32C-140 0/h
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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): t 7 C. O N 5 7 !4l/ G 1'1`d�t - (� `C _
Address: 3s, &- / -t l/ S r -
City/State/Zip:/54o �LUi ex P`n'y � �(�� hone #: 1 _ �S d � ?
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4 . LC_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. 0 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5g 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.E Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.g] Other Re'E
comp. insurance required.] C to Sky L f 4 7 -
*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
fi „r to S1, Sf1O 00 and /or nnr -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Signature: '/ co y �T�c.c -(� `"'pate:
Phone #: 1 11 3 — ,j U— FO fc v 5 D -,F l 7 y
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitlLicense -#
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 #:
,`
.
^ �
Y*rsion17Comme,da Building Permit May 15, 2000
.
SECTION 1
Independent Structural Engineering Structural Peer Review Require �� �� d Yes x_/ No v~/
SECTION 11 OWNER AU ON - TO BE COMPLETED
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
|. . as Owner of the subjec property
---- --------------------- ----- -------------'-'-
hereby authorize
`-__-�_
act on my behalf, in all matter relative to work authorized by this building permit appl
_ _ _ , . , � , _ . ����
Signature of Owner Date
|. /9 . usf*a,em^uthonzed
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
7 i CC7 , ,_ . „„,,,_ , , _ ,„, ., _ „ , _
SECTION 12 - CONSTRUCTION SER ICES
10.1 Licensed Construction S i Not Applicable []
_ - —
Name of Ucense Holder _7 _-T_«-4 �.5-_�-��--�_c_-___-___-_-
License Number
_
~_
Address
_ Expiration Date
.2
ainhamm �� Telephone
SECTION 13
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.
N� ��
Signed Affidavit A�oohed Yes \�� No v~�
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 iW
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
€ i
Address Registration Number
i
Signature Telephone Expiration Date
Name __.._
_ Area of Res_
ponsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
. ... G C Not Applicable ❑
/-iE. ,.. C.P. ✓ �,r� .0 T�a
..� .. .... .. __ - ___._.. .,.,.µ
Company Name:
Responsible In Charge of Construction
Address_ --- - — -- --- - - --- -- - -
°1S
Sig Lure { 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 0 DONT KNOW 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 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 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 Q NO ®®
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 ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs i$1, Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brie f description here Re po l4 c`' 5 kY4 % 4 r
Of Proposed Work: RPi 111 / 6 w /2( , R 1 ,4,...,f r-" f- J C."---' 4 (
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 N 2A ❑
E Educational ❑ 2B - I 14
F Factory ❑ F-1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential R -1 ❑ R -2 ,J R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility Specify ,1.. S r S l
M Mixed Use , 2 Specify:. n.�S i { , A -1 -- 4, � "3'a h ooh
-
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) _ ....._ ... _w__ 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
.,„...,„„,...,,,..,... . . ....rv.... -.� .�
2 nd
2
3 rd
3
4 m
Total Areas 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 ZoneD Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status o €Permit
� ;I �' Buiir�i Department Curb Cut/Driveway Permit ,,
ILA - 212 Main Street Sewer /Se ticAvai
- __ P i#y
Room 100 water/Wen Avar
�� _ $ N k mpton MA 0411036_5°87_1272 T wo ofStructura1 Plans
pone 413 - 587 -1 Fax Plot/Site Sets Plans
Other Specify.
APPLICATION ?(CONSTRUCT, REPA1F RE1 OVATE, 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
" / // S - Map Lot Unit
/6/ dc- •1,77' r ,.444 O /6.4°
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
O .
AS s K �. ^- ._...._ _ . _ . __ . ._._ .. _ U ... �� ... fie ,_ .5 .. S G �.I .. F� ,
Name (Print) Current Mailing Addre
Signature i..ar t/ J. Telephone
2.2 AuthoriYed Agent //
Name (Print) Current Mailing Address:
Signature 0- :__ ... . . r A1! Telephone -- iii?- 6-5?*-- ?9
SECTION 3- STIMATED CONSTRUCTION C
Item Est 4 Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building D ® (a) Building Permit Fee
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
1��y
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Date
Building Commissioner /Inspector of Buildings
•
File # BP- 2010 -0032
APPLICANT /CONTACT PERSON THOMAS KORYTOSKI
ADDRESS/PHONE 359 BARDWELL ST BELCHERTOWN (413) 323 -4393 0
PROPERTY LOCATION 351 PLEASANT ST - UNIT #7
MAP 32C PARCEL 140 000 ZONE GB/URC /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ,/ s�,�
Fee Paid /3 G 6 ° 55
Typeof Construction: REPLACE SKYLIGHT & REPAIR WATER DAMAGED WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 070047
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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 ay
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.
35 t PLEASANT ST - t7NIT f BP-2010-0032
GIS #: COMMONWEALTH OF MASSACHUSETTS
; v1apsBlock: 32C - 140 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0032
Project # JS- 2010- 000043
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS KORYTOSKI 070047
Lot Size(sq. ft.): Owner: ERSKINE LOIS J
Zoning: GB/URC /WP Applicant: THOMAS KORYTOSKI
AT: 351 PLEASANT ST - UNIT #7
Applicant Address: Phone: Insurance:
359 BARDWELL ST (413) 323 -4393 0
BELCHERTOWNMA01007 ISSUED ON: 7/9/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE SKYLIGHT & REPAIR WATER
DAMAGED WALL
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 7/9/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo