37-083 (6) The Commonwealth of Massachusetts
Department of Industrial Accidents
---* Office of Investigations
r 600 Washington Street
Boston, MA 02111
www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_4#2 Co'-' S �. �.e
Address: 359 64,,‹,i-ti-e// ST
City/State/Zip: P/t-6 e'4j'p.�cu j/Rd. O/007 Phone#: �f t 3 °Z S' j �
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. n I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.-0 I am a sole proprietor or partner- . listed on the attached sheet. 7. ❑Remodeling
ship and These sub-contractors have have no employees 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. KWe are a corporation and its 10.2.Electrical repairs or additions
3.[I] 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
Y (1`i P 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have n o
employees. [No workers' 13.2 Other RQ��
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 o f this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u 'er the pans and,enalties of perjury that the information provided above is true and correct.
— 9-/.3
Si•nature: ' 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#:
Versionl..7 Commercial Building Permit May 15,2000
SECTION 10-.STRUCTURAL PEER REVIEW(780 CMR110 11)-;
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 -OVIfNER;AUTHORIZATION-.TO:BE.-COMPLETEP:.WHEN7.
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING;PERMIT
I, _ J,as Owner of the subject property
' b
hereby authorize... . ,�'e?.'i„ Z u�_. i !! ._Y � '.?`� .vS�r °s .�...__......_..__. .._._ ..... to
act on m ,ehalf,in all matters work authorized by this building permit application. ..._
ignatur- of Owner Date
47■ tiP-j .. 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 under the_pains and penalties of.,perjury_
fil /yt,fG?/t
Print Name
€ k
Signa ure o Owner,',-nt Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑ __
Name of License Holder.1 _ _ aTC�2�15--_-*+-.:.,.:w._� !.�--!E!_ c5 zGo
License Number
Address Expiration Date
ilki -ca -YD 5
Signature If Telephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G 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 I..40: 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 CMR116(CONTAINING MORE THAN 35,000 C.F.OF EIJCLOSED:SPACE)
9.1 Registered Architect:
I Not Applicable ❑
i _.. .__.....Ww_.
Name(Registrant): -- __
i I Registration Number
W
Address . ,_._ :_,_,_.....,_____ _...._.......:
1 Expiration Date
I_
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
t _..._ ....._.._.__._._.._...__. .__. .__.....__._...._....__..------..,.......<-__..............._._._....._ ..____.-_.__...___._._...__ ,_.._._.___......... ..---_-_.-_..---.__..._.___..__.._____.._.__._..._....._.._
1
I -........ _ .. ». _ .. ._..__ ..,.,._. ._.w.,_...__.._.__...._.._. i ._._.__ ...._.._....
Address Registration Number
I l
Signature Telephone Expiration Date
Name Area of Responsibility
I f
Address • Registration Number
Signature Telephone Expiration Date
I 1 M__.
i, i
Name Area of Responsibility
3
Address . Registration Number
Signature Telephone Expiration Date
1
Name ___ Area of Responsibility
Address Registration Number
1 71
Signature Telephone Expiration Date
9.3 General Contractor
`'9 4.7 co/i, $nit,'c-ri v 4v L C.c 1 Not Applicable ❑
Company Name:
Responsible In Charge of Construction _
3 ??...1--;i4-,. M1 !,. ._... . a), G� #14 7f'/1 7 D/ay
1�
_Add .. -
el.& i ' 4011111 - 9/3 1,A62e,---- --47,01.5i:
gnature Telephone
Version1.7 Commercial Building Permit May 15,2000
8.. NORTHAMPTON.ZONING::: 4 ,
Existing Proposed . . Required by Zoning ,
This column tare filled in by
Building Department
Lot Size I— _ _. _ I . __--1 __ _ µA
Frontage i. __ i _ ._ a
Setbacks Front r
Side L:t . R: 1 L:1______.1 R:._ i. ,.,_______,
Rear [11____i_ 1 1 1 J
Building Height 1:= ?
Bldg. Square Footage 1,---•__ _._...__...._ % .__.-.___y I I 4 .__
Open Space Footage ..__ I , % 1 1_,„....�!
(Lot area minus bldg&paved ', L__•...., . L S- 3
parking)
#of Parking Spaces 1-----1
Fill: ,1 o
#i
(volume&Location) _. __ i
—. ._.._w_ ._.— __ --------
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW el 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 Q 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:
._I
C. Do any signs exist on the property? YES 0 NO Q
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
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 C NO J ,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 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❑ RepairsX Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description .. 1 t p 0l"G' ' r i' ro .e.-"a U /0.4-41-1.,..
P Enter a brief description here. Ili ei _,,,L� _ f,2,,,, .--� 0,e,-,_,...„,........„
Of Proposed Work: ,Q t".,' ' ' '4 r 0�M a ear S,
n e' •9-K-e cv,�i B 1ec Lc Wt e- IFC,rr`c.- /A--:t J 5 A's/7 c fr.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) ' CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
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 ❑ 1-1 0 I-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ( R-1 ❑ R-2 gL, R-3 ❑ 5A ®.
S Storage ❑ S-1 ❑ S-2 ❑ 5B I ❑
U Utility ❑ Specify: ____
M Mixed Use ❑ Specify:r._
S Special Use ❑ Specify: ._.,._�____ .,_.... ,-,....... r�,"",-..__...
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _ ______ �_, „ 1 Proposed Use Group: ;,_..._..,_ .. _._„_,_
Existing Hazard Index 780 CMR 34):; _ ' Proposed Hazard Index 780 CMR 34):1 ________ _ __1
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
_
1st _. _------...."...; 1st r
_ __ 2nd
2nd
..�-------�__.___.w_.._.�.__.__.__.__..__,___._._.
?
3rd'3ro I
__ __._ _.__.__._. _ _____
_ �
4th i 4
y
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 0 --
Zone _.____ .` Outside Flood ZoneD Municipal ❑ On site disposal system
Versionl.7 Commercial Building.Permit May 15,2000
rya De artmehi use onl
Cali){ ` : City of Northampton St tus'`ofPet i i rcg li ar, *4 ` �:r' ,
' Building Department h CutUDrIVewayPerrnit. ,���W
_ 2013
212 Main Street Sewers eptic arfabdity �
.i t hz;O'O`Od,O' ire` .� ,� >„ x
,.:-1 Room 100 Water/Well A aria � � �i� �3 �
Northampton, MA 01060 .Two SetssofStruct ra[Plans 4 �� �, 3 . `� ti-
Electric,Plumbing&Gas In ' 1 x rt4
Northampton,MA 010 ' 13-587-1240 Fax 413-587-1272 Plot/Stte P ns � �,:
Other Specify . xt r -
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
.41.14-40,9 64...d i4 ,d ro.4.10B•1 1/1/ 16141- S --1 1 :Map Lot Unit
g po 6-4.00€ rj T I
j,'_io TLi , ' ' -'. Aid 0 100 0 j .Zone" Overlay District
Elm St"_District` CB Districts
SECTION 2 :PROPERTY OWNERSHIP/AUTHORIZED AGENT ;i
2.1 Owner of Record:
Name(Print) Cis--�yi c,G,_ to Y If 0,j� - urrent Mailing Address: J
Signatur- .%':.....j ' -_ ;,111 6( Telephone CYi �
,5 v -- 4,G-1i
2.2 Authorized Agent: _./' _ _ _ _
Name(Print) pa - ( `- �;s- Current Mailing Address _
Z ale G ' ,u --W )3 — /G.g/
Signature _..../010/../.1.4.61.—' - . Telephone V/ 6 S G7 - . :i/
SECTION 3-ESTIMATED CONSTRU/ION.COSTS=
Item Estimated Cost(Dollars)to be Official"Use.Only
completed by permit applicant
1. Building OC/b "(a)Building Permit.Fee
2. Electrical (b).Estimated Total,Costof
/^ Consffuetion from(6) _... _.___._,.. ._....
3. Plumbing Building Permit.Fee•
4. Mechanical(HVAC)
5. Fire Protection 5 "0U -we2d __ __.___....__ ._m;
__ 6. Total=(1 +2+3+4+5) P�010 Check Number 090.7507 -,'.
• This_Section For.'Official Use Only.
Building Permit Number Date
Issued
Si gnat /://400/1"/":"7---
Bu • •• -ommis oner/Inspector_of Buildings Date
File#BP-2014-0305
APPLICANT/CONTACT PERSON THOMAS J KORYTOSKI
ADDRESS/PHONE 359 BARDWELL ST BELCHERTOWN (413)250-8095 0
PROPERTY LOCATION 266 GROVE ST
MAP 37 PARCEL 083 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ^ /) *c9-0 Fee Paid p/
Typeof Construction: REPLACEDAMAGED SIDING,SHEATHING&INSULATION&REFRAME WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 070047
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
D:- oh Delay
d ,
"7/;
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.
266 GROVE ST BP-2014-0305
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-083 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-2014-0305
Project# JS-2014-000516
Est. Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS J KORYTOSKI 070047
Lot Size(sq. ft.): Owner: HAMPSHIRE PROPERTY MANAGEMENT
Zoning: Applicant: THOMAS J KORYTOSKI
AT: 266 GROVE ST
Applicant Address: Phone: Insurance:
359 BARDWELL ST (413) 250-8095 ()
BELCHERTOWNMA01007 ISSUED ON:9/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE DAMAGED SIDING,SHEATHING &
INSULATION & REFRAME WALL
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 9/16/2013 0:00:00 $120.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner