38C-077 (5) The Commonwealth of Massachusetts
�. Department of Industrial Accidents
rra, Office of Investigations
fL 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
n
00 C__/
Name(Business/Organization/Individual): 'J lei +� J��/ N 6 `�
Address: 76/ k)de EG
� 14 , ,r) If4C/O e ` zit 7 City/State/Zip Phone#:
Are y u an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1. I am a employer with ] 6. 0 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. 0 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.]
5. E 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
right of exemption per MGL
myself. [No workers' comp. 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.
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 nacre 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. m
Insurance Company Name: e,f! /'/v t b fJ`�
Policy#or Self-ins.Lic.#: LU —3es--` �L /- 010 Expiration Date:6 '4
C ao
Job Site Address: 4571.4110 46( City/State/Zip: 'i)4th
7d A.) ix 4 O
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 016/
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 under the pains and penalties of perjury that the information provided above is true and correct.
�
Signature: cT�—�'--
✓ c35 Date:Cl/ r/lc'y pQ
11.
Phone#: .7 (v,
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#:
S
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 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/
- jj
I, : :-S T`wr- ._>V.W_:_. 4 c3 1-5__6—.. �% as Owner of the subject property
jj k4tx
hereby authorize .___..... .���w_U___,_.�. .... "
act n my behalf,in all matter elative to work authorized by this building permit application.
Signature of Owner Y Date
I, _ . ..._ _„ A iz 0-1 ,ash/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 andpenalties of a 'u
A'ii.0,iJ t., 73 � ,o.
Print Name - _..._._...._..___.,__ _..__w__,.w._. .._. __ _ ._ _
igS' nature of.030/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.'�..,_ —�,..__. -..__�.. --- _ �– - .m,. .�_ �.__ -._ '
License Number
Addrr s Expiration Date
No,��% ,�in-tie fa ti ) a i d‘e `d L 4v/t,.
Signatu Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.152,§25C(6))
Workers Compensation Insurance affidav' must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil • g permit.
Signed Affidavit Attached Yes No
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 ENS LOSED SPACE)
9.1 Registered Architect:
'; Not Applicable ❑
Name(Registrant): i
_._. _ _._
Registration Number
Address # ...__- ._..__.....__..
Expiration Date
i
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
I f .
Address Registration Number __ _
Signature Telephone Expiration Date
-
Name Area of Responsibility
i
Address . Ristration Number
I I I
Signature Telephone Expiration Date
i
Name -- Area of Responsibility
1 I
Address Registration Number
i
_ _ i_._.__. _____..___..._._...__.__.. __..._..___....._._..__._._....._
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
t.-......... ..__..___......._ tom.-. _.._...n..__....-..,._.»._...-.,...._.... ,..__._.......,______^....3
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
S. NORTHAM;PTONZONING
Existing Proposed Required by honing .
This column to 1 e filled in by
Building '-.artment
—
Lot Size I
Frontage ,. .._. ........__... ..
Setbacks Front
Side L:' R:`� l L: .. R:FL ' .
: I i 3
Rear W�.
Building Height
Bldg.Square Footage :---7 1` -' % F.----; i ""
Open Space Footage , , , i % i
(Lot area minus bldg&paved 9 1 i i 1 _
parking)
t ( = F
#of Parking Spaces
Fill: i
E
(volume&Location) --- -°
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
_ NO 0 DONT KNOW 0 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 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 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 Q
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 0 NO 0
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> ti
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory But ing❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief descriptio here. �-. , c ,�b ,Ail C
Of Proposed Work: ? . 'y , 1'( i /) :) GlO/N(2.s � !wn `� {►
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1 A I ❑
A-4 ❑ A-5 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H.High Hazard ❑ -- 3A ❑
I 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 J ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:I " ----°°----°—�--°---�-_._..._.
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UN DERGOING.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)
t
,.._-.._____ -- - 1st
15` .__ -.._...-..t
2nd
2' 1
�a _ ._. .--- ..___-. 3 rd
3rd
m €
4`" 4 i•
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft) ___ __
Total Height ft a.::.p___z_ _.__:nv__.
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 ❑ On site disposal system 0
Version1.7 Commercial Buildin_Permit May 15,2000
City of Northampton
uilding Department e.: : �� ,1,,6,..:,,,,-,-„,,,, a
212 Main Street s a _
2\_________\_.w 70 Room 100 , � , • r
W o , ampton, MA 01060 �, ;,,14.7-:-'7F.,, r
��: ° ..7=1240 Fax 413-587-1272 s , 9 %�`
D�,Lp1N N 0� F 2 ,�. t�
of Vrtio-
A' • • ION 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:
v C ll / 1f( Map Lot Unit
J'��j � ,p Oar . Q�0 C f I Zone Overlay District
-- , _
ErmSt'Drstrict CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of R`eco\rd: \ _ r r�
+.,1 4_ 3.._l 14 J F— ` �3 EC-�v Z1^f� ,'�_ � :_6'Q-1 �►y� �Q l_
Name(Print) Current Mailing Address: _�_`_
Telephone
Signature r� `, \- — / _ 1. p
2.2 Authorized Anent:
Name(Print) �w Current airinAddres _ _ _
Signature s-11 �-5 Telephone `- 'f/!67
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building du
�,/ Q n ' (a)Building Permit Fee ,
2. Electrical - I (b)Estimated Total Cost ofi ._
I Construction from(6) ______,_____.___ __
3. Plumbing _ I Building Permit Fee 5
______„. ,,___,_ ___
4. Mechanical(HVAC) -- ._----
5. Fire Protection __..- _...___..___...__..
.__.._ -__ _ _ ___ I 3 aka
6. Total=(1 +2+3+4+5) � � �( Check Number
This.Section For Official Use Only
Building Permit Number Date
Issued
/
Sgnatur •• 4#10:7 p- –S .; (--/c_
Buiidi • missioner/Inspector of Buildings Date
8 EASTHAMPTON RD BP-2013-1116
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38C-077 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2013-1116
Project# JS-2013-001841
Est. Cost: $4475.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 27442.80 Owner: M&S HOLDINGS LTD PARTNERSHIP
Zoning: GI(95)/WP(59)/SC(5)/ Applicant: B & R SIDING
AT: 8 EASTHAMPTON RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 320-1807 0 Workers Compensation
NORTHAMPTONMAO1060 ISSUED ON:5/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 5/21/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner