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31B-225 (4) ., The Commonwealth of Massachusetts Department of Ltdustrial 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 Leaibly Name(Business/Organization/Individual): 64Ce� (`�/+--- ("QZ S7-1Z 4le— p f(/ Address: c_"/2 City/State/Zip: 0 6 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. E]New construction _2.X I am a sole proprietor or partner- listed on the attached sheet. 7 . 9 Remodeling ship and have no employees These sub-contractors have g F1 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance.1 required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.El 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, §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: Policy#or Self--ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 certify under thepains andpenalties ofperjury that t e i ormation provided above is true and correct. Si nature: Date: 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 REVL.EW 1-780 CMR.110.11) Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 -OWNER.AUTHORIZATION=T&EIE.COMPLETED: WHEN; OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING-PERMIT as Owner of the subject property .... ,.__ _. _....._ __. . .... .... to hereby authorize . .. .... act on my behalf,in all matters relative to work authorized by this building permit application. _.._ _ .._.._._._..,. _ i Signature of Owner Date 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,he„Pains_and penalties,ofp erlury f 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 Signagag, Telephone SECTION 136-WORKERS'COMPENSATLON 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 0 No 0 Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIORSERVICES-FOR BUILDINGS AND STRUCTURES 6UBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF EWLOSED SPACE) 9.1 Registered Architect: Not Applicable Name(Registrant). _ Registration Number AddressI,._.,._ _., ....._,._.., ..., .. . ....._,.,.,.... ,_ ... . ._. Expiration Date Signature _ Telephones 9.2 Registered Professional Engineer(s): Name Area of Responsibility ........................._ ._..,. - t _ _. __ . Address Registration Number Signature Telephone Expiration Date ....... _ _.__......._ ._. . _ Name Area of Responsibility l Address Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date __w..__.._...__. _.. ..._.___ _._,....... i .......... ..._ Name Area of Responsibility I Address Registration Number t I Signature Telephone Expiration Date 9.3 General Contractor _ ..._ Not Applicable ❑ Company Name: Responsible In Charge of Construction . .. Address Signature Telephone r Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON.ZONING Existing Proposed Required by Zoning . This column to lie filled in by Building Department Lot Size Frontage Setbacks Front j Side L.. __...._i R:t _ L:_, J R... . _ .. _:___.__, Rear . Building Height E ; `...____...... Bldg. Square Footage `` % j Open Space Footage % - -< (Lot area minus bldg&paved parking) #of Parking Spaces - "" L. Fill: 1... __.,."_._ .......,__._.._._._ _------_ ......__.._ __.... (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 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 Page; and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q 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 IF YES, describe size, type and location: . ........................... ........._ _........ D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 i acre? YES 0 NO 0 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❑ Roofing❑ Change of Use❑ Other❑ Brief Description ;Enter a brief description here./,)j;u/ J=.�/ 7�✓L�-k/G/= f2 -x�2 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 ❑ 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 ❑ 5B ❑ U Utility ❑ Specify, M Mixed Use Specify. c 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) T �Y Proposed Hazard Index 780 CMR 34) L.1­_1'11_1_­­.­_. SECTION.6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE°USE ONLY Floor Area per Floor(sf) 1st 1st 2nd 2 nd 3,d 3rd 4th 4th _.__ _ .._.._ _...__._ ._ , _... ___.. Total Area(so 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: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone E Outside Flood Zone❑ Municipal ❑ On site disposal system[] i Versionl.7 Commercial Building Permit May 15,2000 z �� F Departure #useQonl t` City of Northampton Status'Qf,Permft E k i 1 1 Building Department Curb Ctit/©tiueway Pbrrnit.:.I_ < 212 Main Street Sewerlsepticyarrabilrty 2 3 2015 Yj Room 100 Wafe�/We1 Auatfatalllfy' i I orthampton, MA 01060 Twa Set's of Structural Plans lectric, F.0 i;n x' ,s t 3-587-1240 Fax 413-587-1272 PlotfSitetPlans Northampton KAA(;oeo Ot�ers$peclfy 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 This section to be completed by office 1.1 Property Address: _..... , __....._ _......._. .__.._... _ Map Lot Unit o Zone Overlay District —--- (J � ��✓� � �, -- .... El St:DistricV CB District' SECTION 2,PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address. Signature Telephone 2.2 Authorized Agent: _.. _ Name(Print) Current Mailing Address Current M Signature Telephone SECTION'3-EST MATED.CONSTRUCTION:COSTS Item Estimated Cost(Dollars)to be Official Use Qnly completed by ermit applicant 1. Building �— v I (a)Building Permit Fee '. 2. Electrical (bj Estimated Total,Cost of l> 00 J Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection __.... 6. Total=(1 +2+3+4+5) �^D 4 D Check Number This Section Foe Official Use Onl Building Permit Number Date Issued Signature:_ Building Commissioner/Inspector of Buildings Date File#BP-2016-0090 APPLICANT/CONTACT PERSON RAYMOND WISCHHOF ADDRESSIPHONE 10 Blackberry Circle HOLYOKE01040(413)533-2520 PROPERTY LOCATION 8 BEDFORD TER MAP 31B PARCEL 225 001 ZONE EU(100)/URC(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 Typeof Construction: CONSTRUCT NEW ENTRANCE RAMP,CLOSE DOORWAY&OPEN DOORWAY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 052126 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO13MATION 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 D i ' Si of Buil 'ng 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. 8 BEDFORD TER BP-2016-0090 GIS#: COMMONWEALTH OF MASSACHUSETTS MV:Block: 3 1 B-225 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-2016-0090 Project# JS-2016-000163 Est. Cost: $35000.00 Fee: $245.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: RAYMOND WISCHHOF 052126 Lot Size(sq. ft.): 9583.20 Owner: SMITH COLLEGE OFFICE OF THE TREASURER Zonin : EU(,100)/URC(100) Applicant: RAYMOND WISCHHOF AT. 8 BEDFORD TER Applicant Address: Phone: Insurance: 10 Blackberry Circle (413) 533-2520 Workers Compensation HOLYOKEMA01040 ISSUED ON.712712015 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT NEW ENTRANCE RAMP, CLOSE DOORWAY & OPEN DOORWAY 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 7/27/2015 0:00:00 $245.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner