32C-067 (8) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
't- =5: =7;1 600 Washin Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organizatiorv'Individual): �� S� C
Address:
City /State /Zip: SA. �'^Y� cv 1 "'∎ Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ram 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
listed on the attached sheet. 7. ❑ Remodeling
2. El I am a sole proprietor or partner-
ship and have no employees These sub contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
No workers' comp. insurance comp. insurance.t
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.
? Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
T-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. I�,f� l,,
Insurance Company Name: Q1"-Vc "`!) \A S'u rccA r°`P C c-
Policy # or Self -ins. Lic. #: C 0 ° C) a ° d Expiration Date:
Job Site Address: )- C 11 << `E' `�" City/State/Zip: VOA— t, `^ nr,
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
Investigationsof the DIA for insurance coverage verification.
I do hereb certify un r t lair; s s nd p.1") . ties of perjury that the information provided above is true and correct.
Sienature: —
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 #:
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, as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I ��ce ....,, h4(\ P U , 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 perjury,
- 3 -- O ..Q ik AIn_e C
Print N\ e
Signaturjrf Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ._ . _
License Number
r�
CB Vvr< ....__ c-c , .... VA CA 01 0 O el 7 �a a (
A,.ress + ;, Expiration Date
iipa-
Si j n. ture Telephone
SECTION 13 - WORKERS' OMPENSATION 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 €he - issuance of the building - permit. - - - - - - -- —.__-
Signed Affidavit Attached Yes No 0
. .
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND FOR BUILDINGS
CONSTRUCTON CONTROL PURSUANT TO 78oCMR11V(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Ar xdmct:
�� -----------� N��Applicable
[]
,`' [/"`�! i _-
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Profe sional Engineer(s):
� ----------
[
A~ R
Name
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address
Signature Telephone Expiration Date
Name A�ooxneoponoiomh
---------��---
Address Registration Number
Signature Telephone Expiration Date
- - - - -----�------- ---------------------
_________'
Name ���R�m�vi�uy
'------------ '
Address Registration Number
Signature Telephone Expiration Date
g.3 General Contractor
� --_-----_-_--__- Not Applicable []
Company Name:
mc��e mco��u�n
- --'--'-------------
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. •- . ,. R. ,_, ....._ L.,_....... 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 (3 DONT KNOW YES 0
tar
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DONT KNOW (3 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 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 (3 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 com OI1 plan
that will disturb over 1 acre? YES 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
J .
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 0 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other g"
Brief Description Enter a brief description here.
Of Proposed Work: I l 1
Pp Letr p ...._._,. � 0!- ..w 4 ►''c d ._.. 1 `0 o<t t t ik A S l ' ..
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE t
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 0 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: — �_�....
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 15i
2nd . .. .._ ... . _.....,._y 2 _,,....... _
3rd 3r
4 th
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 ❑ Zone , _ __ __, Outside Flood Zone❑ Municipal ❑ On site disposal system❑
. ,
. .
Version1.7 Commercial Building Permit May 15, 2000
Department use only,
City of Northampton Status of Fern -= ° ' , k , -' ,-' '' ,0 ,, ' <
Building Department cA6'cuttEiv!I;liayPer1:nit
212 Main Street Sewer/Sepbc Aver a t
Room 100 WaterMieliRvailability
Northampton, MA 01060 Tvvo Sets of Structura
(iDane 413-587-1240 Fax 413-587-1272 PInt/Sit, Plans
Other ,
ther 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
) C \ Clp(f e‘U'Q Map Lot Unit
i
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor11 , 5,,, ve
5....Drc,4),,
Mo. vyl-Q 42 .- L. tQs.\- v(c" oco
--- -ilevk s '— 1-- /'
Name (Print) Current Mailing Address:
• - ' '
Signature Telephone
2.2 Authorized Aoeht: iri■--
,
Name (Print) Current Mailing Address:
i0P 7 c 6j-j->n6
:-. PC,ri , t ■ L? N (4) Iikck °( °C) ( —
Signature Telephone
SECTION 3 - ESTIMATED t , STRUCTION COST
Item , Estimated Cost (Dollars) to be Official Use Only___
completed by permit applicant
1. Building (a) Building Permit Fee _
2. Electrical --' - I - ' (b) Estima Total Cost of
Construction from (6)
3. Plumbing 1,:j (in) Building Permit Fee
4. Mechanical (HVAC) __, __
. , ....
5. Fire Protection t■..) .., ., ,...
6. Total=(1+2+3+4+5) ck 6 0 C 1 65
Check Number
This Section ForOfficial Use-Only
Building Permit Number Date
Issued
_ -
Signature
-
Building Commissioner/Inspector of Buildings Date
•
File # BP- 2010 -0302
APPLICANT /CONTACT PERSON JOSEPH KENNEDY
ADDRESS/PHONE 38 HARKNESS AVE EAST LONGMEADOW (413) 525 -1735 0
PROPERTY LOCATION 2 CONZ ST
MAP 32C PARCEL 067 001 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 A l!v �-
Fee Paid
Typeof Construction: REPLACE 12' OF ROTTED SILL PLATE, PLY & SIDING - 2C MAPLE AVE
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License 055440
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
2- 2 -- 2 ao
Signature of Building Officia 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.
•
BP- 2010 -0302
GIS #: COMMONWEALTH OF MASSACHUSETTS
, in k :3 C 661.. -- `= CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2010 -0302
Project # JS- 2010- 000324
Est. Cost:
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH KENNEDY 055440
Lot Size(sq. ft.): 30666.24 Owner: MAPLEWOOD SHOPS INC
Zoning: CB(100)/ Applicant: JOSEPH KENNEDY
AT: 2 CONZ ST
Applicant Address: Phone: Insurance:
38 HARKNESS AVE (413) 525 -1735 () Workers
Compensation
EAST LONGMEADOWMA01028 ISSUED ON:9/22/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 12' OF ROTTED SILL PLATE, PLY &
SIDING - 2C MAPLE AVE
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 9/22/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo