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32C-030 (14)
The Commonwealth of Massachusetts —_ Department of Industrial Accidents Office of Investigations - — 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ii n Please Print Legibly Name (Business/Organization/Individual): M C Co r'�%t�► - 4 N u,M C-=, V -I C_ Address: L.5 S' chKRZn ��Cr rt' % Pub 4JM 0 aN1ol City/State/Zip: r i Phone #: 3. Are you an employer?Check the appropriate box: Type of project(required): 1.[/]'I am a employer with 40 4. ❑ I am a general contractor and I 6. ❑New construction employees(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 ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing al work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ d.S g�k�G �L' X� %A rz.�c a_t� Policy#or Self-ins.Lic.#: rnC�'- '2=0 -Z t=y 2. 2.) 14* Expiration Date: 1 Z° 31 1 Job Site Address: L i k frc Q ctc� St, ®t'r ItA-Q► City/State/Zip: rv�cA 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: V, - Date: Phone#: 413 `m l. %LCw 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#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 15OA. Address of the work: Y7 WEWST�� C D U The debris will be transported by: 1� `—,�,k-AL'U1''`- CO, —]�;A) C-- The debris will be received by: }¢ C 0 Building permit number: Name of Permit Applicant 1 1 OL) Date Signature of Permit Applicant City of Northampton s _ SAS •r% Massachusetts t( DEPARTMENT OF BUILDING INSPECTIONS ? , 212 Main Street • Municipal Building vti ca Northampton, MA 01060 ssNyya�^`1 INSPECTOR Louis Hasbrouck Fax: 413-587-1272 Chuck Miller Building Commissioner Phone: 413-587-1240 Assistant Commissioner CONSTRUCTION CONTROL DOCUMENT (For professional Engineers/Architects responsible for Entire Project) Project Title: V tip-��'�'*�ia�.1�-�- Date: Project Location: v�. ��i 544 y a U1, J L- Map: Parcel: Zone: Scope of Project: 0 e k, E(A ,-Q'_ � ,1 e_k%(A • { -_ In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107.6: Mass. Registration# Being a registered professional Engineer/Architect hereby CERTIFIES that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: ['ENTIRE PROJECT For the above named project and that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable Laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 10.7.6.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 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, in general, if the work is being performed In a matter consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the b i ial a final report as to the satisfactory completion and readiness of the project for occupancy. �asiD AftC,�jP q c 7,- No.7141 nature and Seal of Reg istere rofessional MpNSON, �- MASS• C ti Day of 20� (seal) 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: Not Applicable ❑ I_ Ir Name(Registrant): C Registration Number Address Expiration Date Sin Wni Telephone 9.2 Registered 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 Not Applicable ❑ Com,(p_annyO jNaame: Rr- Responsible In Charge of Construction Address ! 7 .7 Signature Telephone Version 1.7 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 1, MARL A * �C�/ �`�""'� as Ow r/Authonzed Agent reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge elief. Signed under the pains nd penalties of perjury. Print a Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: f� Not Applicable ❑ Name of License Holder: -- License Number 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 No 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 S aces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES IF YES: enter Book Page and/or Document#'9� B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, exqavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r 7 Versionl.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❑ Repair Additions ❑ Accessory Building❑ e Exterior Alteration ❑ Existing Ground Sign El New Signs❑ Roofin EI Change of Use E3 Other❑ _. _..... Brief Description Enter a brief description here. @ate e-v' 6,1 C 8 S jilt -; C- r-,P-y&.E�O- 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 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I 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 _. ... _._ 15t .W 2nd 2nd 3d __. ._ 3rd th 4th Total Area(sf) Total Proposed New Construction(sf)y .............................._........_....._...: 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 Outside Flood Zone[] Municipal ❑ On site disposal system[:] I t � Versionl.7 Commercial Building Permit May 15, 2000 Department use only ,.�^„ r RE N� -� City of Northampton Status of Permit *s Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability NOV 4� ? ' Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans DEPT.Or B; phone 413-587-1240 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 Map Lot Unit C Zone Overlay District _.............. ... ...... ..... ......... ................................. Elm St.District CB District SECTION 2-Pi4OPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i� ,,/Name(Print) Current Mailing AddresS��Q� Signature Telephone 2.2 Authorized Agent: S Name(Print) Current Mailing Address Signature Telephone (1 td SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant w.. .... 1. Building 00 �© (a) Building Permit Fee • _. 2. Electrical W (b) Estimated Total Cost of Construction from 6 . 3. Plumbing 1®� Building Permit Fee [. 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) i S- Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0718 APPLICANT/CONTACT PERSON MCCORMICK-ALLUM CO INC ADDRESS/PHONE P O BOX 4890 SPRINGFIELD01101 (413)737-1196 PROPERTY LOCATION 17 BREWSTER CT MAP 32C PARCEL 030 001 ZONE CB(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT p.944 4f Fee Paid Building Permit Filled out Fee Paid Typeof Construction: GENERAL COSMETIC RENOVATIONS FOR NEW OFFICES New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 069763 3 sets of Plans/Plot Plan �i �G7,,CcLri%C gic/ THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR 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 Dglay Sig ure 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. 17 BREWSTER CT BP-2016-0718 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-030 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:renovation BUILDING PERMIT Permit# BP-2016-0718 Project# JS-2016-001201 Est. Cost: $48445.00 Fee: $339.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MCCORMICK-ALLUM CO INC 069763 Lot Size(sq.ft.): 4268.88 Owner: BESSEMER TRUST CO-TRUSTEES R FRENCH&T D'ALLESSANDRO C/O HAMPSHIRE PROPERTY MG Zoning: CB000)/ Applicant: MCCORMICK-ALLUM CO INC AT: 17 BREWSTER CT Applicant Address: Phone: Insurance: P O BOX 4890 (413) 737-1196 WC SPRINGFIELDMA01101 ISSUED ON:1113012015 0:00:00 TO PERFORM THE FOLLOWING WORK:GENERAL COSMETIC RENOVATIONS FOR NEW OFFICES POST THIS CARD SO IT IS VIS 1 111 1,E FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Undergrour Ji: Service: Meter: Footings: Re►=gh: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Departricnt Fireplace/Chimney: Rough: Oil: Insulation: Fir Smoke: Final: THIS PERMIT MAY BE REVOh""a BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType• Date Paid: Amount: Building 11/3012015 0 00:00 $339.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner