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17C-229 (15) i r i 9 s 3 7�j Awl V The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,A L4 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): n t h r A t'�4'V 1�5 Address: {O a City/State/Zip: VJ, � i f Phone.#: ( 3 7 Are you an employer? Check the appropriate bog: 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, F-1 Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. $ 9. Building addition required.] 5. We are a corporation and its 10.0 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' 131J 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 zContractors that check this box must attached an additional sheet showing the name of the subcontractors 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 the pains and penalties of perjury that the information provided above is true and correct Signature: 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 i SECTION 10 S RtJGTCIRAL SEER REU(EIIIt(Z80 CMF11011 Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTIQN111 OWNER=AUTMPRIZATION TO,-BE-COMPLEEEi� WkIEP� OWNERS AGENT OR CONTRACTORAPPLIESTOR BUILDING PERMIT` T , i t✓ ,as Owner of the subject property�n r hereby authorize PD 1�1'2`l��-r/`�/t ��c�� >Or to act on my behalf,in all matters relative to work authorized by this building permit application. i U Signature of Owner Date I, i't.L nom^J 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 an enalties of Dedurv. Print Name Signature of Owner/Agent Date SEGTI�N'CZ,.CONSTR�tC'IIONSERt/IGES- 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: license Number - Address Expiration ate Signature Telephone SECTION 13 WORKERS'COMPENSATION:INSUIICEA)=FtDA�IIi`fvMGL.c;152x§25CE6} 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 r i Version 1.7 Commercial Building Permit May 15,2000 ` CO STRUCTION CONTRO PURSUANT TQ 780 CMR 1161(CONTAI NG M©EB H!Al 35,000 C�F O ENC OSED ACE) O PACE) 9.1 Registered Architect: } Not Applicable ❑ f Name(Registrant): t Registration Number I f Address ! Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): i Name Area of Responsibility Address Registration Number f ! Signature Telephone Expiration Date E f Name Area of Responsibility r Address Registration Number I Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date I � Name Area of Responsibility Address Registration Number i Signature Telephone I Expiration Date 9.3 General Contractor TT-U 1 1G Not Applicable ❑ Company Name: f Responsible In Charge of Construction f ! Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 1 S - S Frontage Setbacks Front f I—J I a Side L:' I R: Lf R:" Rear �---� t - --, -Budilaing Bldg.Square Footage Open Space Footage % i (Lot area minus bldg&paved arldn ) #of Parking Spaces Fill: ' volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW 0 YES IF YES, date issued: I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book I Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO y DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q 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 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 0 ' NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ti 7 Version 1.7 Commercial Building Permit May 15,2000 r SECTION d CONSTRCTCTLON SERVICES FORPROJEfTS HESS THAN 35,000' . CUBIC EEETOFENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions o Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief description here. Of Proposed Work: ! '0. 0 r-�� ,�n✓�, i SECTION 5-USE GRb UP ANE1 CONSTRUCTION TYRE „ USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 0 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ -- 2A ❑ E Educational ❑ 2B ( ❑ 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: M Mixed Use ❑ Specify: j S Special Use Specify COMPLETE TFf&SECTION tF EXISTING BUILDING UNDEL2GOIN7G RENOVATCOIVS :ADDITIONS P,NI�OR,CHAIVGE IN USE Existing Use Group. I Proposed Use Group. t ? Existing Hazard Index 780 CMR 34):` Proposed Hazard Index 780 CMR 34): i SECTION G-BUILDING.k1EiGHT ANQAREA.. BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St n � , 1st ' 1 2�a _ 2 t 3rd 2. 3t°1 4th ; 4th Total Area(sI) DC)0 Total Proposed New Construction sf Total Height(ft) Total Height ft ! 1 s ,E 't tirw9 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone[:] Municipal ❑ On site disposal system E] *► Version 1.7 Commercial Building Permit May 15,2000 J_ 0 _ City of Northampton Building Department 212 Main:Street evsre Se ti...'- t Room100 x . Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 Pla lans:. expect` APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION_I ;- 1NFORMNiTtON Tars sectroRto be Comp[efed#i} offree . 1-Property Addres x k e A m om "? T L-. ot, Untt NOR ftv EIttStrD�stnc> _ _ 'CBD�sfrTGt _ _._.. SECTION 2-PROPERTY�OINN0 ikkUTHORIZED-AGENT 2.1 Owner of Record: ! © ! �4i'LJ�C�G7� Name(Print) Current Mailing Address: Signature ° Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: r w r eq 1-1A,F_rV Signature �--�� Telephone l 3 13 2-C� "1 l , --SEC71014 3-ESTl1iAQTED"GONSTRUCTI"ON'COSTS Item Estimated Cost(Dollars)to be Officiat_Use Only; completed by ermit applicant 1. Building t C� i (a)�Buitding'Permiffee ; 2. Electrical _ ss (b_)�Estimated Tq t Cost of ! i 'Constcuctrori from 6 > 3. Plumbing Buldmg.Permit Fee 1 4. Mechanical(HVAC) 5. Fire Protection 6, Total=(1+2+3+4+5) Check Number l 7t is Section For...OWO f the Onl Building Permit IYurntier. Qafe r Signature: Building Commisslonedlnspecfor'of Buildings Date File#BP-2007-0868 APPLICANT/CONTACT PERSON ERIC PAYNE ADDRESS/PHONE 100 LAUREL HILL RD WESTHAMPTON (413) 529-7175 PROPERTY LOCATION 28 NORTH MAPLE ST MAP 17C PARCEL 229 001 ZONE SI 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 WALLS POR STORAGE ROOM New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 086442 3 sets of Plans/Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: ke9Approved 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 ssion 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. r � BP-2007-0868 CIS#: COMMONWEALTH OF MASSACHUSETTS W 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-2007-0868 Project# JS-2007-001431 Est. Cost: $5800.00 Fee: $50.00 PERMISSION IS IIEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ERIC PAYN E 086442 Lot Size(sq. ft.): 16422.12 Owner: LAWTON ROBERT W& Zoning: SI Applicant: ERIC PAYNE AT: 28 NORTH MAPLE ST Applicant Address: Phone: Insurance: 100 LAUREL HILL RD (413) 529-7175 WESTHAMPTONMA01027 ISSUED ON:312212007 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT WALLS FOR STORAGE ROOM 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 3/22/2007 0:00:00 $50.001259 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Conunissioner-Anthony Patillo