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The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street Suite 100
Boston,MA 02114-2417
www.massgovfdia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Craig Sweitzer& Co LLC
Address:231 Butler Road
City/State/Zip:Monson, MA 01057 phone#:413-626-1498
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 3 4. ❑ I am a general contractor and 1 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. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for mein 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.❑ 1 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 ] 13.❑Other p orch re p required.)t c. 152,§1(4),and we have no air
q
employees. [No workers
comp. insurance required.]
*Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information.
f 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:General Casualty Co
Policy#or Self-ins. Lie.#:CWC 0397276 Expiration Date:6/5114
Job Site Address: 138 Elm Street City/State/Zip:Northampton, MA
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 e. 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
March 25, 2014
Signature• Date:
Phone#: 413-6261498
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
'4 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations p
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information /'Please Print Le6ibly
�
Name(Business/Organization/Individual): O I C, sl-,- i✓ t Z �' co L L
Address: -r(.7t / J
City/State/Zip: Nile tw y«f Phone#: ! _ buo
Are you an employer?Check the appropriate box: Type of project(required):
1.EPIam a employer 4. E] I am a general contractor and I
with_�- 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
_2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
-- These sub-contractors have
ship and have no employees 8. E]Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
�.❑
officers have exercised their 11. Plumbing repairs or additions
I am a homeowner doing all work
- right of exemption per vGL
myself [ o workers' com p.
12.F-1 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
employees. [No workers' li.[* 'Other Ij�t/lq/.� 41
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 co_py of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information:provided above is true and correct.
Signature: Date: I &
- -
Phone#:
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
f
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 -OWNER'.AUTHORIZATION:Td BE'COMPLETED WHEN.
OWNERS AGENT OR CONTRACTOR:APPLIES FOR.BUILDING PERMIT
..._ m�"?'!yr� i�L � as Owner of the subject property
fLA
hereby authorize ._ � rJ t t l°
__ _.... ...... ..._. . _ ._. ._M.._. ._.w W„ _ ..� .. .. . ...__.. ...._._._.. .,._._. . _.y _..
act on my behaifo�'n all matters relative k authorized by this building permit application.
�/LCt 5 l
Signature of n r 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
Print Name
Signature-'CrOwnfrAgVt Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .� .� �.:T�.- ... .,,, -._ d_ t_ _.7_-��--.J.__- ._._.
License Number
Address Expiration Date
Signature Telephone
SECTION 13 WORKERS'COMPENSATIONIKSURANCE AFFri DAV'T(M G L.
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 0 No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN'AND CONSTRUCTIOWSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR116(PQN.T INING1.MORE THAN 35,000 C.F.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
......... ... ....._.._ ........ ........... ._...:.....__. .:.,,..__._.
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address R�qjstration Number
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
Signature Telephone I Expiration Date
.
_.. ................_.......... .._..............._ _..__ _._._._ ..,._......._.__..._.. ....... _. . _._.._.._.__._._. _.._.._.._._.. .__ _ ._.
Name Area of Responsibility
Address Registration Number
Signature Telephone I Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
__W w
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
J
8.. NORTHAMPTON ZONING _
Existing Proposed Required by Zoning
This column to'li filled in by
Building Department
Lot Size
Frontage
Setbacks Front }
Side L:'._.�..._ i R: ^. L:l R �
Rear
Building Height r
Bldg. Square Footage - % - - i "-
Open Space Footage %
(Lot area minus bldg&paved S
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 YES 0
IF.YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES __. ._. _____...._. ...
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (4--" DON7 KNOW Q YES
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 0 NO
IF YES, describe size, type and location:
......._......_...
. .. ...._.. . _ . . ..__... _..;:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
_ IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavati r 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 Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
SECTION.4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAK 35,000 t
CUBIC FEET OF ENCLOSED SPACE-
Interior Alterations ❑ Existing Wall Signs ❑ Demolition E3 Repair Additions ❑ Accessory B^ui�ldi
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ER
Brief Description €Enter a brief description here. (L G w j-ri,je. �P`'C N
Of Proposed Work: M 4 r Rt,4 6 j 4- D6-j t
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ — _ ==- _ 3A ❑
Institutional ❑ I-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 F-1 Specify _._.._.--------
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:���.� ..�.._��-..�.�__....��.._.._..,_�....-...._._. .w.___...._.._.�......_...__..�.._ �.._
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/ORCHANGE IN USE
Existing Use Group: _.___ ._� _... _ _ ___ _ Proposed Use Group:
Existing Hazard Index 780 CMR 34) Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE.ONLY
Floor Area per Floor(sf)
ist
y:
1st
........_._—_._,..._._.--_._M...�,
2nd
2nd
3 rd
3 rd
4 t 4 3
Total Area (so Total Proposed New Construction(sf)
Total Height(ft) _.__.. _ _._ .._._....
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood_Zone,lnformation: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
+ Departure t use,o"I' t
[ City Of Northampton status o€`Pem�Et
-� Y
Building Department Curt?Cut/Drveway F?erm
Main Street Sewer/SepticAvatla6rlrty
1�1f1M� ,
oom 100 W6terNVel1Avallab1
N pton, MA 01060 Two:Sets of.StructuralPlans
t.
Alec'
C.
` hone_4 240 Fax 413-587-1272 Plot%Srte Plans
FAPPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to.be completed by office
_...__,_.... .. p._._.._._ .....__....._._.._.:._._.._._..............._._..._.__._.._.....__..__.___....__
Ma p Lot Unit
I
Zone. District
t
-- - Elm'St.District CB District!
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
�: �°�s�->�:t �. ..._._..__. w._�.+.,..4 t'ZGr?.'�_.__M.�..�__..� ±2�L.._.. L'.� -_.��.�!!I�'N��Q�•�_. s?._...�C31G'�'
Name(Print) Current Mailing Address:_
Signature Telephone
SECTION 3-E MA CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 5'0 (a)Building Permit:.Fee
2. Electrical
(b):Estimated TotalCost of
Construcfion from(6)* _. _�.............._._. ....__._. ..:
3. Plumbing f Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _. _._ ....__ _ .._...._. _ _..__....
_6. Total=(1 +2+3+4+5) 3, 50 U Check Number 77 13 7
This Section For Official Use Only.
Building Permit Number Date
Issued
Si nature:
Building Commissioner(Inspector,of Buildings Date
File#BP-2014-0975 l� O
APPLICANT/CONTACT PERSON CRAIG SWEITZER&CO LLC ..• e �
ADDRESS/PHONE 231 BUTLER RD MONSON (413)626-1498x
PROPERTY t
LOCATION 138 ELM ST-ADMISSIONS HOUSE
MAP 31B PARCEL 243 001 ZONE URC(100)/EU(57)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR PORCH W/LIKE MATERIALS&DESIGN TO DUPLICATE EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinp-Plans Included:
Owner/Statement or License 15713
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO!�UATION 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
e olition Delay
gnature of ui ding 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.
138 ELM ST-ADMISSIONS HOUSE BP-2014-0975
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-243 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-0975
Project# JS-2014-001698
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CRAIG SWEITZER & CO LLC 15713
Lot Size(sg. ft.): 11194.92 Owner: Smith College
Zoning:URC(100 /E) U(57)/ Applicant: CRAIG SWEITZER & CO LLC
AT. 138 ELM ST - ADMISSIONS HOUSE
Applicant Address: Phone: Insurance:
231 BUTLER RD (413) 626-1498 WC
MONSONMA01057 ISSUED ON:312712014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH W/LIKE MATERIALS & DESIGN
TO DUPLICATE EXISTING
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 3/27/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner