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:{t`'=s The Commonwealth of Massachusetts
Department ofIndristrial Accidents.
Office oflnvestigations
)Tr { '
J '.1 600 Washington Street.
Y r Boston,MA 02111
www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): z2e 4��c Se2ViCe
Address: /,2.Q 4e
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a.employ with 4. I am a general contractor and I
mP Y er 6. ❑New construction
mployees(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
These sub-contractors have
ship and have no employees .. 8. E]Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.t - -
required.] 5. 0 We are a corporation and its 10.[]Electrical repairs or additions
a.❑ I am a.homeowner doing all work
officers have exercised their I L 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 13.❑ Other
employees. [No workers'
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 i 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 the information provided above is true and correct.
Sienature: c Date:
Phone#:
Of use 011111. Do not write in this area,to be completed by city or town officiaL
---- —
City or Town: _- - --------.-_- _-..--------___ _ _______ Permit/License# _
Issuing Authority(circle one):
I.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
J
SECTION 10 STRUCTURAL PEER REVIEW(780.;CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 OWNER AUTHORIZATION TO:BE COMPLETED"WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING:PERMIT
77
.._._........_ ._._ _..�._,_ _ .. .
,�! J ��'✓1/ `� a� , /f=�._._C . _._.._ . _.. ...__.__:.___.... ,.. .._ as Owner of the subject property
hereby authorize �... cJ __..... ..._._.._.__.__._...__.._..._._.. ..___ _.....__..'to
act on my behalf, in all matters relative to work authorized by this building permit application.
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 the pains,and penalties_of perlunf
__... ..... _ :,__ w....._ ., _._..__._.t
Print Name
l
Signature of Owner/Agent Date
SECTION:12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑ _
Name of License Holder:1, '�l�l� lJ..-:C;.,L��r �.. ", W I.. ......._.
License Number
Address Expiratio Date
Si natur Telephone
9 !d i .
SECTlON:13' WO; RS'.;COMPENSATION INSURANCEAFFIDAVIT
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 CONSTR,UCTION;SERVICES FOR;BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL.:PURSUANT TO 78Q CMR.116(CONTAfN1NG,MORE TNAN.3S;000 C.F:OF E1LOSED;SPACE) .
9.1 Registered Architect:
i Not Applicable ❑
Name(Registrant). ._..,_.
i Registration Number
F
Address ?. _..,_,. _._..«,.. .._. ._..,.«._...,.._.._,
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
_.__._._,... _.......-- ........_..._.__ _._.
_...... . _......_ ,..._......_.,. __..,,_., .. e_. _.._
i •
L�
Address Registration Number
Signature _Telephone Expiration Date
._........_..............
- - --
Name Area of Responsibility
Address Registration Number _
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
a
Signature Telephoney Expiration Date
Name Area of Responsibility
Address Registration Number
i
t `+
Signature Telephone I Expiration Date
9.3 General Contractor
r
3
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
}
_,
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to lie filled in by
Building Department
Lot Size _
Frontage
Setbacks Front
Side L:;......___ R.=..1 . . . L:J. R:
Rear
Building Hei ht
Bldg. Square Footage j-_...__ % __..»....._y £.:..._..:.._.:
Open Space Footage 1 %
_ I
(Lot area minus bldg&paved „_M
#of Parking Spa ces
-°
Fill:
(volume&Location) -- - -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES Q
„IF•,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES _.._...... _ .-_.
and/or Document# .
IF YES: enter Book 3 Page? ;,.:_._.._.__...__...__-._..........;
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: /j`� � l�n yo'%� Cs�� f% fit✓
D. Are there any proposed changes to or additions of signs intended for the property? YES or NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavatigri, 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.
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 EY
Brief Description jEnter a brief description here
Of Proposed Work:.1 o Billboard
SECTION 5 USE GROUP AND.CONSTRUQTIONiTYP.El.
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 E] 1A ❑
A-4 ❑ A-5 ❑ 18 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B « ❑
F Factory ❑ F-1 ❑ " F-2 ❑ 2C ❑
H Hi h 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 ❑
UUtility ❑ Specify:�._�,...__:._..,..___...�_« .._........_..-,___.�-.___� .,_,___--..__..._..._.. .. .�.... _...,_.:. _. ._.. .._.. -..
--
M Mixed Use Specify: i
S Special Use ❑ Specify:
COMPLETETHIS SECTIO-N IF:EXISTI.NG'BUILDI.NG UNDERGOING RENOVATIONS AaDI-TIONSAND/OR CHANGE IN USE
Existing Use Group: -. _ ...___ _...._._ . ___.._ _._ _.__ Proposed Use Group.
Existing Hazard Index 780 CMR 34) ,.. ? Proposed Hazard Index 780 CMR 34):
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION. C3FFICE:USE ONLY
Floor Area per Floor(sf)
1 st t -..._.,___ w
St L
__...__ _..___,,.,.. . _..__,_.__... 2nd ;
2nd'
3rd1 ( !_.: .........___......�.,_._.....,_..._. _._.,,.____:
thm __�._. _._.... _.._.._..._._.._ _
1
4 1
Total Area(so Total Proposed New Construction(so
Total Height(ft)
Total Height ft
'.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
'ublic ❑ Private ❑ Zone ,_.F..,,•„,_,, Outside Flood Zone E] Municipal ❑ On site disposal system❑
Versionl.'7 Commercial Building.Permit May 15,2000
Departrye t use,only s
ity of Northampton s Y r
ilding Department Cft Gut/Qrlvewa., Perin�tr2 M f N
12 Main Street Sew /Septic,Mailabillty `
aci�ons ROOM 100
Wlbf&w IAv'dildkiffty
Electnc,p err 30
Nc nG - mpton, MA 01060 Twa Sefs�of�5tructuralPlans
phone 413-587-1240 Fax 413-587-1272 Ploflste
Other Speci fy' a 1
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:
__.._. ..__. .._..__._..__._
Unit
Northampton Transmission Map Lot
245 North King. Street Zone Overlay District
7.
Northampton, MA
Elm St District. CB District'
SECTION 2,PROPERTY OWNERSHIP/AUTH'ORIZEp AGENT
2.1 Owner f Record:
Name(Print) Current Mailing Address: _.._
Signature Telephone
2.2 Authorized Agent:
Charles J. F1or.i_o_
.. .. ...._.... _.. .
Name(Print) Current Mailing Address:
Signature l/"�'�t1 c T- ,C Telephone l/
SECTION 3-ESTIMATED CONSTRUCTION.COSTS
Item Estimated Cost(Dollars)to be : ... Official Use Qnly. :
completed by ermit applicant
1. Building (a)Building Permit Fee
_ .. ._.. .
2. Electrical ):Estimated Total Costof
Construction from. 6 _, __..,.___.. ... .........._.
3. Plumbing l Buildin PermitFee
.................
, .
4. Mechanical(HVAC)
5. Fire Protection _...__. ..... .,..: .. . ....
6. Total=(1 +2+3+4+5) .Ch:eckAwber
.
This:Section For:Official'Use Oral
Building Permit Number Dafe
Issued
-- -Signature:__
Building Commissioner/Inspector,of:Buildings Date
File#BP-2016-0136
APPLICANT/CONTACT PERSON HUNTER JOHN L&SHEILA C
ADDRESS/PHONE 245A NORTH KING ST NORTHAMPTON01060(413)519-3330 Q
PROPERTY LOCATION 245 NORTH KING ST
MAP 18 PARCEL 005 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 4
Building Permit Filled out t
Fee Paid
Typeof Construction: SAFETY IMPROVEMENT TO BILLBOARD
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 010777
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
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.
245 NORTH KING ST BP-2016-0136
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-005 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0136
Project# JS-2016-000228
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: FLO-ARC WELDING & CRANE SERVICE 010777
Lot Size(sq. ft.): 46304.28 Owner: HUNTER JOHN L& SHEILA C
Zoning: Applicant: HUNTER JOHN L & SHEILA C
AT. 245 NORTH KING ST
Applicant Address: Phone: Insurance:
245A NORTH KING ST (413) 519-3330 O
NORTHAMPTON MAO 1060 ISSUED ON:81312015 0:00:00
TO PERFORM THE FOLLOWING WORK:SAFETY IMPROVEMENT TO BILLBOARD
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 8/3/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner