31D-195 (2) 'L'hc Officc
PF PETER FROTHINGHAM
Rcglstcrcd Architect 4 214
181 Main Street,Suite One Electric, PVumbing&Guy ir,:�iions
Northampton MA 01060 Northampton, MA 0;
The Commonwealth of Massachusetts
Department of IndustrialAccidents
F Office of Investigations
W
d I Congress Street, Suite 100
Boston,MA 02114-2017
wives mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Name (Business/Organization/Individual):
Peter Frothingham, R.A.
Address: 181 Main Street, Suite One
City/State/Zip: Northampton MA 01060 Phone #:413 585 5910
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. F]New construction
2.N I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑■ Demolition
working for me in any capacity. employees and have workers' 9. ❑ 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 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'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 rti nde a pRand pe allies of perjury that the information provided above is true and correct.
14 January 2014
Signature: ro Date:
Phone#: 413585591
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#:
11 SCHOOL STREET, LLC
114 3rd San Marino Terrace, Miami Beach, FL 33139-1124
Peter Frothingham, Registered Architect
181 Main Street, Suite One, Northampton, MA 01060
DEAR PETER,
I hereby designate you as my authorized agent at 11 School Street, Northampton, MA. This
authority is limited to filing a permit with the City of Northampton for the purpose of selective
demolition of non-structural interior finishes and fixtures at my single-family residence
located at 11 School Street, Northampton, NIA.
THANK. YOU!
'7vk
ALAN Ful. MILLER, OWNES.'
MM
114 3rd San Marino Terrace, Miami Beach, FL 33139-1124
0
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable G
Name of License Holder.f (�CJk�"'t-� 7L30 I LyL4A
License Number
(',tilts 21 bc _3-__ . _.._
Expiration hate
Sigrilature Telephone
9.Registered Home Improvement Contractor: Not Applicable
CornpanV Name Registration Number
Address Expiration Date
Telephone
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 wiA result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No......
11. - Home Owner Eaemton
The current exemption)for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or hro(2)families
acid to allow such homeowneer to engage an indi�idtnat 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 or llomeow'ner• Persatn(s)wlto own a parcel of land on which he/she resides or intends to reside,on which there
is..or is untended 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-oil 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 piesence on the jot)site will he required from time to time.during and upon
completiou 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 Armrotated,you may he liable for person(s)
you lure to perform work for you under this permit.
The undersigned"homeowner"certifies and assutnes responsibility for compliance with the State Building Code,City of
',.Northampton Ordinances.State and Local Zoning Law's and State of Massachusetts General Laws Annotated.
Homeowner Signature _-----__--�
SECTION 5•DESCRIPTION OF PROPOSED WORK(check all applicablel
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [ a Decks [ ) Siding[ j Other( j
Brief Description of Proposed
Work: I2I210L%1111 D1-S ( 1J'�j1121.)( 2 ill? In2 If�l i5c-tijf X-n,� `>
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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. Dim Ions
e. Number of stories? 7
f. Method of heating? ;5Mrasscheesk eplac or Woodstoves Number of each
g. Energy Conservation Compliance. Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of t ands? Yes No. Is construction within 100 yr, floodplain Yes No
j. Depth of basement or c r floor below finished grade
k. Will building co rm to the Building and Zoning regulations? Yes No.
1. Septic nk City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Alan Michael Miller
1, . as Owner of the subject
property
hereby authorize Peter Frothingham, Registered Architect
to act o behalf, In all matters r 1 tine to work authorized by this building permit application.
® ( - 11 -aD
S19na ure of Owner pale
I,
ELSA
as Owner/Authorized
Agent'ereby declare that the statements and info anon 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 e
SGtny4w
Ownearlllg,nt [?ale
Section 4. ZONING All Information Must Be Completed Permit Can%Dented Due !o Incomplete Inforination
Existitiv. Proposed Required by Zoning
This coltuan to be filled m by
Budding Depaitinent
Lot Size
Rear
Building Height
Bldg. Square Footage 5r% 7A0
Open Space Footage
Mces
Of Parking SI
A. Has m Special Perm ityVmriance/Finding ever been issued for/on the site?
�� VV
N� �_/DON'T KNOW ��� YES �~��
�
!F YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
�� VV �� ��
N� �� ��DON'T KNOW YES
��
IF YES: enter Book Page and/or Dooument#
\~/VV �-\ /~~\~�/\
B. Does the site contain a brook, body ofvvakmrorwetlands? NO ��/ DON'T KNOW YES
IF YES, has permit been or need tn be obtained from the Conservation Commission?
`
Needs kobeobtained \~�/�� Obtained /~~� Qs�m �nyu��'
�_� ' '
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 7 YES v~-\ NO
|F YES, describe size, type and location:
E� Will the construction activity disturb(clearing,grading mtion.or filling)over 1 acre orIs|t part mfa common plan
that w1||disturb over 1acre? YES ���) NO �M
��
|F YES, then m Northampton Storm Water Management Permit from the DPW isrequired.
Department use only
1 �
'.)I,-__ �l �`�� y of Northampton Status of Permit:
1.
�f ilding Department Curb Cut/Driveway Permit
2014 �i J 212 Main Street Sewer/Septic Availability
-
2014 �' Room 100 Water/Well Availability
I Flo hampton, MA 01050 Two Sets of Structural Plans
Electric-, --_.1
- horl+d,, Q 587-1240 Fax 413-587-1272 Piot!Slte Plans
A; X6.0 �o
Other Specify
F APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING-1
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
11 School Street, Northampton, MA Map Lot Unit
Zone Overlay District
Elm St_District GCB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 11 School Street, LLC 114 3rd San Marino Terrace, Miami Beach, FL 33139-1124
Name(Print) Current Mailing Address 305-531-1221
` Telephone
5ignalure
2.2 Authorized Agent:
Pet Frothingham, RA 181 Main Street, Suite One, Northampton, MA 0106
rmt) A Current Healing Address
N 413-585-5910
Sign ture Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Y1 ltinf) (a)Building Permit Fee(' )
2. Electrical W (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 7 Check Number
This Section For Official Use On
Date
Building Permit Number: sued:
Slgnatur -`f ! <6 4
Building Commissioner/Inspector of Buildings Date
11 SCHOOL ST BP-2014-0807
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D- 195 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catelzory: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2014-0807
Project# JS-2014-001393
Est. Cost: $2500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 3746.16 Owner: MILLER ALAN M
Zoning_URC(100)/ Applicant: MILLER ALAN M
AT. 11 SCHOOL ST
Applicant Address: Phone: Insurance:
114 3RD SAN MARINO TERR (305) 531-1221 ()
MIAMI BEACHFL33139 ISSUED ON:112112014 0:00:00
TO PERFORM THE FOLLOWING WORK.SELECTIVE INTERIOR DEMOLITION
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 1/21/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner