatr btlrty s . M; 1 _' ' "
t ��NG 1NS l Room 100 ater�elt ltab�llity, ,' " n `ra� r, :
�. orthampton, MA 01060 Two et of Sfrt cturalPrarts s� � ��0 ,H
• ,�
phone 413- 587 -1240 Fax 413 -587 -1272 Plo Plans
ther
O 0peeify
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
V roperty Address
This section to be completed by office
(J ( /� �,L ... 4-r ,
Q Map Lot Unit
\VA(ttil. k ,, i— i , "' P ,I) ' Zone Overlay District
Eim St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print ___ . _ Curr nt Mailing Address
/ , 7
/
Signature / ,61111111 Telephone
2.2 Authorized Aqent: _____________ _____ _ .__ ____
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 . (a) Building Permit Fee
--------- .__w_
2. Electrical _ (b) Estimated Total Cost of
Construction from (6) _ _.__ _ . __ _. _ _ ._.
3. Plumbing - r'i . G ` � p Building Permit Fee
,/ 7-- GI r, Gl(t
4. Mechanical (HVAC) _ __ _..._..._.__._.....__.m _,
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number it _Cgr
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0298
APPLICANT /CONTACT PERSON KELLY MELISSA C
ADDRESS/PHONE 4 CROSBY ST NORTHAMPTON (413) 265 -1480 Q
PROPERTY LOCATION 110C MAIN ST
MAP 32C PARCEL 012 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building / t' 1
Building Permit Filled out
Fee Paid
Typeof Construction: USE AS SALON
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
T ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO RMATION PRESENTED:
A pproved 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
/4-'./L-----Q 9 / 1 1 112--
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.
110C MAIN ST , . BP -2013 -0298
GIS #: COMMONWEALTH OF MASSACHUSETTS
- — 32C 012 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate gQJy: Non st o oural. interior renovations BUILDING PERMIT.
Permit # BP -2013 -0298
Project # JS- 2013- 000393
Est. Cost: $1065.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 1481.04 Owner: GARE EDWARD JOHN III REVOCABLE TRUST
Zoning: CB(100)/ Applicant: KELLY MELISSA C
AT: 110C MAIN ST
Applicant Address: Phone: Insurance:
4 CROSBY ST (413) 265-1480 ()
NORTHAMPTONMA01060 ISSUED ON:9/14/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: USE AS SALON
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: IHoii6a # .Foundation:
Driveway Final:
Final: J 4- ) 2, .. k', r Final:
' Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: 0 1: Insulation:
Final: Smoke: Final: q-17-19-0:-.
THIS PERMIT MAY BE RE • I 'd .' " T , 13 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AN ► G• e
Am:. c. a w4: •
Certificate of Occupa cy natu
FeeType: Date Paid: Amount:
Building 9/14/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner