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32C-149 (39)
The Commonwealth of Massachusetts . Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 M s�•'� www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'blv Name(Business/Organization/Individual): Address: City/State/Zip: hone.#: Are you an employer?Check the appropriate box: Type of project(required): 1 A I am a employer with // 4. ❑ I am a general contractor and I 6. ❑ 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. 7. ernodeling ship and have no e ployees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. $ 9. ❑Building addition required_] 5. F-1 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.❑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.❑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. (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'compens pd insurance for my employees. Below is the policy and job site " information. Insurance Company Name: 4z4Pj11hL 91 �-, , Policy#or Self-ins.Lic.#: /J Expiration Date: Job Site Address: 4(OS_T�,Q � City/State/Zip; A, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ation date). Failure to secure coverage.as required under Section 2')A 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 fire of up to$250.00 a day against the violato Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLkAIr' urance e verification. I do hereby certify u th a s es of perjury that the information provided above is tr a and correct Signa fore: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offcciaL 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 r.. SECTI0N1 4.f-.RUGTURAL PEERREVIEW(Z80 CMR'11D 11 , _ v _ Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION=11--OWNNERAUTHORIZATION .TO°BE<COMP_LETED7W'HEU O WlNERS AGENT.OR CONTRACTORAPPLIES-FOR ulLDING 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. gnature of Owne Date i I,; as Owner/Authorized Agent hereby declare that the statements and' tion on the foregoing application are true and accurate,to the best of my knowledge and belief. Si ned under the ains and es u Print Name 9 i Signature of Owner/Agent ate =SECTfOI�C'1:2 1COh1STRtILTtO.N SERUIEES - , ,„ 10.1 Licensed Construction Sue isor: Not Applicable E3 Name of License Holder:I License Number v Address Expiration Date r 70 Signature Telephone SECTION 13 WORKERS'COMP_ENSATfON'INS'tRANCE AFFtDAY1T 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 0 r Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FORBUILDIM3 AND STRUCTURES SlIB3ECTTO CONSTF2UCTION'CONTROL PURSUANT70 780-CMR 116 CONTAINING; MORE THAN_35;000 G F.OF ENCLOSED-,SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number i i Address i Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date � 1 � Name Area of Responsibility Address Registration Number I I Signature Telephone Expiration Date j Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date � t Name Area of Responsibility } Address Registration Number i t 1 i Signature Telephone Expiration Date 9.3 General Contractor i Not Applicable❑ Company Name: I _ Responsible In Charge of Construction r i Address s � Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 � 9R :O1�ZiQ Existing Proposed Required by Zoning This column to be filled in by Building Department J t ' Lot Size ' 1 Frontage Setbacks Front =! i Side L: R: L' R:" TT Rear �ut7ding ieiggham— Bldg. Square Footage % Open Space Footage r� __ % (Lot area minus bldg&paved arldn ) #of Parking Spaces Fill: ' I volume&Location) i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 yj DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: C. Do any signs exist on the property? YES 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 0 NO IF YES, describe size, type and location: j E. Will the construction activity disturb(clearing,grading,Fnt vation,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 Managem erm it from the DPW is required. Version 1.7 Commercial Building Permit May 15,2000 SECTION_COti�$TRIfC'[ION BEkVICES FORPi2OJECT:S CESS THAN 35,000 CUBIC-FEET OF;I=NCLOSED S„PACE Interior Alterations ❑ Existing Wall Signs �Demolition;soRepairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ er❑ Brief Description 'Enter a brief description ere. Of Proposed Work: 'SECTION 3 USE�GROUP=AND CONSTRUCTION ME _; USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A 71 ❑ A-2 ❑ A-3 ❑ 1A A-4 El A-5 El B Business ❑ 2A ❑ E Educational ❑ 2B ( ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 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 0 Specify:s f S Special Use Specify: COMPLETE THIS,SECTION TF EXISTING BUILDIN G 13NDEE�GOII�G'RENOUATf©NS�,.Al) ONS AND/ORtHA,NGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34). Proposed Hazard Index 780 CMR 34): •SECTION'S"BUILDING HEfGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ry �: Floor Area per Floor(sf) 1st 1st � t r . h< 2nd 2n �r fir. 3m _ 3`d 4th t € 4 ! ( o ' Total Proposed New Construction(sf) Total Areas P s p Total Height(ft) Total Height ft � w 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone I Outside Flood Zone E] Municipal ❑ On site disposal system❑ Versionl.7 Commercial Buildin Permit.May 15,2000 r- City of Northampton .'Building Department - ___. -- 212 Main Street ' Room,100 r^U �C 7 Nort hampton, MA 01060 phone 413-587 1240 Fax 413-587-1272 ,APPLICAt#.ON-T-0-�_-9aSTR l T,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECtIQN i SITEtNFORMiAT10N La --- rx Sl pis:sectronto�ecomp[efedbyr-office s ----'H-Property-Address: / ! 1 � 1Lo Una` �o� erta�i CB DtsfTiCt - :�EIQIS..tr„sD15t�ilG In,�ua SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED 4GENT_ 2.1 Owner of Record: Name Print) 71 Current Mailing Address: Signature Telephone L 2.2 Authorized Agent: Le I Name Pnt) CurrerdWailing Address: �� Signature Telephone SECTION 3-,ESTIM - ST KU N STS Item EAima,edl Cost(Dollars)to be Official Use:O;rJly com leted by ermit applicant 1. Building (a)Buitding'PerFnit Fee i E 2. Electrical @)Estimated'Total'Cost of° r Construction from: 6 3. Plumbing Building Per_4jCFee 4. Mechanical(HVAC) 5. Fire Protection Check:Number 6. Total=(1 +2+3+4+5) This'Section For..Official Use On1 �Bu�IdtcigPernalt.l�furr4"ber�; - Date'° ; issued r Signature: Building,Commissioner/In specfor.of-Buildings Date