17C-220 (5) NOTICE NOTICE
TO � TO
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EMPLOYEES EMPLOYEES
$4
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
MA Healthcare Self-Insurance Group, Inc
NAME OF INSURANCE COMPANY
10 British American Blvd. Latham, NY 12110
ADDRESS OF INSURANCE COMPANY
019003100004107 4/01/2007 - 1/01/2008
POLICY NUMBER EFFECTIVE DATES
Webber & Grinnell Ins. Agency 8 North King Street Northampton, MA 01060 413-586-0111
NAME OF INSURANCE AGENT ADDRESS PHONE#
Se.rviceNet, Inc. 129 King Street Northampton, MA 01060
EMPLOYER _N /. ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OF I ER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
3D
NAME 0 HOSPITAL x AD RESS
TO BE POSTED BY EMPLOYER
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 Please Print Legibly
Name(Business/Organization/Individual):
Address: 4,)-!?
City/State/Zip: & f o A,,
IM
Phone.#:
Are you an employer?Check the appropriate box: Type of project(required):
1 I am a employer }l 4. [] I am a general contractor and I
with � 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ,Remodeling
ship and have no employees these sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers 9. ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑ g P
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 131-1 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: A14 f1 e6rZZ ,,I&t,
Policy#or Self-ins.Lic.#: 0/9100.5/CJ GOQ y/D Expiration Date: G'/ e7 t
Job Site Address: {S/� /V 1�'1/?/� f'/ City/State/'Gip ' e-/.
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
InvestiLyations of the DIA for insurance coverage verification.
I do hereby certify nder the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: G
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..1 -7—RUCTURXZP-EERREVIEW{780CMR L1011 _
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 =OWNERAU.THORIZATION TO=BECOMPCETED WHEN
OWNERS-AGENT OR`CONTR 4CTOR4PPLIES.FOR BUILDING PERMIT
A �/ jhl- - as Owner of the subject property
hereby authorize � f��� c� 3
H C.�/16=5 Ito
act on my behalf,in all matters r ative to work authorized by this building permit application.
- i
Signature of Owner Date
as:Cu thorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the nowledge
and belief.
Signed unAVhe pains and eenaltiea of a'u
Print Name
Signature of Owner gent) Date
SECTfOt�G12, COHSTRUCTt01�SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
0,5 -70
Name of License Holder: � ''� T - —
License Number
1A A
Addr Expiration Date
Signature Telephone
SECTION 13:WORKERS'COMPENSATfO PC1NSURATICEAFFIDAU1Tni;M
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
r
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINOS AND STRUCTURES SUBJECT.TO
CONSTRUCTION CONTROL PURSUA ",T' 780-.CMR 116{CONTAINING -MORE THAN-35;000 C.F.OF ENCLOSEMSPAGE)
9.1 Registered Architect:
Not Applicable ❑
i
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
f
Name Area of Responsibility
Address ' R�stration Number
t � �
Signature Telephone Expiration Date
r
Name Area of Responsibility
l
Address !Registration Number
E �
Signature Telephone Expiration Date
Name Area of Responsibility
t
Address Registration Number
i
Signature Telephone Expiration Date
9.3 General Contractor�I
f P /77 9�-U f J Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Ads
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size {
Frontage
Setbacks Front $ t
Side L:`' R:� L:! i R:E J
Rear ��
Bldg.Square Footage ! % �z
1
Open Space Footage %
(Lot area minus bldg&paved
arldn )
#of Parking Spaces
Fill:
j;
(volume&Location) f
I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued: I
i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page; and/or Document#j
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES i
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 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 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 0 ` NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
t..
SECTION 4:66N'ti'RUGT1 SERVICES=FOR�PROJECT�ESS THAN 35,000
CUBIC FEETOF ENCLOSEDPraCE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration_ ,R'Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description :Enter a brief description here. .
Of Proposed Work:
f�/ n7
>
SECTION 3..USE GROUP AND CONSTRUC'WON.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 ❑ 213 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 ❑ Specify:
i
M Mixed Use 0 Specify:
S Special Use 0 Specify:
I
COMPLETE THIS SECTIONIF EXISTING BUILQI�IG UNDEE�GOII G RENOVATfONS;,AbO 'ONS�ANDIOR CH?;NGE IN USE
�F.
Existing Use Group 1 Proposed Use Group:
Existing Hazard Index 780 CMR 34): i Proposed Hazard Index 780 CMR 34):
SECTION 6,BUILDING IEtGHT 1ND AE2EA, -
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION �FFIGEUSEONL � #
Floor Area per Floor(sf)
St i € nkx�� rtk n
St
nd
3
b
Total Area(sf) Total Proposed New Construction(sf)
+ a, r�'w`'". F
Total Height(ft) € ��
Total Height ft a �`
7.Water Supply(M.G.L,c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone i } Outside Flood Zone❑ Municipal ❑ On site disposal system E]
Versionl.7 Commercial Building Permit May 15,2000
P
-- �f Northampton
i1 il�g Department
r-- 2 2�Main Street
2 (}� om.100
AEG ? �Klorthpmpton, MA 01060
phone 41-3---1a7-12 0 Fax 413-587-1272 � .
hS J _
OF
AP IGATIO r� 4 _ S REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 7='S1TE'1NFORM�4TION�-_ � _ _ - -
'•-� � , ` 3Thts sectton��tQ�e compfeted.by-oft'ice
---- -"-Property Address: --
I1dap Lots Und
p� 2 ;S-
!
1 � �"��rF�x =� `,� �"• „ .r fur ;,k '�-«;5����� «a. � 'f•,...+r? —s
SECTION 2; PROPERTY_OWNERS'HIP!AlVTHORIZEDAGENT -
- n_n _
2.1 Owner of Record:
Name(Print) Current Mailing Address
yid
Signature Telephone
2.2 Authmized Age t:
!Gn'7 �O S.• I '7
Name(Print) Current Mailin2 A ress:
J 61 A,-WP
I
Signature `i � �' Telephone
SECTION-3-:ESTIMATED GONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Offciai Use Oral}
cornoleted by rmit applicant _ .. . . . .
1. Building I (a ' wldmg'PermitFee
r I
2. Electrical , (b)'Esfimated Total Cost of
1 '—" i ,'`�Constriaction froii 6, `
3. Plumbing ' i Buldtng Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total--(1 +2+3+4+5) _ Check Number ®3 J
This`Section For.DfficiaFllse Oni
Build ing.Pernit Kumtier Date°
=_ -Issued;
r ,
Signature:
Building Commissionernnspecforof-Buildings Date
File#BP-2008-0191
APPLICANT/CONTACT PERSON Thomas Gross
ADDRESS/PHONE 237 Plumtree Rd SUNDERLAND (413)665-8235
PROPERTY LOCATION 17 NORTH MAPLE ST
MAP 17C PARCEL 220 001 ZONE GB
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: REPLACE 5/4 PT DECK BOARDS ON RAMP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 059093
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJIATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OK 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
lu 08 ?--310 7
Signature of Building icial 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-2008-0191
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-2008-0191
Project# JS-2008-000290
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Thomas Gross 059093
Lot Size(sg ft.): 10410.84 Owner: ServiceNet
zoning: GB Applicant: Thomas Gross
AT: 17 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
237 Plumtree Rd (413)665-8235 Workers
Compensation
SUNDERLANDMA01375 ISSUED ON.8/24/2007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 5/4 PT DECK BOARDS ON RAMP
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 8/24/2007 0:00:00 $50.006035
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo