23B-015 (17) The Cotnmoizwealth of Massachusetts
Department of Industrial Accidents
Office ofLxvesti�ations
o
600 Washington Street
Boston MA 02111
w =" , www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Leaibly
Name(Business/Organization/Individual): i 1�'�^��' µ1 -i t
Address:
City/State/Zip: Phone#:
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._ I am a sole proprietor or_ listed on the attached sheet. 7: F-1 Remodeling
partner-
ship nd have no employees These sub-contractors have g
p ❑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. o workers comp. right per
y � ' ht of exemption MGL p 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
COMP.L 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 certify under th penalties of perjury that the information provided above is true and correct.
tSignature: Date: � Z�." I-I,
Phone#:
Eonly. Do not write in this area,to be completed by city or town official
n: - - - - _ _.-_ Permit/License#hority(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-,STRUCTURAL PP-ER:!REV.I:EW(780 CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes w No 0
SECTION 11 -OWNER AUTHORIZATION--TO:SE:COMPLETED;;WHEN:c:
OWNERS AGENT OR CONTRACTOR APPLIES FOWBUILDING:PERMIT. .
V J (, ........._',as Owner of the subject property
hereby authorize ._
act o my e alf, in all matters relative to Ark uthorized by this building permit application.
{
Sign ure of Owner Dat
c 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor. Not Applicable ❑
t
Name of License Holder: t ��,r2v� .. d _.__ �n__w 3 .._.. �(.�_ _............. __._..'
License Number
Address � Expiration Date
Signature Telephone
SECTION 13-WORKERS''';COMPENSATION INSURANCE AFFIDAVIT
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
' a
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 CMR 116(CONTAINING:MORE THAN 35;000 C.F.OF EI�LOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
_...__,_....__., __..__. ..,._..__._..._..__----
I Registration Number
Address ( r.
Expiration Date
f
Signature Telephone
9.2 Registered Professional Engineer(s):
f
Name Area of Responsibility
II#
Address Registration Number
Signature Telephone Expiration Date
_.._........................._...,...._............._.....
Name Area of Responsibility
Address R�istration Number
Signature Telephone Expiration Date
3
Name Area of Responsibility
Address Registration Number
j {
_,__._._,,,.:_..,._..._.,.....__.... ............,_.............................._..........._...............__.......,
Signature Telephone Expiration Date
.........._._..........._....._...
_.__.__.._._,.__. .___._.
i..................................._......_......_........._............ .........___.._._-------_..____.......,......... I 5
_
..........
Name m M _ — Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction _
_.....,............_...............-....._..._.,._._.__w_... __.. _.__..._ .._._.._.__._ .. ... ..._.._ .......
Signature Telephone
s
e
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON,,.ZONING
Existing Proposed Required by Zoning .
This column to Ge filled in by
Building Department
Lot Size
Frontage �. _........_.._�_.__._.._...�' ' �.,.�..,�._ _...� .._...._?
Setbacks Front
Side L:= R:=_ _s L:=_.._...._.._...a R:=
Rear _
Building Height
Bldg. Square Footage _. " %
Open Space Footage %
(Lot area minus bldg&paved
parking)r_�....._
#of Parking Spaces `
Fill: 1
(volume&Location) -- -- ----: — —-
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES Q
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 0 DONT KNOW C YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: » m
C. Do any signs exist on the property? YES 0 NO Q
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: _.
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 C
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1 �
Version 1.7 Commercial Building Permit May 15,2000
SECTION:4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 36,000 +
CUBIC FEET OF ENCLOSED SPACE * ''' 44
Interior Alterations ❑ Existing.Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofingtg Change of Use❑ Other❑
Brief Description , Enter a brief description here..
Of Proposed Work:
SECTION 5-USE GROUP ANUCONSTRU.CTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 El A-2 El A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 18 ❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H-Hi h Hazard ❑ -- ---- - - -_ .- 3A El
Institutional El 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:r-'�°° .-....._.__.._._,........._....�..___.._._._..__
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE'THIS SECTION IF:EXISTING:BUILDINGt UNDERGOING RENOVATIONS; MUS E
Existing Use Group. _ _ Proposed Use Group.
Existing Hazard Index 780 CMR 34) .,._. r :.-_ _..,,..._ Proposed Hazard Index 780 CMR 34):
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION =OFFLCE USE:ONLY
Floor Area per Floor(so
st _.....- ..._ .. St
1 i
2nd 2nd = ;
3rd 3ra
F ,
_� to ;
4tr t 4 t
Total Area(sf) E Total Proposed New Construction sf)__
�.
.._..._.. _............
Total Height(ft)
--- —-- -- - - Total Height ft-
-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
AIM
t s�1 ft`t x r Departure t GSe plya rx r
1, City of Northampton statr�s�fPea It � �
L,p g` {e � # .p�''��' .7"zSk%�rax�'
I3 U Building Department Curb Cuf/DnuewaYYPerm � � y k
a " ; ii . �' # xS 'F r tis. za �212 Main Street SewerbepticAvatrantltty ��. t w o& .eC ionS Room 100 ll{/afeft ill/yailf �&Gas insp MA 01060 rthampton, MA 01060, one 413-587-1240 Fax 413-587-1272 ploflSte Efansa ' x z
Other Specify ��
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>byoffice
_... ----------- __.____.-_ .._
Map. Lot Unit
b l Zone Overlay District
--; EIm.St:District" CB District
SECTION 2-:PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature 1�kl Telephone
2 2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'!ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be - Official:Use Only
completed by ermit applicant
1. Building 1 (a)Building Permit Fee
ZA �•Un i
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing s Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _.......... ......._.__..,... ._......_.........__.......:........._m_r
6. Total=(1 +2+3+4+5) Check Number
This Section..For Official Use Only.
Building Permit Number Date
Issued
Signature:__
- - - -
Building Commissioner/Inspectorof Buildings Date
�PtAAI
File#BP-2014-0216 //�Q i�OU� G
APPLICANT/CONTACT PERSON C PHILIP ANDRIKIDIS �-
ADDRESS/PHONE 52 Main Street FLORENCE (413)585-9171 P
PROPERTY LOCATION 6 HATFIELD ST ve tA
MAP 23B PARCEL 015 001 ZONE SI(100)/
THIS SECTION FOR OFFICIAL USE 0 1`
PERMIT APPLICATION CHECKLI. v
ENCLOSED
ZONING FORM FILLED OUT
Fee Paid / 4�
Building Permit Filled out
Fee Paid `..J
Typeof Construction: STRIP &SHINGLE ROOF S
New Construction
Non Structural interior renovations
Addition to Existing d �/
Accessory Structure
Building Plans Included: f,4,y (✓J///(�Clh
Owner/Statement or License 071107
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICA'
INFORMATION PRESENTED:
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
Demolition Delay
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.