31B-213 The Commonwealth of Massachusetts
Department of IndustrialAccidents
—'=
Office Investigations
.ff o f.
Investigations
600 Washington Street
Zl Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizadon/Individual):
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.El 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 an capacity. employees and have workers'
C, Y P tY 9. Building addition
[No workers' comp.insurance comp. insurance.T ❑
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 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per 1vIGL 12.7 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
13 3. Other
employees. [No workers'.
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 anew 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
L.... F
information. , ' -• ,,,, � •� `
Insurance Company Name:
Policy#or Self--ins.Lic.#: .a Expiir tiori brafe:
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 ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Of 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
a
t
SECTION 10-STRUCTURAL PEER REVIEW(780;CMR.110 11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER.AUTHORIZATIO,N-.TO BE COMPLETED,WHEN'.
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
herebyauthorize s...._.. ....___ ._..._ ... ._ ...�_ _,w __ _ . ._.._.:._ ___._... �..� � __ .._ __..__._..___ _.,__
act on my behalf, in all matters relative to work authorized by this building permit application. .__.. ._
Signature of Owner 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...._ .. �.M ,. �_M ...__ __ ..w. ....._....
Print Name .,, __.._ _,. _ _ _ -.__ _....,,
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: _ Not Applicable ❑
1{<.
Name of License Holder:
License Number
Address _.« µ m.:_.. Expira ion 11ate
3-0.7-77e,r.
S n ure Telephone
SECTION 13-WORKERS'`COMPENSATIOK INSURANCE AFFI0All1T
. :
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
r.
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 EN
,SLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): — -- — - -
s Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
_.. _.._........__._......._._. ......___...._._ �_.. _._.._....____. --_.. __ __ _.-_. __.w_._
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address _ Registration Number
i
Signature Telephone Expiration Date
Name _._..___.._.....�-__�..___....�.��,._,e.,_.� ..e.....�._.,_._ a,-...... Area
of Responsibility
Address Registration Number
_..__._.,.___.____.__ ___._. __._.___._.._._.............._,....._............._ ._..__,
Signature Telephone Expiration Date
..... -. .
Name Area of Responsibility
Address Registration Number
Signature F Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addres
Si a Telephone
Versionl.7 Commercial Building Permit May 15,2000
S. N0RTHAMPT0N.40NING
Existing Proposed Required by Zoning
This column to 6e filled in by
Building Department
Lot Size �._ ........� _,.. ......... .�� € .__�-___
Frontage
Setbacks Front
Side
Rear
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 YES 0
IF`fES, 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 DONT KNOW 0 YES C)
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 properiy.i�YES � '., NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradir�excayation,-or,;fillin,g):ovcr e rj or is it pertDf a cgmmo,n plan
that will disturb over 1 acre? YES 0 NO `
IF YES,then a Northampton Storm Water`Managerrierrt Pei=.naerom the DPW is required.
Version 1.7 Commercial Building Permit 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 aI ing❑
_ +�
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing� Change of Use❑ Other A r ,ii .�
40 „ras
Brief Description ;Enter a brief description here.
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYP.E
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B 1 ❑
B Business ❑ 2A ❑
E Educational ❑ 28
F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑
H High Hazard ❑ ^- 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential C& R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:l
......
M Mixed Use ❑ Specify
S Special Use El Specify:
COMPLETE THIS SECTION IF EXISTIN&BUILDING}UNDERGOING-RENOVATIONS;ADDITIONSANb/OR.CHANGE IN USE
Existing Use Group. _�..� ._ ._..__ W _ _ ";F'rbposed 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) z
.. .... -_ ......_.., 1st ,
1sc
2nd 2nd ?
3 rd 3rd
4
4 cn
h _.
Total Area (sf Total Proposed New Constructions µ
_.._. _.
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 ZoneEj Municipal A On site disposal system❑
-a
Versionl.7 Commercial Building.Permit May 15,2000
C? Departure t use;only
4 � ity of Northampton Status of#Permit
uliding Department Curb C,u nueway P 66tt:
SEp Jl()?OI 212 Main Street Sewer '6ptimAvatlability
Room 100 WaterlWell Availability
orthampton, MA 01060 � Twa Sets of Structura€Plans
A 1'3- 87-12 {}ti Fax 4j 3-687 427 Ptot/S�te P€ans l
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 L , 33e)
1.1 Property Address: This section to.be completed,17y office
,Map Lot Unit
Zone Overlay District
Elm:St:District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
13 oO
_.:_.._. _G
... .v.w __a_._ .__.. .....__.
Name(Print) Current Mailing Address K .
Vh
Signature Telephone 13 Svt —5-3Y
SECTION 3w ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building t2 (a)Building Permit Fee
g .
2. Electrical (b)Estimated Total,Cost.of
Construction from 6 __,._ ... ..: ._
3. Plumbing { Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) ( Z 4 pa Check Number
This.Section:For'Official Use Only.
Building Permit Number Date
Issued
Signature: _
Building Commissioner/Inspector of Buildings Date
File# BP-2015-0330
APPLICANT/CONTACT PERSON HANDYMAN HANK
ADDRESS/PHONE 136 MIDDLE ST HADLEY (413)537-0315 Q
PROPERTY LOCATION 71 GOTHIC ST
MAP 31 B PARCEL 213 001 ZONE URC(100)/GB(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: STRIP& SHINGLE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 053684
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORI�V kTION 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
lition Delay
t�
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.
71 GOTHIC ST BP-2015-0330
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B -213 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0330
Proiect# JS-2015-000610
Est. Cost: $94752.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HANDYMAN HANK 053684
Lot Size(sq. ft.): 4835.16 Owner: HAHN KENNETH&ANDREW S RIVIN
zonin--: URC(100)/GB(0)/ Applicant: HANDYMAN HANK
AT: 71 GOTHIC ST
Applicant Address: Phone: Insurance:
136 MIDDLE ST (413) 537-0315 O WC
HADLEYMA01035 ISSUED ON.101212014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 10/2/2014 0:00:00 $75.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner