25A-106 The Commonwealth of Massachusetts
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Department of Industrial Accidents
g,47".
Office of Investigations
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): CSSZ tl erik/ •✓►'K•'l
Address: Li 0
City/State/Zip: e t oc C t O(Cb Phone#: '-'t t 3_°56'?- (Plea
Are you an employer?Check the appropriate box: Type of project(required):
4. am I a 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- on
listed the attached sheet. 7. 0 Remodeling
These sub-contractors have
ship and 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. 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 11.0 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 514 i •
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.
I.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 ain� 'penalties of perjury that the information provided above is true and correct
Signature: Date: /O /7 /3
Phone 8;'[
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 REVIE1N(780 CMR 110.11) .. ,
...,,_
Independent Structural Engineering Structural Peer Review Required ' Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED:WHE N
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,
j 4 1 -cA•A.t.r. - 7- 4-KA,v-e---70.4 ye7
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,as Owner of the subject property
hereby a uthorizel._ _... .€:)., C_ ...... _______,______ ____ ____ __ to
act on ehal, in all m rs r ati e rk to horized by this building permit application.
At
/ 7
Signat — Date
-:1--L' 'All ee e- 1
_ ...._ ,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 •enalties of.e 'u . ------------,
__.---)‘-e _ Man Cfrrie, !
Print Name
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_..... ,.... ,._.,.... 0
AM00. ----: 3
/fir(o -17'n 1---gen AtiriP/1111„..-111111.- Date
CTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable CI
1 fr....7-7 La i r,"
Name of License Holder:! 0.7e-55e-1 _ ()Me ---: ' Lei ' 1 --LL -
_dit___
License Number
L-10____C -t- ,1 :____+'_.17. -1. C-J1.C..e _ 4 ,. 010 __ :, /. .,----7.,i_ _L-Y__ _ ____
Address Expiration Da e
s..„Irlrlf 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 0 No 0
Version1.7 Commercial Building Permit May 15,2000
J
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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'EIILOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): t -- ~
i Registration Number
Address ' .—____ _ ____.___
_..
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
I
1
Name Area of Responsibility
3
F
Address Registration Number
i
Signature Telephone Expiration Date
i j
Name Area of Responsibility
Address y
Registration Number
I i
Signature Telephone Expiration Date
Name Area of Responsibility
r_
Name
Address Registration Number
Signature Telephone Expiration Date
r
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
-3-C.M. e- 1t _ .. __. _ ....._i Not Applicable ❑
Company Name:
___...2 ( _ . 0 f.fy . __
Responsible In Charge of Const
ctio
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ctc, ce _
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_.
Address__
Signatur- ------ Telephone
•
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON,ZONING ,
Existing Proposed` Required by Zoning ,
This column to 6e filled in by
Building Department
Lot Size '___. ! ; 1 _
Frontage ...._.___________
Setbacks Front [ , . i
Side L:' --mi R:C"1 L:! I R:1-1 3
$ a
Rear ,...—__1
Building Height —..
Bldg.Square Footage _"-1 (" `... % i_—_._} [.._ ___1 , µ
Open Space Footage , , %" l E I V
-- (Lot area minus bldg&paved l i # 1 _ 1 _ I
parking)
#of Parking Spaces _ € '
Fill: l ,
(volume&Location) -- --
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 181, YES 0
i
IF,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 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 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: 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 0 Noe
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
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 4
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❑
i
Brief Description Enter a brief description here.
n /�
Of Proposed Work e� w i_ , Gznd Imo°+_ C LiCtj S_ ,f I . �1•
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 1:1 1A A El
� ❑
A-4 ❑ A-5 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify: ____
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:}
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: __ i Proposed Use Group: ', _
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):' _._..__.,
SECTION 6 BUILDING HEIGHT AND AREA
I 'OFFICE USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf)
c
1st __
2nd 2
3r° . _ - . w _. 3�
m
4th F 4 _ _ M._
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
Version1.7 Commercial Buildin_Permit Ma 15,2000 , -:„.--e-,+014.;-.4:taill;;;A,' ....;:. '-'44:':
ERI FE C i \\,r° e i of Northampton • A
di ing Department ", - -::i �d 1�:,#��
2 Main Street •a
OCT 1 8 2013 Room 100 1
L— _. Nrth mptan, MA 01060 ' .
Electr"�. r phpn �4lg! -1240 Fax 413-587-1272 ;" - _ � s-
s
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
5 " Ii i--i `2A. ` Map a6, Lot >6 f e Unit
`fie v / `T
A °(* /14' o 'C) ° ; Zone Overlay District
{ _ ._ -Elm St:Distnct', CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: __ _ _
_,...4.;Q___ „...._____4;i_t_._/ ,
Name(Print) Current Mailing Address: _
Signature r���� Telephone tf.e _ M nvt_O/0 6Z
9
2.2 Auth•rized Accent:
Name(Print) Current Mai Address:
Signature _ Telephone
SECTIO . - 'ATED CONSTRUCTION COSTS
Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building c 600 I (a)Building Permit Fee 3
2. Electrical I (b)Estimated Total Cost of F
i Construction from(6) _ _._.w..._..._w._._—
3. Plumbing 1 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection __..._ __...___..___..__..__...__
6. Total=(1 +2+3+4+5) _5—C-X-Y�. Check Number 3 3 rf3
1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
357 BRIDGE ST BP-2014-0491
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 106 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-2014-0491
Project# JS-2014-000834
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sq.ft.): 35719.20 Owner: HUTCHINS FAMILY PARTNERSHIP
Zoning: SC(63)/URB(37)/ Applicant: JESSE MONTGOMERY
AT: 357 BRIDGE ST
Applicant Address: Phone: Insurance:
40 OAK ST (413) 585-8482
FLORENCEMA01062 ISSUED ON:10/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SHEATHING & REPLACE 400 SQ FT
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 10/21/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner