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31B-149 (2) The Commonwealth of Massachusetts Print Form . _,,. Department of Industrial Accidents ' — , �M Office of Investigations : g 1 1 Congress Street,Suite 100 '— Boston,MA 02114-2017 4 t' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): .j � . t.l 2-3 — Address: � r-- 66, City/State/Zip: �64'e.1 t 014 ,010 '%3 Phone#: G�'S-° 7 0� Are you an employer?Check the ap priate 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.I required.] 5. ❑ 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.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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. 1Contractors 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: /1Z-\\JC RS Policy#or Self-ins. Lic.#: OS'?34-1 "WO/ -1 7 1 3 I(28 Expiration Date: /-a q c O i c.,) oG0 Job Site Address: ''? / TRVin b leffq City/State/Zip:ncfjit-rivim*l Afie -fretteti 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 certft nder the ns and penalties of perjury that the information provided above is true and correct. Si g nature: l Date# 41 1; �3 Phone#: 9(7)` 31 "t-1 J 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 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes ® No)( SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, f�c)bi.0 F L o S 3.Ct,, p D TIZ jUJ (Yl&/011-6, C_ Foe- tJYS P(1-i Pr`06-S 1-1-- ,,as Owner of the subject property hereby authorize Iietyiws b do to act en y behalf, in all matters relative to work authorized by this building permit application. t Signat re of Owner { `, Date I, f.1 a55 , 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 an pe alties,_of perjures t� Print Name �.� " . VAS Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ,.,/46(t 1. a-05 5 V ! 9)t S License Num er VC 24 / N . l.../A;rr c: fr • ©wt,i, T. vy Address Expiration Date -4- 1413-3-7q--7W3 Signature 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 uilding permit. Signed Affidavit Attached Yes No O 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 ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration N,imber Address Expira/ti Date Signature Telephone / 9.2 Registered Professional Engineer(s): f Name // Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name J Area of Responsibility Address Registration Number Signature Telephone E ,iration Date Name Area of Re •onsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor 11 ) o S /11=12, 1 - Not Applicable ❑ Company Name: Responsible In Charge of Construction y/`//(y 7, Address A 3b 4 Signature Telephone Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&pave parking) #of Parking Spac Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Ca YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 it DON'T KNOW 0 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: C. Do any signs exist on the property? YES (31.. 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 O 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 ® NO el 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 0 RepairsrY Additions ❑ Accessory Building 0 Exterior Alteration 0 Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 El 1A I ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-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 [ ❑ U Utility ❑ Spe i : M Mixed Use ❑ Specify: , .r S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING R OVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Pr osed Use Group: d Existing Hazard Index 780 CMR 34): r:`Proposed Hazard Index 780 CMR 34): s' SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSEDvNEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1St 1st \\,, 2nd 2nd 3 d 3rd 4m 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 ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 — - Department use only R EC; �'---a/ " gity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit Ar6 2013 ! 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability QE or c J Nopthampton, MA 01060 Two Sets of Structural Plans NORI'"'A"Fr ,h r h 413+587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 3) -ievn11 0a_ 1j. Map Lot Unit tiI�RT�t��P7D'Jo C rie t' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: TTY P i.VC,En1.3 k H RL Y tA. S&t<`3 , ►�� ►'�1L. Name(Print) K p),f v r. (t J 5 I PfLope 1f m(c Current Mailing Address: P.L?,O c - I C`l, col C1�-(,. fS, u�Q & n'Il Signature1. —"`L(J l i Telephone ��- - �5� � CJ Mu, 2.2 Authorized Agent: /�ocs 4!� �i4f►11%5 R £x ,/vi)• I71i�+ �l -h� rv►rG1 Name(Print) Current Mailing Address: 11/ ; c 7si3 Signature Telephone SECTION 3-ESTI ATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building , J (a) Building Permit Fee JO 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _JJ 6. Total=(1 +2+3+4+5) 1t _c Check Number v � (. 5 am This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-0904 APPLICANT/CONTACT PERSON JDR BUILDERS ADDRESS/PHONE P 0 BOX 4 NORTH HATFIELD (413)665-7 :7 e PROPERTY LOCATION 31 TRUMBULL RD MAP 31B PARCEL 149 001 ZONE URC(100)/ THIS SECTION FOR OFFICIA USE ONLY: PERMIT APPLICATION C ECKLIST ENCL SED .� ( % ZONING FORM FILLED OUT A' Fee Paid Building Permit Filled out • Fee Paid INraffIgiV _ Typeof Construction: REPAIR STAIRS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074105 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 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.