24D-070 (9) The Commonwealth of Massachusetts
Department of Industrial Accidents
��'. Office of Investigations
1 Congress Street,Suite 100
f" Boston,MA 02114-2017
J�
, ...'s;, www.mass.govl dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): En
c... .A r-r •
Address: ) ) �,1 x,,e.�
City/State/Zip: N .,dsa, t N 4, C c65-1 Phone#: \G3 _ 5 c- t., 'y -7
Are you an employer? Check the appropriate box: Type of project(required):
1)14 I am a employer with 3 4. ® I am a general contractor and I 6. CI New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ,Remodeling
2.® I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ® Demolition
working for me in any capacity. employees and have workers'
g Y p tY 9. ® Building addition
[No workers' comp. insurance comp. insurance.:
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 12.0 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.
f 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: .7.71.T.Nz 4.- ,,,. " S'orArN c.c.
Policy#or Self-ins. Lic.#: Wf A Igo S ILI[1 Expiration Date: 1I 7 / 41
Job Site Address: ...)'''' )C.∎n(1: SA, City/State/Zip: 1\em-11.....1‘ 0-1-A 0 i a(o
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 c: ify under the pains and penalties of perjury that the information provided above is true and correct.
Si_nature: '_. Date: ii -I n /
l
Phone#: ko Z. . 3 g'- CC 'l
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#:
Version!.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No .44
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El*, y
Name of License Holder: �e.. ( . 1 —� C. 5 " 0 lr`
l( ,� License Number
� (
E,1 � fuu koi S \iQ \AO',\S / tr kit()
Address Expira ion ate
Lo3 3 (A 1 7
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 building per it.
Signed Affidavit Attached Yes ,r"<74 No
VersionI.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BU + ' ___ STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE T +,r fi F.OF ENCLOSED SPACE)
9.1 Registered Architect: G-12-t•- et C4-(e <MOW t-Q O
Not Applicable
Name(Registrant to g 7
Registration Numb
'-14t/'�.
Add /G Expiration Date
a Tehoe -sgoo / ) Z / G.�t
Signature t Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
II
Signature Telephone Expiration Date
j 9.3 General Contractor
q -rt"-N „ Not Applicable❑
Company Name:
1\1
Responsible In Char of Construction
tria4 A INC 1.1cLIbr.. l (`1'N a3 a.3--1
Address
t,b3 o)3
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 L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW 18i YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO O
IF YES, describe size, type and location: c c,r,
E. Will the construction activity disturb(clearing, grading, x vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
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 14 Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use Other❑
Enter a brief description here.
Brief Description
Of Proposed Work: 27w1 �rdu �� 6,e2T---�l/tts
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 El 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 I ❑
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: 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) �
1St �� r S F 1St 1 (ad S.4
O 2nd
2nd �
3rd 3rd
4th
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 Se a Disposal System:
Public Private ❑ Zone Outside Flood Zone Municipal On site disposal systemO
VersionI.7 Commercial Buik lino Permit Ma 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
Room 100 WaterlilVeltAvaitability
Northampton, MA 01060 Two Sets of Structural Plans
phone 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
This section to be completed by office
1.1 Property Address: J,�'1! kt 1.1s'
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) 4;l—. S4-v�a �� „�t}�,�r �.a LL - Current Mailing Address: l 3‘1" P1\4.
O s:) ) c.,ck
Signature 7 .,+ 7 Telephone 1-)– 110, -g -
2.2 Authorize. Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
11 I 0-c> Construction from(6)
3. Plumbing Building Permit Fee
4, Mechanical(HVAC) .€?'
5. Fire Protection
6. Total=(1 +2+3+4+5) c3 Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissionedinspector of Buildings Date
Version1.7 Commercial Building Permit May IS,2000 0/C0 S-Ztert(hit
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Drveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans'
phone 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: ��'V to This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) h.Q5f ��� 5��+cr..� t Cu, LL C Current Mailing Address: �'�1i'S' W t,�' S t l�u r�t7
c ) Lck
Signature Telephone 41/ -110.-
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
3 `-)/ 0, 0
2. Electrical (b) Estimated Total Cost of
v Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 3?-7
5. Fire Protection
6. Total =(1 +2 +3+4+5) S" `a, On'c) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signatu . ,
Bulking Commissioner/ pector of Buildings Date
228 KING ST BP-2014-0674
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-070 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0674
Project# JS-2014-001150
Est. Cost: $54000.00
Fee: $364.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EMPIRE HOMES INC 068655
Lot Size(sq. ft.): 330184.80 Owner: TARLIN LLOYD D&JACOB RABINOV ARTHUR L SHERIN&SIDNEY R
RAB C/O STOP&SHOP SUPERMARK
Zoning: HB(100)/URA(0)/ Applicant: EMPIRE HOMES INC
AT: 228 KING ST
Applicant Address: Phone: Insurance:
17 ELNATHANS WAY (603) 594-8744 WC
HOLLISNH03049 ISSUED ON:12/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR FIT FOR GREAT CLIPS
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 12/4/2013 0:00:00 $364.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner