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23A-149 (4) AThe Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Y Cole �'JJCTZ Address: _4 cj Vw ,,,n G City/State/Zip: 4 C7 Phone #: _ Are you an employer? Check the appropriate box: Type of project(required): 1�I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 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' y F-1 Building addition [No workers' comp_ insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, X1(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: Y^i v. ( _ Policy#or Self-ins. Lic. #: L.I 3Aq 1 l Expiration Date: 1 2-1 1j, Job Site Address: \o ,Wc cA_ City/State/Zip: (44 Attach a copy of the workers' compensation policy declaration page(showing the policy number and Vxpiration 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 ai andpenalties ofperjury that the information provided above is true and correct. Siwi afore: Date: 0 Phone#: ��l -3 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#: g 11h Roseburg �/� 11:2 7-8-15 m 3am I of 1 CS Beam 4.12.3.5 G InnBeamEnOne 4.12.5.1 Materials Database 1515 Member Data Description: Member Type:Beam Application:Floor Top Lateral Bracing:Continuous Bottom Lateral Bracing:Continuous Standard Load: Moisture Condition:Dry Building Code:SBC Live Load: 40 PLF Deflection Criteria: L/360 live,L/240 total Dead Load: 10 PLF Deck Connection:Nailed Member Weight: 15.6 PLF Filename:Beam1 Other Loads Type Trib. Other Dead (Description) Side Begin End Width Start End Start End Category Replacement Uniform(PSF) Top 0' 0.00" 15' 0.00" 15' 0.00" 30 10 Live ` �� A A� 15 0 0 Q 15 0 0 Bearings and Reactions Input Min Gravity Gravity Location Type Material Length Required Reaction Uplift 1 0' 0.000" Wall SPF#3/Stud 2x or 4x End-Grain(650psi) 3.500" 1.500" 4482# 2 15' 0.000" Wall SPF#3/Stud 2x or 4x End-Grain 650 i 3.500" 1.500" 4482# Maximum Load Case Reactions Used for applying point loads(or line loads)to carrying members Live Dead 1 3277# 1206# 2 3277# 1206# Design spans 14' 6.750„ Product: 2.0 RigidLam LVL 1-3/4 x 11-7/8 3 ply PASSES DESIGN CHECKS Connect members with 2 rows of 16d common nails at 12.0"oc NOTE:Nails must be applied from both sides Design assumes continuous lateral bracing along the top chord. Design assumes continuous lateral bracing along the bottom chord. Allowable Stress Design Actual Allowable Capacity Location Loading Positive Moment 16319.# 33194.# 49% 7.5' Total Load D+L Shear 3873.# 12053.# 32% 0.23' Total Load D+L Max.Reaction 4482.# 11944.# 37% 0' Total Load D+L TL Deflection 0.4251" 0.7281" U411 7.5' Total Load D+L LL Deflection 0.3108" 0.4854" U562 7.5' Total Load L Control: LL Deflection DOLS: Live=100% Snow=115% Roof=125% Wind=160% Design assumes a repetitive member use increase in bending stress: 4% All product names are trademarks of their respective owners Copyright(C)2015 by Simpson Strong-Tie Company lno ALL RIGHTS RESERVED. —Passing is defined as when the member,floorjoist,beam or girder,shown on this drawing meets applicable design criteria for Loads,Loading Conditions,and Spans listed on this sheet.The design must be reviewed by qualified designer or design professional as required for approval.This design assumes product installation according to the manufacturers specifications. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �hdi'e ✓ J. &-de License Number Addres Expiration Date go Signature Telephone 1 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Na Registration Number Address c� Expiration Date Telephone / 31 SECTION 10-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....... X No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 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 � DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW ® YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® 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 ® 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F--J Addition ❑ Replacement Windows Alteration(s)-91 Roofing ❑ Or Doors l] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other[E] Brief Descriptiqn of Propose J ��yf Work.Q h 4 �� !C �!7 i7//` Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: 40 Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. ` Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ✓ a�u� J as Owner of the subject property / / hereby authoriz ti �rc�t/ L!e. to act on my al , 'n all matters relative to work authorized by this building permit application. Signature of er Date I, /4 rte'"/ e'-' /,,- , 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 perjury. "'A dr��✓ l�LQ Prinf Name Signature of Owner/Agent Date _ Department use only City of Northampton Status of Permit: i Building Department Curb Cut/Driveway Permit At 13 2015 212 Main Street Sewer/Septic Availability Electric,Plumbing&Gas _:1'�ons Room 100 Water/Well Availability Northampton,MA 01 C 60 Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 1 10 t?t<v.0' 40'1-rt-c:' Map Lot Unit �Vw rCL NNA Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: q,'• Sri {_ Il® Prnt �/, rf®.ti•r, "f1 GI�J�Z Name(Print Current Mailing Address: kly0 Telephone Signatur 2.2 Authorized A ent: A 110 Cale Yd?I-V4 I g,ol 44 61)?5"`9 Name ntI Current Mailing Address: ell-?-3 z S"-, Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 9 c�--►6 (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= 0 +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-2016-0035 APPLICANT/CONTACT PERSON ANDREW COLE ADDRESS/PHONE 469 MAIN RD GILL01354(413)325-1383 PROPERTY LOCATION 110 PINE ST MAP 23A PARCEL 149 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid lypeof Construction: REMOVE KITCH/LIVING RM WALL REMODEL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• - Owner/Statement or License 92165 3 sets of Plans/Plot Plan THE F1,LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF NATION 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 e liti D I a`� Signature of Bui ding 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. 110 PINE ST BP-2016-0035 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 149 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2016-0035 Project# JS-2016-000072 Est. Cost: $8500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ANDREW COLE 92165 Lot Size(sa. ft.): 43995.60 Owner: SAGE DANIEL Zoningz:URB(100)/ Applicant: ANDREW COLE AT. 110 PINE ST Applicant Address: Phone: Insurance: 469 MAIN RD (413) 325-1383 WC G I LLMA01354 ISSUED ON.711312015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE KITCH/LIVING RM WALL, REMODEL KITCHEN 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 7/13/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building Department 212 Main Street Northampton, MA 01060 �0 ---------- 6d 2&Yee