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�• 0 I 5 10 20 ALTERATIONS TO REAR UNIT
d 376 PLEASANT STREET, NORTHAMPTON, MA
09 -05 -12
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,mot.; The Commonwealth of Massachusetts
Department of Industrial Accidents
y i - , 4= Office of Investigations
r _ 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): S C. V-N —t / ('
,
Address: 6, tm-A p
City /State /Zip: 5 e242 L Phone #: q t 3 - (o so > - q GI i (
Are an employer? Check the appropriate box: Type of project (required):
1. I am a e to er ith 4. ❑ I am a general contractor and I ,
MF Y 6. ❑ New construction
employees (full and/or part- time).* have hired the sub contractors
2 . ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 111 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
capacity. employees and have workers'
working for me in any p ty. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] . 5. ❑ We are a corporation and its 10. El Electrical repairs or additions
officers have their Plumbing repairs or additions
3. ❑ I am a homeowner doing all work ave exercised 11. ❑
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. El Other
employees. [No workers'
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. ` A t I 9
Insurance Company Name:
A , i . -4 .. W 1 4 &1&14 (\1 11.
Policy # or Self -ins. Lic. #: Expiration Date: . 2./ (-4' J13
Job Site Address: .37 ( PL1`r s t-ta S - City /State /Zip: 0T 7 - 4 ,4
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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Signature: L' Date: / i —1 ----
Phone #: 4( 3 (o (p c - c ( c / )
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
. _ _ .w _ . _.. T . . , __ _, __ , as Owner of the subject property
hereby authorize'_. ........_ . ,__ .... __,. v._ -r... W..
act on my behalf, in all matters relative to work authorized by this building permit application. _ _ _µ_
Signature of Owner Date
- 3C3 . vM4.._m._µ�'_ S 5 _. _. _____ . _..__....._._ _____ , 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,penalhes of Perfu„ry.
Print Name r .__......__ .. ___ _______ w. _ _..
Signature of 0 ir er /Agent Da
SECTION 12 - CONSTRUCTI® SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . 2 t �... ..._ 1 .... .. . ... . ........ ....
.�_ License Number
Address Expiratio Date -1---------) Signatur Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida9.-Fritrsi be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bu ng permit.
Signed Affidavit Attached Yes No 0
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 ❑
L. _.. f I c6 µb- Gig .
Name (Registrant): _,.
r_ G/1 A_ F N kilt, Registration Number
Address _
6 li & eft/Lk/1,1)5 A ,� t � / � � ^ �� 3 Y Expiration Date
Signature Ape 1- lG+" 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
4 L` l_ - -... -• -. —' Not Applicable ❑
Company Name:
4 0 146 54 ( A f Responsible In Charge of Construction C� \
Construction
Address
Signature Telephone
Versionl.7 Commercial Buil ing Permit May 15, 2000
8. NORTHAMPTON ZONING
N
Existing F Proposed Required by Zoning ,
This column to ee filled in by
Building Department
Lot Size
Frontage _ .._.:...._ ..___.,..
Setbacks Front
Side L. ...__ R.__....__ L.L_. _._. R ._.x.._ - ______ _ .
Rear , _ ____
Building Height
Bldg. Square Footage % �.....w,
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 a YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 4) DON'T KNOW 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 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 n NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4.
• 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 IA Existing Wall Signs ❑ Demolition 0 Repairs ❑ Additions ❑ Accessory Building`] S
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other 0 a
Brief Description Enter a brief description here.. €)C S Qs.--P 6 F' fl--)CA. 5ft 4L Q('u21-4,T, T-tt w.
Of Proposed Work PA(, l t (c,. Q S I RL1 sJ)c-w t-} \/ �C� I _IN t-�D�
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A ❑
A -4 ❑ A -5 0 18 ❑
B Business ❑ 2A 0
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I -1 ❑ 1 -2 ❑ I -3 ❑ 3B ❑
M Mercantile ❑ , 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 0 5A ❑
S Storage ❑ S -i ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
..-.�
�N-
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING. RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:,. M M _.._,
,
Existing Hazard Index 780 CMR 34): ____ w ....__._ __,.._..:_...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)
1st .. _. ... 1 st
2nd ...... _..,._. _.,___._,_.._ __._..... 2 n d
3rd 3 rd ' ,„
4 h __. ____ _m....___. _—_ _,.. -..._ ___ .__...._. 4 -
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 0 On site disposal system
"r
Version1.7 Commercial Building Permit May 15, 2000
Departmetuse only
ECEIVED C of Northampton status of ire it t � �r
B ilding Department Curb Ccat t?ertTtit. �
SEP ZOIZ 212 Main Street SewerxSe�t�valtbtty�
Room 100 ', Oater711tte1. Avattabilif * A tt a o .
No hampton, MA 01060 Ewa e s Qi Sfrtct atPlan
OFBUILDING IN
NORTHAMPTON 413- 87 -1240 Fax 413 - 587 -1272 PlattS,te Ptans
Other S "pecify '
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:
3�1 ( Q ‘(-,5 Map Lot Unit
1 A(51- 6 's k r t. 1 r Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
• L * Q 6 S to t lr._ - ? _ _ .__ c e_ps TS (Ark. ... it4 cn. .. _.`
Name (Print) Current Mailing Address:
Signature site, per. ll(((lJS i mp LA (. 1L .. Telephone
2.2 Authorized Agent:
Jo b _�.._ t __. e 5 v q S v Ot z
Name (Print) Current Mailing Address
r 4«— ` _ _-
Signature Telephone
SECTION 3 - ES, !MATED CONSTRUCTION OSTS
Item Estimat: d Cost (Dollars) to be Official Use Only
complet-d by permit applicant
1. Building - P C �-� ` (a) Building Permit Fee
J I vv
2. Electrical (b) Estimated Total Cost of
S (/ \ v Construction from (6)
3. Plumbing Z U v 11 i Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection Q _ ...._
6. Total = (1 + 2 +3+4+5)
`3 h yo Check Number JO 'Y /
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0444
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 0
PROPERTY LOCATION 376 PLEASANT ST
MAP 32C PARCEL 182 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid / / d g(P SA
Typeof Construction: REMOVE COLLAPSING ROOF STRUCTURE,NEW TRUSSES,MASONRY
REPAIRS,NEW ROOF & SLAB, AMENDED 5/1/12- REBUILD OWNER'S STUDIO,RENO BATH & ADD
1 /2BATH TOSTUDIO " ,, :l i OR PARTITIONS, DRYWALL,HVAC,LAUNDRY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 040714
3 sets of Plans / Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O 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
00 W ; molitio r. a
IMP 7 — " fir-7 - 1— \
- : a e of B I ildi fOfficia " Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
376 PLEASANT ST BP- 2012 -0444
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 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: renovation BUILDING PERMIT
Permit # BP- 2012 -0444
Project # JS- 2012- 000715
Est. Cost: $59000.00
Fee: $534.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 7361.64 Owner: SZLOSEK STEFFIE AND OTHERS C/O 6 CRAFTS AVENUE LLC
Zoning: GB(100)/ Applicant: SACKREY CONSTRUCTION
AT: 376 PLEASANT ST
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 () Workers
Compensation
SU NDERLANDMA01375 ISSUED ON:11/7/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE COLLAPSING ROOF
STRUCTURE,NEW TRUSSES,MASONRY REPAIRS,NEW ROOF & SLAB, AMENDED
5/1/12- REBUILD OWNER'S STUDIO,RENO BATH & ADD 1 /2BATH TOSTUDIO, AMEND
9/19/12- INTERIOR PARTITIONS,DRYWALL,HVAC,LAUNDRY
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: 155
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner