24D-121 (2) The Commonwealth ofltMassachiisetts �T
Department of Industrial Accidents cZ
— Office of Investigations
t r r 600 Washington Street C�
�a Boston, MA 02111
,. r
wwwanass.gov/dia -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print LeQibl
Name (Business/Organization/Individual): oot>,G q�+c]
Address: c5 Am j4 c= 3 '
City/State/Zip: Arc MA Phone#: `I 3 � �� -7 3�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..X 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 any capacity. employees and have workers' ❑
9. Building addition
[No workers'comp.insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.[1 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 12.7 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#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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: ( A r jll9��1JQ
Policy#or Self-ins.Lic. #: _ (,y` D Expiration Date: C6
Job Site Address: e2zo �6 3'" City/State/Zip: - " 8v
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
o£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 a under the paid and penalties of perjury that the information provided above is true and correct.
` 2�- .� --
Signature: '� Date:
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#:
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-,STRUCTURAL PEER REVIEW(780 CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION TO!!BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT "
� 'f t t.,JAS_ _ _...__.. ._ ._._-- --w_._.._ ___. ___..v._.__. .... as Owner of the subject property
hereby authorize ....._ ._ . t __.._
nA
_ __._.__ _.°to
t on beh f n II matters ative to work authorized by this building permit application.
W
Signat O er 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
3
Print Na
Signature of Owner/Agent Date
SECTION 12—CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
T1 L
Name of License Holder: ! .. _�
License Number
Address ~W__M . .�..._.�........_:.:__�. _ Expiration Date
NA)NA c5t W1w MA—
Signature / Telephone
SECTION 13=WORKERS'COMPENSATIO N INSURANCE AFFIDAVIT(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 CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL.PURSUANT TO 780 CMRJ1 6(CONTAINING.MORE THAN 35,000 C.F.OF EN
SLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration bate
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
............................. ........... .......................... .........................
...............
Address Registration Number
Signature Telephone Expiration Date
—7
...............
Name Area of Responsibility
Address R�_gistration 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
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
................... ...... ..........
15
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON:ZONING
Existing Proposed Required by Zoning .
Ibis column to.Ve filled in by
Building Department
Lot Size
Frontage =..:w_. ...... ..._.._.,_.,._ .. .......... . ,._ _ ._: ''_....,.., _..._. _.. _>
Setbacks Front
Side Li--_? R:—" '-__j
Rear
Building Height
Bldg. Square Footage I" "' %
Open Space Footage %
I t ,
-_ (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 0 DONT KNOW 0 YES 0
;IF,XES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 0 DONT KNOW C YES Q
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 0 NO 0
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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Pen-nit May 15,2000
SECTION 4-CONSTRUCTION:SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE -
Interior Alterations ❑ Existing.Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Chang of Use❑ Other❑
Brief Description E r a brief description here. I v
Of Proposed Work:
taj�tr f
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 28 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ - - - - 3A ❑
Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B Cl
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 Ir~
S Special Use E-1 Specify:
COMPLETETHIS SECTION IF EXISTING'BUILDING UNDERGOINOR ENOVATIONS1 ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _ _._.. !! W Cl P�.__._. __._._= 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(so
d,
_, ..
_..,.__�.. 2nd s
2nd
3rd
3ro
lh , ...... ......,..............._:........,. ......,.. ... .. -
4 th 4
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.,Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[—] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
! �� �` Departure tuse,only �, ,
City of Northampton Statius of Pemift .....
Building Department curb Gut/Drveway Perrrtr
212 Main Street Sewer/SepficAvatla6i(Ity
L: APR _ L �* : �' Room 100 Water/Well Ayallabllify
Northampton, MA 01060 Twq=Sets of StructuraiPlarts , . ,:ti."
c ph-1wa, 3-587-1240 Fax 413-587-1272 Plo(%Sife Plans
Other Specify t
APPLICATION 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
..
.._._._._. _.._... Map Lot Unit
Zone' Overlay District
f
Elm St:District' CS District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED"AG ENT
2.1 Owner of Record:: 7
Name(Print) � ..
( ) urren rent Mailing Address:
Signature Telephone
2.2 Authorize Ag t:
f M
Name(Print) Current Mailing Address.
Signature Telephone
SECTION 3`-ESTIMATED:CONSTRUCTION:COSTS
em Estimated Cost(Dollars)to be Official Use:On y
completed by ermit applicant
1. Building G'�U a)Building Permit:Fee
2. Electrical O'Estimated Total Cost of
Construction from- 6 _..._ _.,....,__:. .. .... .......:
3. Plumbing ; E uildirig.Permit.Fee
" 4. Mechanical(HVAC) �_..._._.. .......�.. _,��,_..,_. ...,._._; _
_. ...
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.Section..Forr �cia1 Use Only.,I
Building Permit Number Date
Issued
_Signature: -
Building Commissioner/Inspector.of Buildings Date
File#BP-2014-1001
APPLICANT/CONTACT PERSON MARK SMITH
ADDRESS/PHONE 5 ANNA ST WARE (413)531-7342
PROPERTY LOCATION 200 KING ST
MAP 24D PARCEL 121 001 ZONE HB(100)/
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 FRONT PORCH RAILS/DECKING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 104325
3 sets of Plans/Plot Plan
TH FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IORMATION PRESENTED:
���
,j�////// 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
4Bu' ing ' n Delay
Signaturic' Date
Not e: 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.
200 KING ST BP-2014-1001
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 121 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-2014-1001
Project# JS-2014-001742
Est. Cost: $5000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK SMITH 104325
Lot Size(sq. ft.): 11586.96 Owner: VALLEY BUILDING COMPANY INC
Zoning: HB(100)/ Applicant: MARK SMITH
AT: 200 KING ST
Applicant Address: Phone: Insurance:
5 ANNA ST (413) 531-7342
WAREMA01082 ISSUED ON:41312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR FRONT PORCH RAILS/DECKING
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 4/3/2014 0:00:00 $105.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner