32C-102 (2) t
The Commonwealth of Massachusetts
Department of Industrial Accidents
---- 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): D Os It-
Address: 1 6 514 Ep F iC Lp L. &I
Di
City /State /Zip: r '- trt' e t\l c € tV\ 4 Phone #: Sy 6 `i 3 147
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 g. ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ 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:
V 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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un' -r ths.pains a d penalties of perjury th?Zi riche information provided above is true and correct.
Si • ature: 41/jargow — Date: • 'Lc' ' //
Phone #: S S 6 4 3 4 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 #:
t
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 a/
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Q A'J 1 0 . N) 1..) Pi-FY
I
hereby authorize . _ 1:),40, ` i 6 ..._. _ .... lc `to
act on my be , in all matters relative to work authorized by this building permit application.
9 zk "
Signature of Owner Date
I, .774-v dD C 4'4
' , 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 pes • ury _p ,
Print Name
.P #t tl i b L1_ 14 0( /► 1. L S 4/ _.._
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ._.. _.. _. __ Pt V i D C L-4 {L K 6 3 S
License Number
1 514 tr F il-0 L , _., __ Z`_.
Address -- Expiration Date
.�,‘ W 3y
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 Cri No CD
•
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
___.___._.__._..._ ..... Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
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. ._ ,._.r L. R:
Rear __M.
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 ® YES
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 V and /or Document #;
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES
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 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 (3 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 (3 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing"® Change of Use ❑ Other ❑ 3
Brief Description Enter a brief description here. R e b F f' R E p A I ii S T0 .___,.,_. f c. et — __... .
Of Proposed Work: Rtr t, F S A- P R a e k 7 G e S dt F,
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B r ❑
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 ❑ 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)
1 sr
151 ,
2nd _ _ _._ ._____ ,. ____, 2 nd
3rd _.._... 3�d
41" 4
Total Area (sf) Total Proposed New Construction jsf)
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
•
— Version1.7 Commercial Building Permit May 15, 2000
\ \1E°
gE- GE City of Northampton
:uilding Department
212 Main Street epbH
Room 100
nmsIs pEcilotis
No. hampton, MA 01060
of stx - 1- ' °641 a 13-587-1240 Fax 413-587-1272
_,. tiocatim or •
qer
'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
This section to be completed by office
1.1 Property Address:
( jL 7 1 C K1 Z. S
Map
Lot Unit
Zone Overlay District
o A (1./1/4).
Elm St District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Apent:
Name (Print) CurrentMailing Address: _
'Re A e e ;
Signature dr■o■ 111111 Telephone S C" 6 di j q 7
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
( 1 Building Permit Fee
1. Building R *C"'P • i 4 - 0, 4 . - ""Q '
kaz tle)
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) Check Number L foo
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
44 CONZ ST BP- 2011 -0881
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 102 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0881
Project # JS- 2011- 001439
Est. Cost: $6000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CLARK 000635
Lot Size(sQ ft.): 10802.88 Owner: MURPHY DAVID A
Zoning: NB(100)/ Applicant: DAVID CLARK
AT: 44 CONZ ST
Applicant Address: Phone: Insurance:
16 SHEFFIELD LN (413) 586 -4347
FLORENCEMA01062 ISSUED ON:5/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:ROOF REPAIRS TO APPROX 70 SQ
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 5/2/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner