31B-258 (2) The Commonwealth of Massachusetts ,
,: Department of Industrial Accidents I ,
,'r- - Office of Inv ' ., ' . ' 600 Washington Street ..
f
Boston, MA 02111
-u -'` www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print 7I
Name ( Business /Organization/Individual): 1 v" • 7x-7
Address: 6 1 5 r k t, 5A d� Al / i)
City /State /Zip: N i '} r l A 0 0 Phone #: �\ S ' - '1- - fi�
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. 0 I am a general contractor and I
have hired the sub - contractors ❑ 6. 0 New construction
iployees (full and/or part-time). - 7. • Remodeling
2 I am a sole proprietor or partner- listed on the attached sheet.
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.]
5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a. homeowner doing all work
officers have exercised their 11.n 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 13.0 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.
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 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 nder the pains and pens to of perjury that the information provided above is true and correct.
Sii;nature:(47 Date: 3__ 7 /
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)
w
Independent Structural Engineering Structural Peer Review Required • Yes 0 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR`CONTRACTO APPLIES FOR BUILDING PERMIT
1, __. . ,. ...._ _ . _._. „. ._. .._ _ . _ ..�.d __._. _, as Owner of the subject property
hereby authorize �.............__.... _....,.ew _ . ....... ._... to
act on my behalf, in . i'm- r lativ o work authorized by this building permit application. _ m /
Date y ^
ignature of • ner ____
., T. ,r�"� °� _...___. , as Owner /Authorized
II
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 andpenalties of per w �
Print Name
lbw ,"".. .1111„IfeAdirlaillfr - -- - .„- --„ --- - — -- - -„- „ - - -
Signature of 0 r-r /Agent Date
SECTION 12 - CONSTRUCTION. SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder .e. ._, d_
___ C., License Numb r
Address / _ Expiration Date
3 , ,.. 9,.„6/ Signature Telephone / .r2/4` :/
(1/
SECTIO - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 0 No
•
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGNAND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR.116 (CONTAINING MORE THAN, 35,000 C.F. OF EIJLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
_.......,_. „ ... m._ "..
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
•
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning ,
This column tote filled in by
Building Department
Lot Size
Frontage . ...., ,._.,..,... _. "_ "_,.
Setbacks Front
Side L :'._.._, -_-,._ R. „_w _... 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 KNO YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
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
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained
(3 , 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 (3 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Version1.7 Commercial Building Permit May 15, 2000 if. -
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition • - epairs ❑ Additions ❑ Accessory Building ,
m + e
Exterior Alteration ❑ Existing Ground Sign ❑µ New Signs ir. Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter brief description here. ,. �'`� '' / '
Of Proposed Work: 7 / - ' y
SECTION 5 - USE GROUP AND CONSTRUCTION TYP
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 ❑
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 I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify: -... _____ _. bw. -.... �..�...�,...��.,.__m.w ._�____ ...,..,__ �-
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): ___ __________ _____ __a.
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st ,
1 st ---------------
...._ ........................_...... ............_.,................ ,.., 2 nd
2 .1d
3ro _ -e_ �_. _ _�a_. w. 3 � _... _.._._ ______ ______ _ ..
--
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
Versionl.7 Commercial Building Permit May 15, 2000
Depattni0.4:liseionl.z.I
_. _ :I
City of Northampton
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212 Main Street
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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:
r, , ,..., 6 4..., A , ,c--1 , Map Lot Unit
• N - N ) ' 0 i Zone Overlay District
, .
.. , ____ . . --- -- --- ---- - ---------- Elm St, District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT . : .•
2.1 Owner of Record:
- ;
Name (Print) --- Current Mailing Address:
e' --- i ‘-4
I
Signatur . 1, Telephone
2.2 Authorized Anent:
"4 ' i i .___..____.__________________ ___._______
Name (Print) --- ----- ----- CurrentMailing Address: _ __
Signature e24 Telephone
P t c -
'---- -----
SECTION 3 - TIMATED COSTS
Item Estimated Cost (Dollars) to be . . Official .Use Only
com -. ted by permit applicant
1. Building (a) Building Permit Fee
2. Electrical ;-------- - ' -----7- (b) Estimated Total Cost of
Construction from (6) ..„. _ .__.,
3. Plumbing . -------77-7-- -7-7- Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1+2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
.
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
.,.
File # BP- 2013 -0808
APPLICANT /CONTACT PERSON JAMES ROBERTS
ADDRESS/PHONE 30 Edwards Rd WESTHAMPTON (413) 527 -6078
PROPERTY LOCATION 69 STATE ST
MAP 31B PARCEL 258 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ��j
Building Permit Filled out w"
Fee Paid
Typeof Construction: STRIP & SHINGLE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 99404
3 sets • f Plans / Plot Plan
THE • LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 4 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
di e • Delay
— y
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.
69 STATE ST BP- 2013 -0808
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 258 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0808
Project # JS- 2013- 001385
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 8276.40 Owner: SERIO COSIMO A & CLAIRE A LEBORIO J & MARY G SERIO
Zoning: CB(100)/ Applicant: JAMES ROBERTS
AT: 69 STATE ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTON MA01027 ISSUED ON:3/11/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 3/11/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner