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17C-245 (8)
i 85 NORTH MAIN ST BP-2020-0242 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 17C-245 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO N T HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit# BP-2020-0242 Proiect# JS-2020-000419 Est. Cost: $10000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAMES MAILLOUX ELECTRIC 081694 Lot Size(sq.ft.): 15681.60 Owner: MAILLOUX JAMES Zoning: URB(100)/ Applicant: JAMES MAILLOUX ELECTRIC AT: 85 NORTH MAIN ST ` Applicant Address: Phone: I Insurance: 221 PINE ST SUITE 160 (413) 585-1592 Liability FLORENCEMA01062 ISSUED ON.812812019 0:00:00 TO'PERFORM THE FO�LOWING WORK.-REPLACEMENT WINDOWS 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: I Final: Final: Rough Frame: Gas: Fire De6artment Fireplace/Chimney: f Rough: Oil: , Insulation: I 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 8/28/219 0:00:00 $100.00 212 Main Street,Phone(413)5874240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Versionl.7 Commercial Building Permit May 15,2000 6" 7 �� Qepartrrient use,only City IIf Northampton status,of Permit Builditlg Department �Curb'Cut/Driveway Permit . - 212 Main StreetS`ewedSeptic,AvailabIII Room 100 WateiMeII Availability Northa T pton, MA 01060 Two Sets of Structural Plans: phone413-587-1240 Fax 413-587-1272 Plot(Slte Plans.~ , ; APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE•USOR ANY BUILDING OTHER THAN A ONE OR TWO_ FA ILY V C SECTION 1 SITE INFORMATION / I I AUG 2 :r his section.to6e P. -P ed 6 office 1.1 Property Address: t �S N �t1 i JA/ Map DEPT OF aur�'d+R 1NSP Unit' -N©RTHAMPTON.? SCTIQNS !-)a��vt(,P � MA 0106 Ove<ayaaq Elm St D� CB Dis it ) � SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �`16, Name(Print) Current Mailing Address: _ Signature Telephone 2.2 Authorized ent: Name.(Print) Current Mailing Address: ------------------------------------ Signature Telephone SECTION 3 'ESTIMATED-GONSTRUCTION'.COSTS: Item Estimated Cost(Dollars)to be Official:Use Only completed by permit applicant 1. Building (a):Building Permit Fee 2. Electrical (b)Estimated:Total.Cost of Construction from 6I 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection j. .. 6. Total=(1 +2+3 +4+5) (' oo '.Check Number. 1 _ .This.Section,For Official'Use Only Building,Perrnit Number ":Date• I Signature Building:Commissionertl'nspectorofBuildimgs W4 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❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Ld Of Proposed Work: 1 h, r. d'1 1-k a o SECTION 5'-.USE GROUP ND ACO.NSTRUCTION'TYPE USE GROUP(Checkas applicable) CONSTRUCTION TYPE A Assembly. I A{1�r,n 0� ;9th C A-2 ❑ A-3 ❑ 1A ❑ fA-4 ❑ A-5 al ❑ 1 B ❑ B Business 2A ❑ E Educational ED `r 2B I ❑ F Factory ❑ -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`THI'S SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS:ADDITIONS`AND/OR:CHANGE IN USE'' Existing Use Group: ____ Proposed Use Group: Existing Hazard Index 780 CMR 34):1 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) 1 St St ti r 2nd 2nd a' 3rd 3rd 4th 4th Total Area(sf) Total Proposed New Construction s r 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 E] Private [3Zone E � Outside Flood Zonem Municipal ❑ On site disposal system❑ A Version 1.7 Commercial Building Permit May.15,2060 8., NORTHAMPTON ZONING" .11. 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 0 f DON'T KNOW YES " IF YES, date issued: IF YES: Was thepermit recorded at the Registry of Deeds? NO . DONT KNOW 0 YES 0 IF YES:" enter iBook ___ Page and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES I IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained i Obtained , Date Issued: I C. Do any signs exist on!the property? YES NO f IF YES, describe size, type and location: � f D. Are there any proposed changes to or additions of signs intended for the;property? YES NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 11 acre or is it part of a common plan that will disturb over 1 acre? YES NO I IF YES,then a Northampton Storm Water Management Permit from the DPW isi required. I I � , _ t 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 1.16(CONTAINING MORE THAN 35,000:C.F.OF ENCLOSED SPACE) . 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address = Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility t 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 ❑ Company Name: ` Responsible In Charge of Construction Address Signature Telephone .4 I , Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780,.CMR 1'10:11) Independent Structural Engineering Structural Peer Review Required a Yes No P 9 9 4 SECTION 111-OWNER AUTHORIZATION-TO BE,COMPLETED,WHEN ; OWNERS AGENT OR CONTRACTOR Af PLIES,FOR BUILDING:PERMIT as Owner of the subject property i hereby authorize to act on my behalf, in all matters relative tolwork 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. I Sic ined under the pains and penalties of Periurv. 41 kIOL-N Print Name Signature of Owner/Agent Date SECTION 12=CONSTR TION`SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder �j License Number J, 10 '� V ►�fJ C w �4 � 0?�� D 9/ 6 9 7 Address Expiration Date /C 160121,019 Signature Telephone SECTION 1.3-WORKERS"COMPENSATION'INSU RANCE"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 � I I ' • I 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 150A. Address of the work:" The debris will be transported byi L4,4 LN The debris will be received by: VA LY Building permit number: Name of Permit Applicant Date Signature of Permit Applicant I The Commonwealth of Massachusetts , Department of Industrial Accidents 1 Congress Street,Suite 100 c Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information —�! Please Print Legibly Name (Business/Organization/Individual): �/�JV1�✓� /1/�/J1l/�L� Address: Z2 L vt.. �L u City/State/Zip: Ro r o YL(,?_ / Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I a employer with employees(full and/or part-time).* ❑ 7.. []/New construction 2. I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10j E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12 Plumbing repairs or additions 5.F1 I am a general contractor and I hav�hired the sub-contractors listed on the attached sheet. 13I. Roof re alis These sub-contractors have employees and have workers'comp.insurance.: p 6.❑We are a corporation and its officers have exercised,their right of exemption per MGL c. 14'.[—]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy'linformation. 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 isproviding workers'compensation insurance for my employees. Below is the policy andjob 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as Iwell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.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 pails 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the.performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance: If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly,. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia