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32C-130 (19) The Commonwealth of Vassachusetts DepartntentofIndustrial_4ccidents v _ Office of Investigations 600 1I'ashington Street Boston, MA 02111 »7wnwitass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Le6ibly Name (Business.iOrganization/Individual): Address: City/State/Zip: Phone #: Are you an employer'Check the appropriate 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.[P I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in an capacity. employees and have workers' Y P t5 4. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions myself. o workers' com right of exemption per MGL Y � P• 12.7 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] `Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. r 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 nacre 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 imprisotunent, 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 DLA for insurance coverage verification. I do hereby cer ' under tl gins a penalties of perjury that the information provided above is true and correct lip S i Qrtature: Date: 7— 7- OA Phone#: 1 2 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 O No O SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 Si nature of Cwner/Agent Date_T TION 12.-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: � _... /` ►lh .�llL. _._ License Numb r `� !. Address S Expiration Qate_C Kkt Signature Tel hone 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 O No Version l.7 Commercial Building Permit May 15,2000 S. 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 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW @ YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q 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 Q NO Q 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version 1.CCommercial 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 Number Address Expiration Date Signature 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 Reg istration Nu mber 1. Signature Telephone Expiration Date 9.3 General Contractor .. .... ___,_.. .,_._...._.. Not Applicable ❑ Company Name Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 a (�h " -Ali r; 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❑ Brief Description Enter a brief description here. jam' r-CA m E C 1 0T��"" Of Proposed Work: `Q.l .t" r. ._0_t�P ST A `N �1 t L/ � , ` S 0 SECTION 5-USE GROUP AND"CONSTRUCTION TYPE l L�-- jz­C La (N L TT LC_ C` -A I Z �.'A USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 p A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 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 ❑ 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): _v SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 1s 1st 2nd 2 nd 3rd 3rd 4tn 4 th ...._.A ,_ ..„... Total Area (so Total Proposed New Construction(so 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 0 Private ❑ Zone 1 11 1 Outside Flood Zone E] Municipal ❑ On site disposal system❑ Versionl.7 Commercial Buiidinl-Permit Mav 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 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Sitd�s = (r � t Other Sp 'ci L r, L APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OC CPA;NCY OF,OR DEMOLISH AI Y UILDING OTHER THAN A ONE OR TWO FAMILY DWG L N� ' SECTION 1 -SITE INFORMATION L__-._,-_----.--_--.-•-- Thi secti � G Idsy ice 1.1 Property Address: r tliu 0 7,q CQ-74, Jam- Zo'p3 2— C Lot Unit I ne U Pt C Overlay District ! - I Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT p c. w He F° u ft(04 2.1 Owner of Record: Name(Print) Current Mailing Address: 7 Co Signature ! \�V Telephone 2.2 Authorized Agent: Name(Print) _ '1 �/�` \� Current Marling Address:, _. W,VIC& Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant _ 1. Building (a)Building Permit Fee 2. Electrical } O (b)Estimated Total Cost of Q 1 lam' Construction from 6 3. Plumbing p Building Permit Fee 4. Mechanical(HVAC) - _. j Ll ©� �/'✓LIN� 5. Fire Protection --- 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0024 APPLICANT/CONTACT PERSON ALBERT SANCHEZ ADDRESS/PHONE 121 MEADOW ST FLORENCE (413)320-9567 PROPERTY LOCATION 74 CONZ ST-APT#2 MAP 32C PARCEL 130 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin,g Permit Filled out Fee Paid Typeof Construction: ADD 1/2 BATH&CLOSET New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 98377 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 C/Mt-:�n� //7�4 07bf-107 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. 74 CONZ ST-APT#2 BP-2009-0024 GIs#: COMMONWEALTH OF MASSACHUSETTS MaR:Block: 32C- 130 C),XY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2009-0024 Project# JS-2009-000024 Est. Cost: $6800.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ALBERT SANCHEZ 98377 Lot Size(sq. ft.): 22128.48 Owner: BROWN STEPHEN A Zoning: URC Applicant: ALBERT SANCHEZ AT: 74 CONZ ST-APT#2 Applicant Address: Phone: Insurance: 121 MEADOW ST (413) 320-9567 FLORENCEMA01062 ISSUED ON:71812008 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD 1/2 BATH & CLOSET 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: � r�;�) House# Foundation: J J�� Driveway Final: Final: ,'�Final: � - 1 ,d;v, A,Y,4 - � Rough Frame: f,�k � �� �;y 7- Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 0 k C7- ©�` THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND 7REGIULAUONS r� Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 7/8/2008 0:00:00 $50.002114 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo