17A-288 The Commonwealth of-Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Mashington Street
3L4 0211-1
BOStOn, 4 0211
wNnN.maSS.gOYldza
-Workers' Compensation Insurance Aff1daAt: Builders)Contractors/Electricians/Plumbers
kpnlicant Information Please Print Legibiv
NN=e(B=ess/0r,,= ation/Individual): (-N� 2.G .
Address: �7 .,,,A ZA,1
City/State/Zip: 177 „„J Awl A , Di 04,Ahone.T: f
Are you an employer?Check the appropriate box: Tyke of project(required): J J,
ek 4. I am a general contractor and I
1.F11 I am a employer with ❑ 6. ❑New construction
employees(`and/or part-time).* have hired the sub-contractors
2.F7 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors Iaave. & ❑Demo'lition
working for me in any capacity. employees and have workers' 9 71 Building addition
[i l0 worice.a' conID.msUrance Comp. intrrranCe,+`
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
right of exemption per MGL
myself [No workers'coma. 12.7 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' 13.F1 Other
comp.insurance required.]
*Any applicant that checks box n1 must also M out the section below showing their workers'compensation policy infoanation-
t Homeowners who submit this affidavit mdicariag they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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.
Insin ance Company Naae: �r`GV.tom P�p�eCS —
Policy#or Sell-ins.Lic. 7: d K V 9 � Expiration Date: l D c?L0, 09—,
Job Site Address: �{�f C is( City/State/Zip:.�`7`EP�
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 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA for insurance coverage verification_
I do hereby certi the pains and penalties of perjury that the information provided above is true and correct
_ t
S t Date:
Phod _ -
T.
Official use only. Do not write in this area,16 be eomplered by eiry or town offieiaL
City or Town: Permit/License T
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone r:
Version 1.7 Commercial Building Permit Mav 15, 2000
FSECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN _T
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property
hereby authorize to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
37
Address Expiration Date
6k3 .f�6_ �s ��
Sig ture Telephone
7_
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§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 0 No 0
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 36,000 C.F.OF ENCLOSED 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
Signature Telephone Expiration Date
9.3 General Contractor
_..,. 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 be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:- R: ._ _ L: .., . R:,,
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 O 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 Q DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q Date Issued: ^^
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 t NO 0
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: t �2�1 �r,' ��D
/1�P�cv ka�c � /
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 ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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 r-i Specify`
u
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING'RENOVATIONS,ADDITIONS AND/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 -T
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
.I st
St
2nd 2nd
3rd 3rd
4t"
Total Area(sf) 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: 773 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit Mav 15. 2000
Department use only
amity of Northampton Status of Permit:
Building Department Curb CutlDriveway Permit"
c212 Main Street Sewer/Septic Availability
- Room 100 Water/Well Availability,
Northampton, MA 01060 Two Sets of Structural Plans
`phone 413-587-140 Fax 413-587-1272 Plot/Site Plans
y
,. Other Specify
APPLICATION rTO 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 U nit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Sig Telephone
2.2 uthorized Agent: Ud
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
I. Building 04, (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
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
File#BP-2008-0532
APPLICANT/CONTACT PERSON Ruili Ma
ADDRESS/PHONE 37 MARY JANE LANE FLORENCE (413) 586-2529
PROPERTY LOCATION 340 BRIDGE RD-#3
MAP 17A PARCEL 288 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Z—Alt A6 CA-
Fee Paid
Typeof Construction: REPLACE KITCHEN FLOOR&2 FLOOR JOISTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 070307
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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.
BP-2008-0532
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0532
Project# JS-2008-000805
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: Ruili Ma 070307
Lot Size(sq. ft.): 18774.36 Owner: FITZGERALD HAROLD R
Zoning:RR Applicant: Ruill Ma
AT. 340 BRIDGE RD - #3
Applicant Address: Phone: Insurance:
37 MARY JANE LANE (413) 586-2529
FLORENCEMA01062 ISSUED ON.121412007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN FLOOR & 2 FLOOR JOISTS
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 12/4/2007 0:00:00 $50.00504
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo