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32C-210 (3) The Commonwealth of Massachusetts ear Department of Industrial Accidents Office of lnvestigalions , r►Ir 4 600 Washington Street •* • Boston,MA 02111 www.rnass.gov/dia _.. _ - . .__. ._...Workers' Compensation incur_auce_A� daYA;,_Builder;z/Contraciors/Electricians/Plumbers,_._ ._._ .. . . Applicant Information Please Print Legibly Name(Business/Organizationfl dividual): Five Star Building Corp. Address: 17 East St City/State/Zip; Easthampton,MA.01027 Phone#: 413-587-4060 Are you an employer?Check the appropriate box: —Type of project(required): 1.m I am a employer with 9 4. Q I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑I am a sole proprietor or partner- listed on the attached sheet t 7. Q Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.ins-uance_ 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 20.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or ad&lions myself. [No woduirs'comp. c. 152,§1(4),and we have no 12.0 Roof repairs Kitchen/Bath insurance required.]t employees.[No workers' 13.0 Other Accessories comp.insuranee required-] 'Any applicant thst checks box#1 must also 611 out the section below showing their worksrs'compensation policy information t Homeowners who submit this affidavit indicating they are doing all wars and then hoer outside contractors must submit a new affidavit indicating such. *Contractors that check this box mtatattached sp eddtianal sheet showing the nacre of the sub-contractors and their warkrss'comp.policy information. I am an employer that isprovidrrrg xnrkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Associated Employers Insurance Company Policy#or Self-ins.Lic.#: WCC500626401200 Expiration Date: 5/9/09 Job Site Address: 47 A Holyoke Street C}ky/Statc/[ip: Northampton,MA 01060 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 fuse of up to$250.00 a day against the 'later. Be advised that a copy of this statement may be forwarded to the(Moe of Investigations of the DIA for'I, coverage verification. I do hereby ice ti , and penalties of perjury that the information provided above is true and correct Si);natnre: . Date: 8/29/08 Phone#_ 413- ,8 -407', Official use only. Do not write in this area,to be completed by dry or torn ofe'n.1 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 it SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Hold r: Kevin Perrier 85319 License Number 17 Eas S reet Easthampton, MA 01027 1/13/09 Address Expiration Date 413 . 587 .4060 Signature / Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ Five Star Building Corp. 134511 Company Name Registration Number 12/3/09 Address Expiration Date 17 East Street Easthampton, MA Telephone4 13 .5 8 7 .4 0 6 0 SECTION 10-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 © No ❑ 11. -Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[0] Brief Description of Proposed Work: New kitchen cabinets, bath fixtures W Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6a.if New house and or addition to existing housing, complete the following: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Amy Milo , as Owner of the subject property hereby authorize Five Star Building Corp. to act on my behalf, in I matte relativ to work authorized by this building permit application. 10. 10 . 08 Signature of Owner Date Kevin Perrier, President- Five Star Building Corp. , asOwner/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 a-• pen-ties of perjury. Kevin Penner Print Name l /� 10 .10 . 08 Signature of Owner/Ag; 'rte/I Date • Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side 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 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 Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES (4D 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 NO 0 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 fp IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: , - Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Se tioAvailability ?��$ Room 100 Water/Well Availability ��� Northampton, MA 01060 Two Sets of Structural Plans `' phone 413487-1240 Fax 413-587-1272 plot/Site Plans Other Specify ' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 47 A Holyoke Street Map Lot Unit Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Amy Milo 4 Birchwood Dr. Huntington,MA 01050 Name(Print) Current Mailing Address: Telephone Signature 413 . 537.4929 2.2 Authorized Acq ent: Kevin Per tie 17 East Street Easthampton, MA 01027 Name(Print) IN Current Mailing Address: 413 . 587 .4060 Signature r' Telephone SECTION /-E IMATED CONSTRUCTION COSTS Item / Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 20,000 (a)Building Permit Fee 6 . 00/1000. 00 2. Electrical (b)Estimated Total Cost of 20000 Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 120. 00 5. Fire Protection �� 6. Total=(1 +2+3+4+5) 20,000 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date • File#BP-2009-0414 APPLICANT/CONTACT PERSON FIVE STAR REMODELING ADDRESS/PHONE 17 EAST ST EASTHAMPTON (413)587-4060 0 PROPERTY LOCATION 47 A HOLYOKE ST MAP 32C PARCEL 210 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 53 ,,�y? j t/pi0 ----- Typeof Construction: INSTALL NEW KITCHEN CABINETS&BATH FIXTURES New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 085319 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demolition Delay 7/ed" 0 " 000g, 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. s: BP-2009-0414 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# B P-2009-0414 Project# JS-2009-000558 Est. Cost: $20000.00 Fee: $120.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FIVE STAR REMODELING 085319 Lot Size(sq. ft.): 3179.88 Owner: MILO SANDRA J Zoning: URC(100)/ Applicant: FIVE STAR REMODELING AT: 47 A HOLYOKE ST Applicant Address: Phone: Insurance: 17 EAST ST (413) 587-4060 () WC EASTHAMPTONMA01027 ISSUED ON:10/17/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL NEW KITCHEN CABINETS & BATH FIXTURES 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 10/17/2008 0:00:00 $120.00532 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo