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25C-095 (43)
The Commonwealth of Massachusetts F Department of Industrial Accidents d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Environmental Services, Inc. Address:90 Brookfield Street City/State/Zip:South Windsor, CT 06074 Phone#:860-528-9500 Are you an employer? Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 50 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] 8. [j Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp. insurance required]* 11.❑ Health Care 4.F-1 We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other Service *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Zurich-American- Evans, Pires&Leonard (agent) Insurer's Address.121 Roberts Street City/State/Zip: East Hartford, CT 06108 Policy#or Self-ins.Lic.#WC 5532864-01 Expiration Date:04/01/16 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' nder the pai and penalties of perjury that the information provided above '•true and correct Si nature: Date: S�f . Phone# 86 -528-9500 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Versionl.7 Commercial.Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(78U GMR 91©t11) Independent Structural Engineering Structural Peer Review Required Yes No Q SECTION 11 -OWNER.AUTHORIZATION-TO BE COMPLEX F_D.,WHEll OWNERS AGENT OR CONTRACTORARPLIES FOR.$U.'L INt3"PERMIT. 'Todd Barron,Trustee of Twin Building Condominium Trust J property ro art as Owner of the sub _... _-.._. p y ;Environmentat Services,Inc. of`Soutb Windsor, CT hereby authorize__.. _____._ _. __ .__-_. _.__.____�___ __._.._ _..... act on my behalf,in all matters relative to work authorized by this building permit applications Signature of Owner Date Todd Barron,Trustee of Twin Building Condominium Trust _-------. ._ 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 an�enalties ofi perjury "Todd Barron __......._..^_.._ _ . _ Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction SuRgn isor: Not Applicable ❑ Name of License Holder.' A _ .__. _ . .. _..... License Number .. _... . ..._... _ i Address Expiration Date i_ Signature Telephone SECTION 13-WORKERS'COMPENSATION INSU,WCEAFFIR"T(M G L 152,192 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 Version 1:7 Commercial Building Permit May 1.5,2000 SECTION 9;PROFESSIONAL.DESIGN AND CONSTRUCTION SERVICES ,FOR SUILDIAIG`a AIJD STRUCTURES 5UB:I.EGT TO t ONSTRUGTION'GO�IVTRCtL TG M CMR 1�IQ(Cf31 1A1iJfNG:sMORE; HAN15 OtI0 C:F OF ENCLOSED SPACE) 9.1 Registered Architect: Not.Applic able ❑ i Y Name(Registrant): _._. _.,:._ ._....._ .._._._ _ _ -._•._.._ ._; Registration Number Address jExpiration Date Signature Telephone 9.2 Registered Professional Engineer(s): A!!t_ �iQ I?ft r�I Gc T-D N ......._ Name Area of Responsibility _ ..... .._._. ___..._ _.. _..__ _.. _.._.,_.._._ .. _................._._......_.............5-0_..__ _...... .. Cj --- ._._. .. ._._.___. .._._... . Address Registration Number .. .. _/J7-5751-Lilo ! oG 3� Zoib ...... ...._.............._ S ature Telephone Expiration Date -.._..-- Name Area of Responsibility t... ........_._ -- Address __ m {Registration Number _ 3 L ..._..... ... —.—._ Signature Telephone Expiration Date ._._.........__...... .__....... ._.... ., f F ! Name Area of Responsibility _ Address Registration Number , Signature Telephone Expiration Date ............. i ._.. Name Area of Responsibility Address Registration Number Signature Telephone I Expiration Date 9.3 General Contractor _ ......_. ......__...... -. _.._._ -- t Not Applicable❑ Company Name: i Responsible In Charge of Construction Address Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 8 N(3tTIA'MPTUI!I Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size t = Frontage _..... , Setbacks Front Side L.,_..._._._I lZ± •.__ L: ....._......... Rear Building Height Bldg.Square Footage "' °lo + "' Open Space Footage _._ % - (Lot area minus bldg&paved parking) #of Parldrig S aces __-_ Fill: l volume:&Location) t ..._...... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: _ IF YES: Was the permit recorded at the Registry of:Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book r Page; I and/or Document#; B. Does the.site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES,.has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued C. Do any signs exist on the property? YES 0 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 Q IF YES, describe size, type and Location: E. Will the oonstruction activity disturb(clearing,,grading,excavation,or filling)over 1 acre or Is it part of a common plan that will disturb over I acre? YES 0 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.Ft)R 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 jA 8'X 10'C-container will place on specified.portion of property to house a.soil vapor extraction. Of Proposed Work:jsystem designed to remedate impacted soils beneath the main structure at 211 North Street. I_ SECTION 5-USE GROUP AND C.ONSTRUCT104 TYFE USE GROUP(Check as applicable:) CONSTRUCTION TYPE A Assembly El A-1 ❑ A-2 ❑ A-3 El 1 A 17 A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 26 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 El 1-3 ❑ 36 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage D s 1 ❑ S-2 ❑ 58 ❑ U Utility ❑ Specify: .,..._ ___ ....._. ._...._._ �,_..._. -. --, ._, ......__ ._ _ M :Mixed Use ❑ Specify: __......,__._ _ S Special Use ❑ Specify: COMPLETE THIS SECTION 1! EXIST[NG SU.fL,DlNG'UNDERrOING RENOVATIONS,. IDDIT10N5 AN CHANGE IN USE Existing Use Group: NA ._..__._.. _____ .—__..--_-._-____ __ ...i Proposed Use Group: l._ __..--- _ _. . ... Existing Hazard Index 780 CMR 34):_ _..__.____.__.....! Proposed Hazard index 780 CMR SECTION-6 BUILDING HEIGHTAND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION CJFFIGi=USE,ONLY' y 4i r` � Floor Area per Floor(s#) . _._._..______.__._ _ ....._. _ 2nd [ 2"d _ a � T a rd ,_..�........._.,__- _......._..�..__— __,y F th th f 4 y. Total Area(sl) Total Proposed New Construqqqnjqq 80 � r Total Height(ft) Total Height tt 7.Water Supply(M.G.L c,4tI,. 54) 7.1 Floo ZopeInformation: 7.3 Sewage Disposal"System: Public 0 Private ❑ Zone i Outside Flood Zone E] Municipal ❑ On site disposal system[] Versionl.7 Commercial Building Permit'Ma 15,2000 e City of Northampton , Building Department 212!Main Street xt MAY g Room 100 No hampton, MA 01060 � " hone 413- 87-1240 Fax 413-587-1272 '� ; Electric,Plumbing&Gas Inspections Northampton, APPLICATION TO CONSTRU ,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOUSH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 4 sectlora to be cdm leted b office 1.1 Prop"Address: p y E } trap; ;211 North Street,Units A-E Lax unit ;Northampton,NIA, 01060 2dne Oa+�rtay District E i�'t�l#�ti'lcE GBDtstrict'" .x._. L SECTION 2-PROPERTY OWNERSHIP%AUTHORIZED AGENT 2.1 Owner of Record: °`Twin Building Condominium Trust 211 North Street,Northampton,MA Name(Print) /'""� Current Mailing Address: s x(413) 5$6-0207 I Signature hone 2.2 Authorized Anent: _ 'Same as above __. _. _._.,..._. .._....._.�___......._........._. __..._..... _..._____ __..._.... Name(Print) Current Mailirrg Address: _ . _. Signature Telephone 3EC°PION 3-ESTIMATED CONSTRUCTION CQSTS Item Estimated Cost(Dollar.)'to be Official Use Only completed b permit applicant 1. Building $2,900A0� (a)Buliding PemlrtFes b Esfimated T>,tall Cost of.. �— — 2. Electrical ' $0;00 t;onstcuction"#rom 6 ; 3. Plumbing $0.00 BuiIZ�In Permrt.Fee 4. Mechanical(HVAC) ___....- $55..00!', $2,900.00 . . 5.Fire Protection B. Total (1 +2+3+4+5) check Number : -.This: ection"I�r°Oflicial'!I>��4Qh1 ,, ° - Bullding Permit Number.Date 1ssued k Signature: { :Building Commissiemerltnspsctor ofi Biiiltlings ©ate File#BP-2015-1134 APPLICANT/CONTACT PERSON ENVIRONMENTAL SERVICES INC ADDRESS/PHONE 90 BROOKFIELD ST SOUTH WINDSOR06074(860)528-9500 PROPERTY LOCATION 211 NORTH ST MAP 25C PARCEL 095 001 ZONE URB 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: ERECT 8 X 10 CONTAINER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 C4=.� 14-161 2i /I 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. 211 NORTH ST BP-2015-1134 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-095 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: shed BUILDING PERMIT Permit# BP-2015-1134 Project# JS-2015-002136 Est. Cost: $5800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ENVIRONMENTAL SERVICES INC- Lot Size(sq. 111 8189.28 Owner: TWIN BUILDING CONDOMINIUM ASSOC Zoning. URB Applicant: ENVIRONMENTAL SERVICES INC AT. 211 NORTH ST Applicant Address: Phone: Insurance: 90 BROOKFIELD ST (860) 528-9500 SOUTH WINDSORCT06074 ISSUED ON.•512612015 0:00:00 TO PERFORM THE FOLLOWING WORK.ERECT 8 X 10 CONTAINER 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 5/26/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner