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25C-007 (20) Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-074500 FRANCIS C MAS9N 589 OLD NORTH1a WORTHINGTON Expiration Commissioner 04/13/2015 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 ' N- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _ Address: l City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, 05emolition 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. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t C. 152, §](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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: bow� Policy#or Self-ins. Lic. #: ALP' ,TO(a2 S_Co Expiration Date: 11.¢ 1 Job Site Address: ��Z �k�t�'V� ��— City/State/Zip: Vet OtC3(00 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here certify under the pains andpenalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: C o f' L:�r1h,1111 1)ton 2 Q Main Sitect, Northampton, fi:A �.11 .1 (, In accordance of the provisions of MGL c 40, S54, I acknowledge that as condition of the building permit all debris resulting from the construction activity governed b this Building Per mit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 1, S 150A, Address of the work 'The debris will be transported by: POAP,k4--t- The debris will be received b - _.V..�._ Building permit number", Name of Permit Applicant Date Signature of Permit , applicant SECTION 8•CONSTRUCTION SERVICES �^�ypx NotApplwable 6 i a 4 Not yA F i [ ..-.r....: ,,,,,..... .,r -.m.. ..,x:: ......_.,..cam® _.v. ..e..a.. ...........e.s..„... .,..r.....�..�...., -,,,.. ...u� 4 -...w.rrr.!.y.a! � .-.. s. f € e � € , SECTION -WORKEAS'COMPIENSATION INSURANCE AFF1 T IM01,c 152, 25-C(6)) I I ejtl t „S.Unam " qtt€day.t YR l.i. t)e comploled,and subijl�tte € tl., , t G.; IklC 1C:':S€'.SYFS$¢".'tNjt. 3 s34'a'< d ii C 3 sua »of tide t�€I t�, x l t _ E ee z jAtfwned w - woo E-sla tioil to tA x,2.}ittzk�" fl` ,ww.:. 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I'D The B?4J:'rq;,an d r kt,`3°.Fumy Yes SECMN 7*-OWNER AVTHOORIZAPON-TO SE COMPLETED WHEN R AGENT OR CONTRACTOR APPLIES FOR RIALOI IT € " } € 93 a mle t is r lw v $,a O'm"0" 3tst"h':^a, zec;.l kh,, 1-�,O Oid Ii%-peznl zlp ";a tsln:g .., .. ». Dak °9 r =,,8 t,e state r.._ and€+ =rs,.s1, 0"1 111C 0,e:4€r<€q ap €';.alv,r are-¢serge and r c"c'uraww 10 Me best of my�rpow f a d , tnZ =z€" ana perk t .......... e Sec t ion I, ZoNm�G Ai irif of€r-A= pr'mu"t N, glvrm_t Uvi Be Der-,,�I To m i i I o°nms")n t cu'luma w tw ffliw m h� i w Sloe NIA r Has Special Perrri i Variance Pinci it ever bi;,en i5swd fbI "oon V-e wte,'�- DON'T FNOW G YES IF YES, darf�issued: If YES: y a-,th,e petmil recotded at 0e Registry of bf-it its,' mo C) DON7 KNOW YES IF YES: page ancilm Duccumerit. 9 /-N F s 5 the site tf,;fiui 'a brook. LucKly c-4 water '-ir "No 0 DON'T KNO'Ai k-11 YES IF YES,h�n a pemiit tw�c-�Q'V fleed to Lw at-t-lifie'd ftom thi� Needs to be obtained Obtained Date Issued: C, Do any sign's t,--*!s4 cni t6-0 pr"*-r ty' f E'S" 0 wo r. size, vfpe an.1 tocatin D, Arr Vl,ef e any= -(,Dfxv�ed cha,'.1ge"i tu,an of 4 t(--Ided kji he p, ty 'k ES ll�. IF YES, desuitie size- uipe and (cicahnr,- E, dt'Mu" J'eanfv,) qadmg excavalicl�';'of fithnqzl Ove'F is"l VES NO IF YE!"', t•'('n a ",Vj"C"o,%43 7a'' � .. r.�s„y.,., �� � _ }� �' ;'#k gam'` t "MF w Zone413-587-1240 Do oaf Nort hampton * of ���P 2 9 ing rtm t �r�tarn Street 1 NPiumbin�8 rtr 0106 APPiLICATION TO CONSTRUCT,ALTER, REPAIR:RENOVATE M USH,A ONE OR TWO FAMILY OWELUNG SECTION SITE INFORMATION Ttft on to to pomp - ,�N. . x zone . r M ,. ,,., ,,,,,,, k ra s r,� �d a s, Aa ess 3 F Current MaOuN areas p .. e E dmq Plat Fee a � Jnc,_ ,uA r ;Estimated lowl Cosi lot of BuiIding Permit Fee Ng ft r`& This Section For Otti ig U r ! Date llr i , File#BP-2015-0357 APPLICANT/CONTACT PERSON WESTERN MASS DEMOLITION CORP ADDRESS/PHONE 30 SUNSET DR WESTFIELD (413)574-5254 PROPERTY LOCATION 142 NORTH ST MAP 25C PARCEL 007 001 ZONE URB000)/ 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: DEMOLISH GARAGE/BARN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildine Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN �RMATION PRESENTED: lll///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 R -- 1 r© z 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. 142 NORTH ST BP-2015-0357 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-007 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2015-0357 Project# JS-2015-000665 Est. Cost: $4200.00 Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group WESTERN MASS DEMOLITION CORP_ Lot Size(sq. ft.): 44431.20 Owner: JOSEPH SPIRIT&AARON BRANDES Zoning: URB(100)/ Applicant: WESTERN MASS DEMOLITION CORP AT. 142 NORTH ST Applicant Address: Phone: Insurance: 30 SUNSET DR (413) 574-5254 WC WESTFIELDMA01085 ISSUED ON.101312014 0:00:00 TO PERFORM THE FOLLOWING WORK.DEMOLISH GARAGE/BARN 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 Siznature: FeeType: Date Paid: Amount: Building 10/3/2014 0:00:00 $20.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner