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3�x ttGtsp+icy ARC HITECTVRE 1
STECL RP-24. 142 MAIN STREET
NORTHAMPTON. MASSACHUSETTS
413 566 5775 S 695 5200 I
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The Commonwealth of Massachusetts
r. Department of Industrial Accidents
V,: Office o Investigations
l4
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Wlr( I l uQt1MSllld 'PES1GN g e�ivsrpleeTn�!
Address: T -&Dx /y/ LESC6 MA 40/oS3
City/State/Zip: Phone#: Alls
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 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.❑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. 1 Other 2 Ll6t t i hbLE
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: —TRAU E LF1y5
Policy#or Self-ins.Lic.M 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 the pains and penalties of perjury that the information provided above is true and correct
Signature: J _ Date: /' ✓nef zO/
Phone#: 7/,3
F only. Do not write in this area, to be completed by city or town officiaL
n: ___ _...-_-- Permit/License#
ority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
j Versionl.7 Commercial Building Permit May 15,2000
J
f
SECTION 10-:STRUCTURAL PEER':`REVIEW(7.80 CMR..'110 11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 -OVIINERAUTHORIZATIO.N T _BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FORBUILDING::PERMIT
...........
....._..__._._......_._._..__._...---___.._..............._._.__._____..__
..........',as Owner of the subject property
herebyauthorize _._........_......�[.luL. _....aJ__�_....._.�l��.1Y.!�.t fed�...�.__._.....,...__....�.......�,.....__....w_._._._._......_-.......___._...____.__._..._._____._..._......_._._..__...___ao
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
il ,a
I.:.............__......._ _._..�_._�....��S2.rri _ ,as OmsWAuthorized
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,__�_•_�_��„ ;,,�•�,_,,,�„__.�___-,v__ __�,_,_�_�,_-____,_,�
._._..._1.1L!2S21Y1S� .��..__
Print Name
Signature of Owner• ent ZDate
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: _{ Ll��� .... ......... .1:IeGA�G�J�l2S. iLl__._.._._.,_....._ _W�:<e .._.a .•......Q. Q_..��� ......._..._......_...____...___.
License Number
Address _ _ Expiration Date
Signature Telephone
SECTION 1:3=WORK ERS'`COMPENSATION INSURANCEAFFIDAVIT §
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
Versionl.7 Commercial Building Permit May 15,2000
s
SECTION 9-PROFESSIONAL DESIGN:AND CONSTRUCTION;SER.VICES-FO.R BUILDINGSAND STRUCTURES SUBJECT TO
CONSTRUCTION.CONTROL._PURSUANT.TO 780 CMR 1.161CONTAINING-MORE THAN.34,000 C.F.:OF f, LOSE :SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): ?.— _,_
Registration Number d
Ad
Expiration Date
Signatu a Telephone
9.2 gistered Professional Engineer(s):
Name Area of Responsibility
I ;
_ ...._...._.................... -......__............................ _ __ ___.._....._..__._..__._ ._.._.__._,.- v...._.__.........-_.....� _...__._.._,...._. ._..__...._.....................
Address Registration Number
---
Signature Telephone Expiration Date
` s
- I ;
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date _ —
4 f —_
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
.-........._.__......._.........___
r ,
_................................... _.. .._...._.._.. _...._............ _....._..—_._.._..__._.._.._... .. --_._....._._.. __.........._......__.._._._.__> .......... ._...,.._.._..._..._._.-.._...._......._................
Name Area of Responsibility
?
i
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
`lLc
' _.. E..,.....«.... 7e9. _ ..._.__.-,..:.._.. _ .. Not Applicable ❑
Company Name:
Responsible In Charge of Construction
..........-.__
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAM-PTON:ZONING y
Existing Proposed Required by Zoning .
This column to Ue filled in by
Building Department
LotSize =.._..._......_._..M.._.._,.� ,w..� �....�...r......___-�� ............._..___..__.�......._� i
Frontage
Setbacks Front"
Side L: —.--1 R:- - L:i.-._...___i R:=
Rear A•–�
Building Height
Bldg. Square Footage --€ —___ %
Open Space Footage % -----
_ (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 (E) YES 0
s
IF,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES O'
IF YES: enter Book ' Page,�» � and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 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,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.
Version l.7 Commercial Building Permit May 15,2000 ,
SECTION:4-CONSTRUCTION.SERVICES FOR P11OJE:CTS.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❑ Change of Use❑ Other CR
Brief Description Enter a brief description here. !:N STA 11 si j onf of 1?AA ki i4 q Lod- Ll(;A-r
Of Proposed Work 1: FASei C A T�IOM O F COJUCeff—f)—= SEE ATTAc gEa �2 fq LJ/,lp
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 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi h Hazard ❑ -
3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑
M Mercantile ❑ 4 0
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 56 ❑
U Utility E] Specify:
M Mixed Use ❑ Specify: y
SSpecial Use ❑ Specify:(�_ �.:�.�..�. ,,..._.......,..._...�.........___.-.__._._.n..._.__._.._..._.-_.._._.._..._.... ,
COMPLETE THIS SECTION:IF:.EXISTING BUILDING UNDERGOING REN.OVATIONS,ADDITIONS/AND/OR::CHANGEIN`USE
Existing Use Group: .. ...._._..__.�:._...�...,,_,...�..._._..w____..,.,,.-.! Proposed Use Group: '.�.,.._ ._._„_,.._-___• !
Existing Hazard Index 780 CMR 34): _1....._.....1_.. ___ . - Proposed Hazard Index 780 CMR 34):
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
:%-OFFI.CE.USErE7NLY
Floor Area per Floor(sf)
1st _...... _...._._._.._...._..........._.__.__.-_.._...... 1st
2nd 2nd
3 r ._£ 3,d _
4m - _ _ _ 4tn
Total Area(sf) i 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 E] Private [— Zone Outside Flood Zone[—] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building.Permit May 15,2000
`I N DelZartme t use,only t
\j, City of Northampton . Status of'Permtt s
22
\L� uilding Department Curb QVDrtvewa}F Permit,: `
212 Main Street SewerTSepfickya+fa6+lrty` '
r
v� z Cons
Room 100 WaterNVeI1 Rv'arlablhf�
pry n� S V5� orthampton, MA 01060 Two-Sets o StructuraF
phone 413-587-1240 Fax 413-587-1272 I?loffSite Plans.
OtherSpeElfy 4 � , ;: ,
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
_........__...... .. :......_,....._._._.........._.....
_..-_..__._.___._...__.____._...__..._.____.
PAR�MDLS .Co PI FS Map Lot Unit
Na�Am?'M J KA ....Z9ne $ Overlay District
--- �°--- _. .- ---- -^- ^�----_-_°_ ��—-- ` .:Elm St.District'" C8 District
SECTION 2-.:.PROPERTY OWNERSHIP%AUTH'ORIZED,AGENT.::::
2.1 Owner of Record:
Name(Print) Current Mailing Address: _
Signature Telephone
2.2 Authorized Accent:
Name(Print) Current Mailing Addresses
Signature / Telephone
SECTION'3'-:EST1 ATED".CONS:TRUCTION COSTS' .. .
Item Estimated Cost(Dollars)to be Official Use.Onky
completed by ermit applicant
1. Building f0� oo :(a)Building Permit,.Fee
2. Electrical (b):Estirnat6i:176tal'Cost of ;
/000 • °O Const'6tfon-from- 6
3. Plumbing :Buildirig!Permit Fee
4. Mechanical(HVAC) �� w
5. Fire Protection -._.. . ..•...---.-•...—..-_._..._._._. ._....
,
6. Total=(1 +2+3+4+5) 2Cuo0. °O :.Check Number
This:Sectiori;�Foi Officiat.Use:Onl
Building Permit Number _Date.
issued
_Signature
Building Commissioner/Inspector•of Buildings Date 7/21/` V
21 CONZ ST-PARADISE COPIES BP-2015-0023
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 118 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-2015-0023
Project# JS-2015-000032
Est.Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM TUROMSHA 000515
Lot Size(sq. ft.): 14679.72 Owner: POWERTENINTWO LLC
Zoning:NB 91 (9)/ Applicant: WILLIAM TUROMSHA
AT: 21 CONZ ST - PARADISE COPIES
Applicant Address: Phone: Insurance:
P O Box 141 (413) 586-4005
LEEDSMA01053 ISSUED ON.71212014 0:00:00
TO PERFORM THE FOLLOWING WORK: STALL CONCRETE BASE FOR PARKING LOT
LIGHT
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 7/2/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner