17C-182 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information C Please Print Legibly
Name (Business/Organization/Individual): �0�•:J
Address:�
City/State/Zip: ��� Q , ��Q Phone#: — d�
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.71 I am a employer with 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
2.F-1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. F_j Demolition
working for me in any capacity. employees and have workers' 9 E]Building addition
[No workers' comp. insurance comp. insurance.$
5. 0 We are a corporation and its 10.❑Electrical repairs or additions
required.]
,. I am a homeowner doing all work
❑
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13-❑ 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 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: SS v_i
Policy#or Self-ins.Lic.#:l_.3 a�% 3 r J 1 af�,C�,y Expiration Date:
QV f
Job Site Address: r- 1 % Q � '�'F'-VCS �► City/State/Zip: b
Attach a copy of the workers' c pensation 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
fin?rrr to S 1,5M 00 and/nr nnP-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER an d 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,4ndpen des of rjury at the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
--C►fy 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
SECTION 10-STRUCTURAL PEER REVIEW(780ICMR 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
as Owner of the subject property
hereby authorize1�'"''
act on my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner bate
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 perfur%„
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§--25C(6))
Workers Compensation Insurance affi avit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bLAding permit.
Signed Affidavit Attached Yes s 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):
_ ........ A_
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 R,istration 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
..o�� �Q'= Not Applicable ❑
__. __
Company Name:
Responsible In Charge of Construction
- Address --- -- - ------- - ---- - - -- — --- --- - --- ----- - -----
Signature Telephone
_ Version l.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZON371G _
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 -•--•--- --w
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q 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 'mTWm y ~m Page m and/or Document# °°._...._._...,_.
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , 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 0 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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
s
Version l.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:
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 ❑
I 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.
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): W,..
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE!ONLY
Floor Area per Floor(so
St
1St
.h
2nd 2nd .. ..,
3 rd 3 rd
__.._ __._.. 4u,
4`n
� p
Total Area(s Total Proposed New Construction
Total Height(ft)
Total Height ft . .... ,_ ._. .
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone.lnformation: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone _ Outside Flood Zone[] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
Deparfrnent.use c�tip
bity of Northampton statesPefmt
t
Building Department CurbCuflbrtyeway PeiTnit
2.12 Main Street SewerfSep#�cAuaabsllr
Room 100 V1laterltlFfell Availability
Northampton, MA 01060 Two"Setsafstructurai"Plans
phone 413 X87-1�40 Fax 413-587-1272 PlattSite.Plans
Other Sb ecify
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
P i Li j.;nQ`l� (�� � Map Lot Unit
JCS J ma ��li cz� r Zone Overlay District
..._e. Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address
Signature Telephone k�
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 (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
Ab
File#BP-2009-1013
APPLICANT/CONTACT PERSON HARLOW BUILDERS
ADDRESSIPHONE 336 COLES MEADOW RD NORTHAMPTON (413)586-0465
PROPERTY LOCATION 28 PLYMOUTH AVE
MAP 17C PARCEL 182 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeeof Construction: REPAIR PORCH(POST BEAM PIER)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory_Structure -
Building Plans Included:
Owner/Statement or License 052460
3 sets of Plans/Plot Plan
THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
Demolition Delay
to
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.
X28 PLYMOUTH AVE :`�-` BP-2009-1013
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-2009-1013
Project# JS-2009-001459
Est.Cost: $8000.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HARLOW BUILDERS 052460
Lot Size(sq. ft.): 16117.20 Owner: JEFFWAY LOUISE E&WILLIAM F
Zoning:URB(100) Applicant: HARLOW BUILDERS
AT. 28 PLYMOUTH AVE
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586-0465
Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:61412009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH (POST BEAM,PIER)
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 6/4/2009 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo