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32C-276 (26) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly II Name(Business/OrganiZation/Individual): Haydenville Woodworking & Design. Inc. i Address: P.O. Box 1070 i Amherst, MA 01004 1 City/State/Zip. Phone#: (413) 665-7402 Are you an employer? Check the appropriate box: Type of project(required): I 1.0 I am an employer with 9 4.1:11 am a general contractor and I 6. ❑ New construction � employees(full and/or part-time).* have hired the sub-contractors 7, ❑ Remodeling listed on the attached sheet. 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition ship and have no employees employees and have workers' 9 ❑ Building addition working for me in any capacity. comp.insurance.$ [No workers'comp.insurance 10.❑ Electrical repairs or additions required.] 5.❑We are a corporation and its officers have exercised their 11.❑ Plumbing repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL c. 12.❑ Roof repairs myself.[No workers'comp. 152,§1(4),and we have no insurance required.]f employees.[No workers' 13.❑ Other comp,insurance required.] *Any applicant that checks box#I must also till 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. 1 am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: A.I.M. Mutual Insurance Company Policy#or Self-ins.Lic.#: WMZ-800-8006257-2014A Expiration Date: 07/06/15 Job Site Address: 81" 8A ,.5t,4— City/State/Zip: /Yfmr—t�o.., ""� O 1 oC C 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 enalties of perjury that the information provided above is true and correct. Signatur Date: Phone#: (413) 348-2733 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#: S:\InspectionsTERMIT APPLICATION FORMSIworkers Comp Aff-pdfdoc Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No �� SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �•�h or sa L!'4 4 r»a f e f ,as Owner of the subject property hereby authorize _A 4"� �. ._.L7`Q ci c S to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner —� Date I �.9 wG� loo D,ES 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 Derjury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supery isor: Not Applicable ❑ Name of License Holder: License Number _oe f!,fle4,O .11"'JO 19ee.11111+1 f-1, Address Expiration Date Ella 35`8,x733 SigRigfure Telephone 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 ey-- 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 35,000 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 �a .��.v�(/e. �/o•d'wo�Gt�-: _L��S. ',. Not Applicable ❑ Company Name: Responsible In Charge of Construction 26 1717 (DIC0 Address yi3 3Yb'z2733 Si ure Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be tilled 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 Q DON'T KNOW (D' YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON'T KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O 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 O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excav on, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 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 L'7 Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other❑ Brief Description Enter a brief description here. �?��la«- Q h �`Y ��c c`S �.► i�!, s @�c- Of Proposed Work: C.' (y �-+o �ro-•,ct_� 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 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential Er 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: 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 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1St 1 St 2nd 2nd 3rd 3'd _ 4th 4th 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: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[-] Versionl.7 Commercial Building Permit May 15,2000 1l l; 2 Department use only D I 1Vl L� City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit L A 3 2015 1,0 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric Plum.inq t,;� inspections Northampton, MA 01060 Two Sets of Structural Plans N rtnam" A,-,A 0, oh ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans 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 1.1 Property Address: This section to be completed by 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 'l Telephone 2.2 Authorized Agent: ........._ . _._._ __ __.__ _.__-. __..__. _ .__._ __ __..._ _.-- 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 f37 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of /U1/1l` Construction from 6 3. Plumbing /' l Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection ( 6. Total=(1 +2+3+4+5) y.�� o` Check Number This Section For Official Use Only Building Permit Number Date Issued Signat . / — 3/"5' Bu mg Commissioner/lnspec or'of Buildings Date 80 WILLIAMS ST BP-2015-0926 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-276 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2015-0926 Proiect# JS-2015-001792 Est. Cost: $9437.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group. HAYDENVILLE WOODWORKING & DESIGN INC 044314 Lot Size(sq. ft.): Owner: KHERDIAN DAVID&NONNY C/O HOLLEY HAYMAKER Zoning: URC(IOO)/ Applicant: HAYDENVILLE WOODWORKING & DESIGN INC AT. 80 WILLIAMS ST Applicant Address: Phone: Insurance: P O BOX 1070 (413) 253-3229 Workers Compensation AMHERSTMA01004 ISSUED ON:41312015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT ENTRY DOORS 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 4/3/2015 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner