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Y , I \ I I , 1 , , —1-1— 1 1 „ ...... 4 1 . 1 r {' ,..,_ ......., ....,_____ ........, ...,_. — --. — ........... — — — — ,'. - --- - - t„. -i ..........H . 1 1 .0.; ...: 1 1 I 1 , 1 ,1 1 , . , . ,., . ■ 1 . 1 . ■ 1 ' I , 1 , 1 1 1 1 1 ' 0 1 Y -,-,) ) U C4 0 Is VI , U) i I , LITHO IN USA N.E. BLUEPRINT 1 i 1 , 1 ' , 1 1 I 1 ■ . , [ 1 1 1 , , 1 1 i 02/16/2010 18:26 I 974233400 CWAFFIN LIGHT MALL 2 PAGE 01/01 7.-. ,, i 1i1,611\1 4. , HY tj y 1, vl I I i r /(� /� /4�mac,} S . .. (/ ol pio\). 4 --- (t , 6 ,.„ j ( --, Ai, -I—, , ,% c..,,„ uw,..,,,, " Ro (2, ---- e7,,,,..f. , Z ereirit . KIL j I I i 1 N ' - ,-, ":*:')-. i'l 1.-.I. 1 / . w 1 c 10 cE- S' Li.% 0,,d1fct,a2 at) . 1 -- -Q , 79J/4,- cti lio 4e, Ntwai I\ n 1 tyliCg/t- G / 4 I ,III. /Y ofkr -- cu I oi , 1 , 0 „ ?he -gat v.tes- -- TTeri, ic tr---- 0,, Received Time Feb. lb. 7:45PM lil 'd S1210 ELS4- 11S—Elti 1VIN30 30N3dO1d Wb'9Z:8 01E 'Cl'a'd 0 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 /PIumbers Applicant Information I [ / (� Please Print Legibly V Name ( Business /Organization/Individual): A �' , e left r t (> Il Address: " OLP STA6 C> I City /State /Zip: e � _ ; (L 14. °to Phone #: riQ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 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. [V] ship and have no employees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' com insurance comp. insurance. re uired. comp. 5. ❑ We are a corporation and its 10.[ lectrical repairs or additions 3. CI q J officers have exercised their 11. Plumbing repairs or additions I am a homeowner doing all work 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 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 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 cert der the pains nd enal es of perjuty that the information provided a ov is true and correct. Signature: U , � / 1"y ~ � 7 --- qt Date: Phone #: T� 1 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 #: , m • • Ycrsionl7 Commercial Building Permit May 15, 2000 SECTION 10 STRUCTURAL PEER REVIEW (7oVCIVIm11V11) Independent Structural Engineering Structural Peer Review Raquire �� �� d Yes \~� No v�/ SECTION 11 - OWNER AUTHORIZATION COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT |. �� ___�____� _ Owner nf the subject property hereby authorize - IP'Ll°14.X,‘ to act on my b ff,iri II matters rel ' e, o work author zed by this building permit application,___ __ _ _, _ _ _ __ _ _ , _ - __ — � s�ammmuwne, / Date . |. . oaOwner/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. S he �� ' - --------~ -- ' -1 et `*«�� __- `_________-______-__-__-_________' Print Name (.. -- .......... 6) s/onammmow my/Agent ' Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable [] e) 5 2 -- ___-______-� Licens w Addre 3 -------� Signatur � e Tv/nvoone SECTION 13lmORKERS^COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 1 -- Workers nsurance affldavit must be completed and submitted with this application. Failure to provide this affidavit wii result in the denial of the issuance of the b ilding permit. , Signed Affidavit Au �� aohed Yon �� No x_/ Version1.7 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 ❑ 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 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 ....-- "�{ .., ... 7 �� .......,, -., Not Applicable El Company Name: I` IA iv,s Pl-tfk (.-kf Responsible In Charge of Construction 1 L'111 _. asIg .rtb.... �J 0 -41,fi L D f 6 ` t 'A Address (7Y gy m... f �� Signature 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 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 /Findin ever been issued for /on the site? - NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW e YES 0 W YES: enter Book ` Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O 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 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , • a Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations LYJ 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. Of Proposed Work l Ro >J SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business f 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 I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: - m � _ S Special Use ❑ Specify: . ____�..., ,... .,._ __ _ .,�,_. „_., _ a.-, e_ .. � _ _ , _ _ _�. ®.m 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 rONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1st 1 5t y M 6 i5g 6,6 — t _ew _o_ 2 nd 2nd 3rd ...... ... .... . ..... ___ __ . _.. _ ._._ , . ___.. 3 , d th 4th 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) F A Total Height ft ( ''r" 7. Water S upply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage pisposal System: Public Private Private ❑ Zone Outside Flood Zone❑ Municipal ® On site disposal systemo 1 Version1.7 Conunercial Building Permit May 15, 2000 Department use only. LI City of Northampton Status vfPermit Budding Department Cui Duf/Drsveway Permit r t.' 212 Main Street Sewer /SepticA "vailability Room 100 Water/Well Av Northampton, MA 01060 Two Sens of Sfriicturat Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Sfte 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 p Map Lot Unit ( Zone Overlay District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address Gt_ Signature Telephone j� c 3S0 2.2 Authorize gent AilktS ti6. Name (Print) t Current _Alf cling Address Signature /� Telephone "D. Li- 7 13 SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building GZ (a) Building Permit Fee 2. Electrical „--- _ (b) Estimated Total Cost of 7 ( e Construction from (6) 3. Plumbing � - Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) l 'Z © i a* Check N umbe r >?1 S 5 This Section For OfficiaI Use Only Building Permit Number Date Issued Signature: cZ Building Commissioner /Inspector of Buildings Date • File # BP- 2010 -0727 APPLICANT /CONTACT PERSON JAMES PHANEUF ADDRESS /PHONE 74 Old Stage Rd W HATFIELD (413) 247 -9993 PROPERTY LOCATION 41 MAIN ST MAP 23A PARCEL 079 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out - , � Fee Paid i(r,JJ 7 r Typeof Construction: EXPAND'WAITING ROOM - SCHWARTZ New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 011632 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION PRESENTED: Approved 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 .:1/ 2,/ /0 Sign re 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. 00-1 c.)., F fe , 41 MAIN ST pi BP- 2010 -0727 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 079 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- 2010 -0727 Project # JS- 2010- 001079 Est. Cost: $8250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: . Const. Class: Contractor: License: Use Group: JAMES PHANEUF 011632 Lot Size(sq. ft.): 7318.08 Owner: FALK 41 MAIN LLC Zoning: GB(100)/ Applicant:_ JAMES PHANEUF AT: 41 MAi iii ST Applicant Address:_ Phone: Insurance: 74 Old Stage Rd (413) 247 -9993 W HATFIELDMA01088 ISSUED ON:2/22/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: EXPAND WAITING ROOM - SCHWARTZ POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: � ervice: Meter: / Footings: Rough: ' 6 ��/` ou h:3 Cf/// �/j House # Foundation: - Driveway Finl: . / 0 Final: .3 , � Final: � 31r �A-P Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke_ Final: OK Vu,Ite ta THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 4 Certificate of Occupancy ci /-- 1 d2 " ` Signature: FeeType: Date Paid: Amount: Building 2/22/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo