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29-152 i i = I ' VN I I I i i� "1 ` 1 (w ry C U ZZ 1, o I ac. rk � I �� I ' ' i � 1 � � I i j I d � � i t � 1 � � � '' � i � ' � ,' � ' - ', � I i I '1` - �' { ' l` � 1 -�,. G I � I i � � i �, 'I '. � r I _ � , �'� � � �1 I I � i � ' ; a. �, : _ , � ;, � , 0 s �► 0 ,� i ,�� .__ � � � � i i i � ,- j — , � — � I a ,j �� � I � i k � I \� � k `�.. �, o ��,. �, h � ,` �. �` � � v � � � �� � !I '� � �� � � � � I. � ,' i ,� The Commonwealth of Massachusetts Department of In dustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly Name(Business/Organization/Individual): ,c Address: A2 City/State/Zip: (o1e/i<- Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet 7. F�Remodeling ship and have no employees These sub-contractors have. g, E]Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp,insurance. 9. Building addition required.] 5. F� We are a corporation and its 10.❑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.❑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_ tContractors 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 fire 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 certify er th p in an d en hies ofperjury that the information provided above is true and correct Si ature: Date: -7 Phone#: /,3 7 0 Official use only. Do not write in this area,to be completed by city or town offlciaC 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#: s Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTl1RLtI.PEEF�REVIEIN'"(Z8Q CMR'11011 Independent Structural Engineering Structural Peer Review Required Yes No SECTIONf1 i OWNER AUTHORIZ T-,tON TO BECOMPLETED WkIER'' OWNERS AGENT OR CONTRACTOR APPLIES:FOR BUILQING PERMIT as per of the subject property i hereby authorize L9`T �"�S Jo act on my b if,in all tters rel 've t ork authorized by this building permit application. i Signature of Owner Date 1, �J vc .,i 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 Denalties of a'u . Print Name `D Q Signature oMWne2& Date SEr TON:.1Z., G_ STRUC>[QTI SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:� c'i✓C n Ur � License Number Address Expiration Date Sign dr Telephone SECTION 13-WORKERS'COMPENSATION 1NSUF=— RFFIDA�fIT(Alf Cr L.C 152,?3„25C(6)} Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit w611 result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No 0 r s. Version 1.7 Commercial Building Permit May 15,2000 SECTION.9-PROFESSIONAL DESIGN:AND CONSTRUGTIOU SERVICES FOl2 BUILDINIGS AND S`FRUGTURES t1BJEGT t0 CONSTRUCTION CONTROL PURSUANT 7Q 780=CMR~11fi(CONTAINING M©RE TFIAN.35A QF.OF ENCLOSED-SPACE) 9.1 Registered Architect Not Applicable ❑ } { Name(Registrant): Registration Number Address Expiration Date I Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility j Address Registration Number Signature Telephone Expiration Date E � Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date � � s i Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date { Name Area of Responsibility I Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Na e: Responsible In Shfirge of Construction I r Address O, ('fl�G�i�yc� �'�, /`J�o i enc f �?� 042 6 , Signature Telephone a V a1 Versionl.7 Commercial Building Permit May 15,2000 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size I ` Frontage Setbacks Front ( ] s Side L:' ! R� L:= R:= r� r— Rear Bldg.Square Footage I % r— Open Space Footage % (Lot area minus bldg&paved arldn ) #of Parking Spaces Fill: ' volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW � YES IF YES: enter Book Page! and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained , Date Issued: i C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 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. s Version 1.7 Commercial Building Permit May 15,2000 i.. SECTION d COiVSTRUCTLON SERVICES FORPRO.tGTSESS THAN 35;000 CUBLC FEET OF ENCLOSED:SE?ACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other(5i. Brief Description liEnter a brief description here. ve-1 ei-L i-l'�j Of Proposed Work:i ✓ SECTION 5=USE GRQUP-ANh}COPISl RUCT10t�FTYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A71 ❑ A-2 ❑ A-3 1A ❑ __ _____ ❑ A-4 ❑ A-5 ❑ 16 ❑ 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 Specify:, S Special Use Specify , i COMPL""ETET�tIS S1=CTf0N iF„ CISTI�}G BUILDING LINDE12G01f+7G RENCCV�TTCOM1IS AaQiTtONS' NN00E CC1N6E fN USE Existing Use Group: �� I Proposed Use Group: Existing Hazard Index 780 CMR 34):` E Proposed Hazard Index 780 CMR 34): i SECTIOPC"6BT11C-D1NG:klE1GHTANDY►REA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) - = u st is 2nd 2 3 3ro E . 4th Total Area(sf Total Proposed New Construction(sf) r Total Height(ft) i Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public Iz- Private ❑ Zone�—�J Outside Flood Zone❑ Municipal JQ On site disposal system _j .Ali Version 1.7 Commercial Building Permit May 15,2000 City of Northampton Building Department = 212 Main Street Room'100 aE Northampton, MA 01060 o S ar phone 413-587-1240 Fax 413-587-1272 I?ir P 4 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUP4NCIY'OF,Ofd DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECIIQN Thls sectron to be- compCefetfhoff cep 1 I-Property Addres j n h ��giu ... yr, p �,eaa`'�'` �a xw+v... .:.-,t �..�'>.�.3. EIIt StD1strr SECTION 2 PROPERTY*OWNERSHIP1AACJTHORIZEET 2.1 Owner of Record: 6.2- Name(Print) ,� ���-'�'-- Current Mailing Add&dS: Signature Telephone 2.2 Authorized Aa t: Name(Print) Current Mailing Add ess: i Signature Telephone .--SEC710NF_3:--ES 1M�4TED CONSTRUCTION':COSTS Item Estimated Cost(Dollars)to be Official UseO,nly: completed by ermit applicant 1. Building Pertniffee r3 L 4 2. Electrical (b)Estimated Total Cost of } ( Consnichonro'tn_6_ 1 3. Plumbing Btiildmg P6ffii- Fee 4. Mechanical(HVAC) ? 5. Fire Protection i 6. Total=(1 +2+3+4+5) 7, Check Number :This Section ifrkW'Use Onl. Buil-dingPern itNt�rnl er QafeF Ts"suad r Signature: Building Commissioner%Inspector.of Buildings Date i 40 File#BP-2007-0954 APPLICANT/CONTACT PERSON DOUGLAS ANDREWS ADDRESS/PHONE 89 LONGVIEW DR FLORENCE (413)584-1370 PROPERTY LOCATION 579 RYAN RD MAP 29 PARCEL 152 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 470 op -tt 44 Fee Paid Typeof Construction:_CONSTRUCT 8 X 8 GABLE ROOF OVER ENTRY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 078947 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: oved 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 Ogti07(t::- 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. r BP-2007-0954 GIS#: COMMONWEALTH OF MASSACHUSETTS IK :I3 � :2 ` 15 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate�.oa.1- BUILDING PERMIT Permit# BP-2007-0954 Project# JS-2007-001554 Est. Cost: $1750.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DOUGLAS ANDREWS 078947 Lot Size(sq. ft.): 959191.20 Owner: NORTHAMPTON REVOLVER CLUB Zoning:URA Applicant: DOUGLAS ANDREWS AT. 579 RYAN RD Applicant Address: Phone: Insurance: 89 LONGVIEW DR (413) 584-1370 FLORENCEMA01062 ISSUED ON.411112007 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 8 X 8 GABLE ROOF OVER ENTRY 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 4/11/2007 0:00:00 $50.00333 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo