10B-093 (4) I request that you grant a modification to waive the requirement for control construction
for the project at 1 Florence Street in Leeds, Northampton, because the work is of a
minor nature, will not affect health, accessibility, life and fire safety, or structural
requirements and is impractical in that the cost of control construction is considerable
when compared to the cost of the proposed work. (I have provided a stamped letter from
a registered design professional in support of this request.))
Thank you for your consideration.
Respectfully,
i //43
The Commonwealth of Massachusetts
Department of Industrial Accidents
— - r Office of Investigations
] " r •
600 Washington Street
` Boston,MA 02111
•
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
•
Name (Business/Organization/Individual): 11je ".-c !7 9/ V/ ✓<4�
Address: / Pore vice
City/State/Zip: E e cLc AlA 6/O' 3 Phone#: q 7L�' 6C 6
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.5;2r I am a sole proprietor or_partner- listed on the attached sheet. 7: ❑ Remodeling
ship and have no employees These sub-contractors have 8. O Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.t - -
required.] 5. 0 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 12.0 Roof repairs
insurance required.]t • c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other Crl-�e�^ Ir
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
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and pena4ies of perjury that the information provided above is true and correct.
`,>4Sienature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
— —City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
. -
Version1.7 Commercial Building Permit May 15,2000
. . .
SECTION 10-,$TRUCTURAL,,PEER:REVIEW:(780 CNIR..11011) ......:....:.,..-:,...:. .. : .....'.
...-
Independent Structural Engineering Structural Peer Review Required . Yes 0 No
SECTION 11 -OWNER AUTHORIZATION.-.:TO,BE.COMPLETEP.WHEN.
OWNERS AGENT OR CONTRACTOR•APPLIES FORBUILbING-PERMIT
I, ! %as Owner of the subject property
i4
hereby authorize, _ _ . _ _ „ . ...:10
act on my behalf, in all matters relative to work authorized by this building permit application. - --
i 1
Signature of Owner . Date
l ,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
Print Na tr—,
y ...1 i__
/'.iC Ad,It(jrt (4Sr-
:Signature of Owner/Agent
Date
_ 1
_ .. ____
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: ( Not Applicable El
-
1 . y 1 !
Name of License Holder:f.— ._.r....!_4.;r._.....t:r....''L6_J_e-f 1C_11,_ ______ ________1 L
License Number
_
—----------_________--- ---------- - ----
Address Expiration Date
,
/ PkIIVAX1 -tS r Leeds IYA- - 1 r03 P7 7 1 1 I I
Signature /.... - Telephone
,44.........4.,
SECTION-134/ORKERS'4,141TIOWINSURANCEAFEIOAVIT--(lill;G:L.:,0:152 §..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 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 35,00(1 C.F.OF EItSLOSED;SPACE)
9.1 Registered Architect:
� ' Not Applicable ❑
I
Name(Registrant) – _ _ _ __ . I __.___._. ,
_ Registration Number
Address I
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
( 1 F
i
Name Area of Responsibility
-
r 1
Address Registration Number
I
Signature Telephone Expiration Date
i
1
Name Area of Responsibility
__.__ _,._,_..e..__.,___ ____._.._— _, ... _ _....,
Address - Ristration Number
i
Signature Telephone Expiration Date
I
! _ i I
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
I I
Name _T Area of Responsibility
Address Registration Number
j
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
8. NORTH MPTON ZO1NIh1G.;;
Existing Proposed` Required by honing ,
This column for filled in by
Building Department
LotSize I_ _.a r. _" .... _..—. ,...._....__... ____a_..... „f
Frontage _w _. '' , . 'M,..,______
Setbacks Front s r---—7 / f ' i
z.Side L:t 7 R:€L__.' L: ._.....J R:.,!TA r-----1 [
Rear ,_.____ `�
Building Height ( I I `
Bldg. Square Footage '_. .� s0-....f % 1----1 I .._____._.
i 1.__?
Open Space Footage % I ;
(Lot area minus bldg&paved r_ 1 i t 3
parking)
77.1#of Parking Spaces i
Fill:
l l-----------(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 Books Page= 1 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: i 1
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
IF YES, describe size, type and location: i
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
CUBIC FEET OF ENCLOSED SPACE •
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building•
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other Ud"'" / --L
Brief Description !Enter a brief description here.
Of Proposed Work:1 � 1/ tusren-r-t $ p Lec1ej
{ T°¢ et ►Ge S
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) ' CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 0 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 ❑
I Institutional ❑ I-1 0 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 E f R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B
U Utility ❑ Specify: 4.___
r
M Mixed Use ❑ Specify:{
S Special Use ❑ Specify:1 i
COMPLETE THIS SECTION IF.EXISTING BUILDING UNDERGOING RENOVATIONS ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: ;____._ ____ . _, Proposed Use Group: ', ___ _ w_ _ __
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)
1st ......_ 1st
.:____.J?
2nd ....w..._-_.._,.___._._._..... 2nd
I
td _ _
3rd S . _ ,
4th ___ ._ _ i 4th _________________ ____
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 p On site disposal system
•
Versionl.7 Commercial Building.Permit May 15,2000
B. ag as 5
1. , ,-1 Departmefi�ueoi l 0 `f ,
` fi G"
S
q
L---------1\UC3`E , ) City of Northampton Stattsgf Pitntt 1, n .. 4 E »
u pe4 " '` 'Building Department c , n v Y Perrnf. 4 , -4 w ,
e � n 212 Main Street SewerISepttr vaifth t it � ' g a� Room 100 * '"WatekO Ayilab it 0 � AtIMAM o V A
' .Aiw ,- 2Z orthampton, MA 01060 TwoxSets of;Stiucra4Pl 0b: `*a Y k
v ,y 43;4 }z� J ;3- ,t $ hi's A p S 4 ;51ci 9 e —587-1240 Fax 413-587-1272 PlotfVEte na y .0 g - €.T E?NTOu R NN dFZ ON p a s g d Y r +
OtherSeCI fS
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
1.1 Property Address:
This section to:be completed by office
/ ; Map • Lot Unit
4 e e c/ Zone Overlay District
`Elm St.District. CB District
SECTION 2 :PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
i
Name(Print) Current Mailing Address:
Signature , Ngral■, �4L _�L:_�ii Telephone
/ - `�� 5f j- /?2...c)
SECTION 3-ESTIMATED. • ION OSTS.
Item ated Cost(Dollars)to be Official Use:Only
completed by permit applicant
1. Building S . (a)Building"Permit.Fee
2. Electrical w.._..-•....___...-- _ ..... ,_— I (b)Estimated Total::COst of
Construction from(6) ._._.__ ..__...____.__...._._3_._..
3. Plumbing _- ....•..__._ . ...__._.._.__...._.___.____ Building Permit:Fee
4. Mechanical(HVAC) _. _-�_- -• °.°.---
5. Fire Protection ....._:_
6. Total=(1 +2+3+4+5) Check Number //� q $05
This Section For Official Use Only
Building Permit Number Date
Issued
Sig re: ..,, ,,,o- i
?—. —a
Building Commissioner/Inspeetor.of Buildings Date
1 FLORENCE ST BP-2014-0118
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-093 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0118
Project# JS-2014-000231
Est.Cost:
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ERIC LILLJEQUIST 064713
Lot Size(sq.ft.): Owner: LAVIGNE RONALD L
Zoning:URA(100)/ Applicant: ERIC LILLJEQUIST
AT: 1 FLORENCE ST
Applicant Address: Phone: Insurance:
1 FLORENCE ST (978) 868-0387
LEEDSMA01053 ISSUED ON:8/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT ROOF OVER ELECTRIC
SERVICES
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 8/5/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner