24B-067 (14) INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE
I, Lisa O'Neil, of 123 Interstate Drive, West Springfield, MA, Underwriting
Administrator, USI Insurance Services LLC, licensed resident broker of Midwest
Employers' Casualty Company do hereby affirm that Forish Construction
Company, Inc. is insured with said insurance company with Policy Number
EWC005891 effective 1/1/15-1/1/16 for Self-Insurance Excess Workers'
Compensation in accordance with Massachusetts General Laws Chapter 152 and
Sub Section 7.05 of the Standard Specifications for Highways and Bridges of the
Massachusetts Highway Department.
(SIGNED)
Subscribed and sworn to before me this 7th day of January, 2015
at West Springfield, MA
Notary Public
MARIA C. SULLIVAN !
nc Notary Public
COMMONWEALTH OF N„ASSACHUSETTS
\I\� My Commission Expires
August 20, 2021
-•mss-x-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
600 Washington Street
Boston,MA 02111
wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): FORISH CONSTRUCTION 'COMPANY INC.
.Address: 21 MAINLINE DRIVE PO BOX 358
City/State/Zip: WESTFIELD,L MA 01086 Phone.#: 413-568-8624
Are you an employer?Check the appropriate box: Type of project(required):
1.[E I am a employer with_20 4. EJ.I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. E]Demolition
working or me in an capacity. employees and have workers'
g Y P tY• $. 9. ❑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 11.0 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
employees. [No workers' 13.® Other Commercial
comp.insurance required.] Construction
*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.
tContractors 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: Midwest Employers Cas'ii41-t'y Company
Policy#or Self-ins.Lic.#: E WC 0 0 5 8 91 Expiration Date: 1/1/2016
Job Site Address: 263 King Street City/Stafe/Zip: Northampton, MA 01060•
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 tip 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 certifyy/under thepai ndpenalties ofperjury that the information provided above is true and correct.
Si ature. cam/-- Date: July_ 7, 2015 _
Linda Day
Phone 0: 413-568-8624
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):
A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8t'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: ir cz-llkp.�1-6 . Date: 1Z
Property Address: �',;72 r�/</ f/1 z j , /6 '
Project: Check one or both as applicable: XNew construction 3�xisting Construction
Project description:
0 0"Y MA Registration Number: �,� Expiration date. am a
= '
registered design professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
ftchitecuiral [ ] Structural [ ] Mechanical
e Protection [ ] Electrical [ ] Other
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit fie l s(see item 3.)together with pertinent
comments,in a form acceptable to the building official � �tia
Upon completion of the work,I shall submit to the official a` struction Control Document'.
n c 34 �
Enter in the space to the right a wet or
P � "wet" � ua i pTC11`'
electronic signature and seal: o
Phone number: Email:
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ' C/—�� '¢ �i9 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Ls`�- J. �z,r,�� 6-5 G�71 i cb
I License Number
N1k *419� 0 fo(FS, l /3/ "-?D/4
Address Expiration Date
Signature � _ � Telephone
SECTION 13-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 YJ No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
-�Js.����� ,✓)��� Not Applicable ❑
Name(Registrant):
16 d�� ,� }7--- / w Registration Number
Address �/j! /
..........
Expiration Date —�
Sig re Telephone
9.2 Regist ed Professional Engineer(s):
Name Area of Responsibility
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
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor S
f°('5�\ �`15 r�� 1�0. , Inc. Not Applicable ❑
Company Name:
19 4 � y
Responsible In Charge of Construction
Address
Si ature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
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 O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO Q
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 O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versiont.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 d Repairs❑ Additions Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description Enter a brief description here. 'RemO',4�k o� 5�`'^�'
Of Proposed Work: AAA8\cA o�C >1ecJ CW rl for-\ak
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 In 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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:
M Mixed Use ❑ Specify:
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): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1St
1St jn/ Cn
2nd 2nd
3rd 3rd
4th
4th
Total Area (sf) j e Total Proposed New Construction(so
Total Height(ft) ,
Total Height ft �S
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ I Zone Outside Flood Zone[-] Municipal ❑ On site disposal system[]
Versionl.7 Commercial Building Permit May 15,2000
- Department use only
of Northampton Status of Permit: -
�! riding Department Curb Cut/Driveway Permit
+
112 Main Street Sewer/Septic Availability
Room 100 WaterMell Availability
Electric,Fiurr '[
rth mpton, MA 01060 Two Sets of Structural Plans
-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
1.1 Property Address: This section to be completed by office
6 3 h"I r S f Map Lot Unit
/V';'4�am O"N! NIA d�U Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
a13 NCA"?+On i���l+r lac C/v ?0 -1�ol, E78-91 1,�S
Name(Print) (�,.�),u.•� L �� Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signatures Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building 50/ 0 , (a) Building Permit Fee
1 �
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) /'S b O,-0 Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0024
C� J
APPLICANT/CONTACT PERSON FORISH CONSTRUCTION CO INC 1
ADDRESS/PHONE P O BOX358 WESTFIELD01086(413)568-8624 ��
PROPERTY LOCATION 263 KING ST
MAP 24B PARCEL 067 001 ZONE HB(99)/GI(l)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT ENTRY PORTAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildina Plans Included:
Owner/Statement or License 027190
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
Approved I Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
VAC 4 Me P
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan s w£C m,
ZONING BOARD PERMIT REQUIRED UNDER: § Z4T6 Ft—A Ki
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
r---,Z,, 7 1-4 16-
Signature of Building bfficial 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.
263 KING ST BP-2016-0024
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24B-067 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-2016-0024
Project# JS-2016-000037
Est. Cost: $150000.00
Fee: $1050.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: FORISH CONSTRUCTION CO INC 027190
Lot Size(sq. ft.): 93218.40 Owner: 293 NORTHAMPTON REALTY LLC C/O WILLIAM LIA
Zoning: HB(99)/G1(1)/ Applicant: FORISH CONSTRUCTION CO INC
AT. 263 KING ST
Applicant Address: Phone: Insurance:
P O BOX358 (413) 568-8624 Workers Compensation
WESTFIELDMA01086 ISSUED ON.812512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ENTRY PORTAL
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 8/25/2015 0:00:00 $1050.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner