Loading...
24B-079 (10) ,. . s��� t �T i"'.:1 ? ' � ,r �,�� ;��. r' � �,.. �_ ���. rr: �,, ;.R � ,i5 �. ..,r. �,'r �,' r. .r ��� r� � �. C " 4 ��/ I cJ �I The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH ED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly //"" Name(Business/Organization/Individual): t'�G 4 4 W at y f4 rmc 5 w'a gn meA Address: ,�75 d tip,. free, City/State/Zip: ,,,l qk 01,5rO/ Phone k y 1,3- Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with_employees(full and/or part-time).* 7. New construction In 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. Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.1:1I 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 1 Ln Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®R p oof repairs These sub-contractors have employees and have workers'comp.insurance. 6. _1W,are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]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. `,1 Insurance Company Name: Ark U 1u 4 Policy#or Self-ins.Lic, #: WM Z - 800- f on fo 10 d- 0 p 14 A Expiration Date: 7/d& 6- Job Site Address: 73 3arre4 &i ,&e f City/State/Zip: Ale.-Ma np1w Mp 0/660 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 panins and penalties of perjury that the information provided above is true and correct. Sienature: / /.. =D Date: T 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#: 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 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I'll l? I, 40t E 5 . t�l IN Ss ►�Y{A� �'l\ _. .. ,as er of the subject property hereby authorize '-) Di" to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, y _-. e.✓ �✓_S._ _._. _ __..._ ._.____ _ __. 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. Si ngd under the pains and_penaltles of perjury. Print Name Sig re of Owner/Agent Date S CTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:��.�IJf1/GtTQ�/✓--._ e°✓!s✓S _ _________, ._. ; C`J_ _ ..Q �_ .___._�____._�__' License Number _ Address Expir t ona ii Da e Sign a 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 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: F- 7, 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 !L Name Area of Responsibility .......... Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone I Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address ,,Si re Telephone Version 1.7 Commercial Building Permit May 15,2000 8. 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 11ch DONT KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page', and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES 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 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 © NO 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❑ New Signs 0 Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work: C�� �% O- P / 1?e .loaf Gve/ �io,✓f �,�tr WG. _ _. . __ . . 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 ❑ 1113 ❑ B Business ❑ 2A ❑ E Educational ❑ 213 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑ 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) St 1St 1 2nd 2nd 3rd 3rd 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: F7.3 ewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ ipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 Dei?arttfiainf LISBNy < City of Northampton Status of Permit: ?' Buildin g Department Curb Cut/Driveway Permit APR 1 a 2015 I 212 Main Street Sewer1$pptic Availability Room 100 'ataiMell Availability Electric, Piumoing&Gas Inspection Northampton, MA 01060 Northampton, MA 01060 Two Sets of Structural Plans. `. phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ether 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 '7 Map Lot Unit / Zone Overlay District 3103 -- 3106 Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent. .JOr.XA4-J c V N.S o?(o Old wv►ill oa�� Name(Print) Current Mailing Address: 413 -_ 6011 -_ 61151.6- Signature Telephone SECTION -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building s 00 (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-2015-0967 APPLICANT/CONTACT PERSON JONATHAN DEVINS ADDRESS/PHONE 26 OLD SAWMILL RD BELCHERTOWN01007(413)801-8985 PROPERTY LOCATION 73 BARRETT ST-BLDG 1 -3103-3106 MAP 24B PARCEL 079 001 ZONE URB(100)/WP(7)/ 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: REROOF FRONT ENTRY WAY(CHANGE FLAT TO SLOPED) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: y' Owner/Statement or License 083221 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9.RMATION PRESENTED: (-I 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 D liti lay 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. 73 BARRETT ST-BLDG 1 -3103-3106 BP-2015-0967 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24B-079 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0967 Project# JS-2015-001869 Est.Cost: $4250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JONATHAN DEVINS 083221 Lot Size(sg. ft.): 785822.40 Owner: HATHAWAY FARMS TOWNHOMES LIMITED PARTNERSHIP C/O SPEAR MANAGEMENT Zoning: URB(100)AVP(7)/ Applicant. JONATHAN DEVINS AT. 73 BARRETT ST - BLDG 1 - 3103-3106 Applicant Address: Phone: Insurance: 26 OLD SAWMILL RD (413) 801-8985 WC BELCH ERTOWNMA01007 ISSUED ON:411512015 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF FRONT ENTRY WAY (CHANGE FLAT TO SLOPED) 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 4/15/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner