32C-166 (7) T
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• rat, + , ma y DEPARTMENT OP BUILDING INSPECTIONS
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212 Main Street • Municipal Building
Northampton, Mass. 01060 ',�
WORKER'S COMPENSATION INSURANCE AkFIDAVTT
L Pioneer Contractors
(licensee/permittec)
with a principal place of business/residence at:
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__ Box 1145 Northampton, MA 01061 _ (phonet0 586 5491
(street/city/slate/rip)
do hereby certify, under the pains and penalties of perjury, that:
(tic I am an employer providing the following worker's colripensation coverage for my
employees workiing on This job:
Wcc 500595701200
AssnciatPrI Employers Insiir.ance Co — -- _ 6/30/10_
( Insurana. Corapa.ny) (Policy Number) (Expiration Date)
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Numbes) (Expiration Date)
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(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach , 4ditionil sheet ifneccaary to include infoxmatiota pertaining to all ouatr'a ton)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
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NOTE: please be aware that while he c mi era who ezaploy persons to do mainseasace, construction err repair work on a dwelling of
not more than throo units in which the homoowocr resides oc oo the grounds appurteuattt thereto at not generally comidcrcd to be
employers under the worker's duos Act (GL152,sn 1(5)), application by a homeowner for a license or permit may evn{e*vY tho
leg
status of an employee under the Worker's. Compcosat ion Act
1 understand that a copy of this ctaicmmi may bo forwarded to the Dcparoneed of Industrial Aacideeroe Offioo of 10 uraoco for the
coverage verification and that fa date to secure mverago under sae ion 25A 011 152 can lead to the imposition of criminal penalties
000sisting of a foe of up to S 1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Ord& and a
fine of 5100.00 a day againrt me.
fro For dcputrnzdal uac only
Permit Number /e. �� ditit m a o Lot #
Silas tune of L1csee/Permi • • e
T.
File # BP- 2010 -0668
APPLICANT /CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586 -5491
PROPERTY LOCATION 196 PLEASANT ST
MAP 32C PARCEL 166 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin l Permit Filled out i
Fee Paid
Typeof Construction:, RENOVATE INTERIOR & EXTERIOR FACADE ann44 (ofb(2
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017890
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�F tMATION 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
ignature of Buil ing 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.
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&196 PLEASANT ST , BP - 2010 - 0668
GIS #: COMMONWEALTH OF MASSACHUSETTS
map:toodclw - 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- 2010 -0668
Project # JS- 2010- 000915
Est. Cost: $450000.00
Fee: $2700.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 5401.44 Owner: MANHAN NARROW LLC
Zoning: CB(100)/ Applicant: PIONEER CONTRACTORS
AT: 196 PLEASANT ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586 -5491 Workers
Compensation
NORTHAMPTONMA01061 ISSUED ON:2/4/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE INTERIOR & EXTERIOR FACADE
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 2/4/2010 0:00:00 $2700.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo