32C-017 (7) The Commonwealth of Massachusetts
Department of Industrial Accidents
a I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): HPC Wireless Services, LLC
Address: 22 Shelter Rock Lane, Building C
City/State/Zip: Danbury, CT 06810 Phone #: 203-797-1112
Are you an employer?Check the appropriate box:
Type of project(required):
1. X❑I am a employer with 75 employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.[J I am a homeowner doing all work myself [No workers'comp.insurance required.]`
10E] Building addition
4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.r7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs
These sub-contractors have employees and have workers comp.insurance.$
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we have no 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 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: Zurich American Insurance Company of Illinois
Policy#or Self-ins. Lic.#: WC 5525538-01 Expiration Date: 07/06/2015
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 MGL c. 152,§25A is a criminal violation punishable by 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.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 ams and enalties ofperjury that the information provided above is true and correct
Signature: — Date: 30
Phone#• 4eb/ 3bl mag-6,
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#:
The Coninion wealth of Massachusetts
Department of Ii2dustrial Accidents
—' Office of Investigations
w 600 Washington Street
=, Boston, MA 02111
_ www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le6ibly
Name (Business/Organization/Individual): —
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.F-1 I am a employer with � 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
El I am a sole proprietor or partner-
listed on the attached sheet. 7. F-1 Remodeling
ship and have no employees These sub-contractors have 8. ❑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 10.7 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, §1(4),and we have no
employees. [No workers' 13.7 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 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob 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 the pains and penalties of perjury that the information provided above is true and correct.
S ianature: 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 l.7 Commercial Building Permit May 15,2000
SECTION 1D-;STRUCTURAL PEER REVIEW(700;CMRAI,0.111)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWN ER:AUTHORIZATION_:T0:BE:COMPLETED�WHEN
OWNERS AGENT OR CON I TRA I CTOR APPLIES FOR BUILDING PERMIT
........... .................... .......... ------...........-------------
............. ................... .............. ..................... as Owner of the subject property
...........
hereby authorize .. ...... ..........
act on my behalf, in all matters relative to work authorized by this building permit 2pplicatioln.—,-----,,-,-----,-,I
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
.......... ...........
................. ................. ........... -
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holcler:'._.�.J*
License Number
7
Address Expiration Date
SiglTa—ture Telephone
SECTION 13`-WORKERS'COMPENSATION INSURANCE AFFIDAVIT
IJM-Q-Lw: el §25C(6)) :
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 (D
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR:1.16(CONTAINING MORE THAN 35,000 C.F.OF EKLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
...._. ......._
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration 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
Name Area of Responsibility
Address Registration Number
_�. __._.. W. .. .__...... .,. w_..- ._ _.. _. _
Signature Telephone Expiration Date
9.3 General Contractor
C Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_Address___
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to.5e filled in by
Building Department
Lot Size
Frontagew,....... ......_;. _ :. .._.._. '....._._...__..._. _..,.. .., _.. ", ...... _,_ _ _
Setbacks Front
Side L. ____._= R...
Rear
Building Height
Bldg. Square Footage %
Open Space Footage _._ %
(Lot area minus bldg&paved
#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 YES, 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: H_w
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES,then a Northampton Storm Water Management Permit from 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 Building❑
Exterior Alteration ❑ Existing Ground Sign[I New Signs El Roofing[I Change of Use El Other❑
_ _ _ _ _:_ ..._... __.. _.., _... .._._............
Brief Description Enter a brief description here. 3 V\-,_ \ 2 -Swt -.,f-
Of Proposed Work: �u�Q _
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 ❑ 1B ❑
B Business ❑
2A ❑
E Educational ❑ 2B - I� ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard E] 3A El
------
Institutional ❑ 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: :
M Mixed Use ❑ Specify:
S Special Use ❑ Specify: _
COMPLETETHIS SECTION'IF.EXISTING BUILDING UNDERGOING RENOVATIONS;ADDITIONSAND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: :_
Existing Hazard Index 780 CMR 34) __,_,_ _ ___.-...__ Proposed Hazard Index 780 CMR 34): _,...._.: _. ,
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf)
1st ,
15 _-
2nd
2nd
rd
rd 3
th __. ..
4
4'"
Total Area(so Total Proposed New Construction(st)„
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❑
Versionl.7 Commercial Building.Permit May 15,2000
Department use,only
City of Northampton status of Permit
uilding Department Curb Cut/b'rivewayPermd:
3 0 2015 '�
212 Main Street Sewer/SepticAvajlabillty
=77777, 7
1 Room 100 Wate" ell Availability
Gas lnspe� hampton, MA 01060 Two Sets of Structural Plans
Electric,Piumbi ion 87-1240 Fax 413-587-1272 Plot/Srte Plans
Ncrtharnp
Other
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
- - - ElmSt:`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:
. .......-...... __ ..._................ ._ -_, r--.._.._ _ _ ..
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 (a)'Building'Permit Fee
2. Electrical "'' _ (b),Estimated Total,Cost of
Construction from- 6 _... _... .r
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) _.,._..._ ...,....__ . _...._
5. Fire Protection
6. Total=(1 +2+3+4+5) Check-Number
This Section For Official Use Only.
Building Permit Number Date
Issued
Signature:-
Building Commissioner/Inspector of Buildings Date
76 MAIN ST BP-2015-0908
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: ANTENNAS BUILDING PERMIT
Permit# BP-2015-0908
Project# JS-2015-000526
Est. Cost: $12500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HPC WIRELESS SERVICES 107527
Lot Size(sq. ft.): 4094.64 Owner: TRIDENT REALTY CORP C/O HAMPSHIRE MANAGEMENT GROUP
Zoning: CB(100)/ Applicant: HPC WIRELESS SERVICES
AT. 76 MAIN ST
Applicant Address: Phone: Insurance:
118B RIVERVIEW PL (401) 301-3396 WC
SOUTH BRIDGEMA01550 ISSUED ON:313012015 0:00:00
TO PERFORM THE FOLLOWING WORK.MODIFY ANTENNA -INSTALL 3 ROOFTOP
ANTENNAS & 3 RRU'S IN BASEMENT EQUIP ROOM
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 3/30/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner