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Page 1 of 1 Campground Master 03/27/12 06:57:46
CITY OF NORTHAMPTON
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: 3'e /fr /A Apt 9 #5! /
The debris will be transported by:
The debris will be received at: no 44 Gc 4/A -C
Signature of Permit Applicant
Date 3/Z Z.�
Building Permit Number:
'` The Commonwealth of Massachusetts
r� Department of Industrial Accidents
' �. t Office of Investigations '
YT 600 Washington Street
— Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Org iization/Individual): / 4 ' 7 / 1". L � � /! 4
Address: Ki g, 5p OA S,s ®/°r3
Cit /State /Zip: Phone #: '5' 1 1:5 --1- 57/
Are you
with 4. ❑ mployer? Check the appropriate box: Type of project (required):
1. am a employer 4 I am a general contractor and I
p Y 6. ❑New construction
employees (full and/or rt- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. C.:1 I am a sole proprietor or partner-
ship and have no employees These sub- contractors have g. emolition
for me in any capacity. employees and have workers'
working Y P ty 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
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'
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.
k /
Insurance Company Name:
Policy # or Self -ins. Lic. #: W e: W.737 Expiration Date: (y
Job Site Address: 7D 4 M City /State /Zip: �!J/,&frG° 4 f '/" 4-'
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 un er t pains and pen ties of perjury that the information provided above is true and correct.
Signature: _ _ - Date: ; 5 7 /T'"
/ .
Phone #: ' , VO2 - ela 4/4i 1Ur 57 e
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 #:
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10 STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,d.._..._ n _ a. uP ...__ -_ .. _ -_ .., as Owner of the subject property
act on my behalf, in all matters relative to work authorized by this building permit application. _ _________ _
Signature of Owner .._ ..... ........._._............__ . .__._T.._..._._.__._._
, 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, enalties of,,,perjury
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder .
License Number
Address Expiration ate
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 0 No 0 r ,c° / 1 1,1w r 7
//()
•
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 mm
I
Signature Telephone Expiration Date
Name Area of Responsibility
1
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
1
Address Registration Number
µ
i
Signature Telephone Expiration Date
9.3 General Contractor
_.._._ ,._ ..__..,.,_ .... .,.._.__ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
•
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by ,honing
This column the filled in by
Building Department
Lot Size __._.....
Frontage _.._.._
Setbacks Front
Side L.
Rear
Building Height
Bldg. Square Footage
Open Space Footage
»
(Lot area minus bldg & paved ; �.._..
—
parking) _w ....,
# of Parking Spaces €"`
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF. YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ' 3 Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 NO
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 ❑ 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. _ C Q
Of Proposed Work _ . a C dr ! � $ � `Gy � /, 5 i
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) I CONSTRUCTION TYPE
A Assembly El A -1 ❑ A -2 ❑ A -3 ❑ ! 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
i
B Business ❑ 2A ❑
E Educational ❑ 2B . r ❑
F Factory ❑ F -1 0 F -2 ❑ I 2C ❑
H High Hazard ❑ j 3A ❑
Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B 1 ❑
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)::`:._ _ _. _._,_....._.,__ __M
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION - OFFICE USE ONLY
Floor Area per Floor (sf)
e .
_- .__ _ 1 st
1st.
2nd ,
2nd ,
_._v__.._. .__ —___ - __.. 4th
_. __.m__.__..__ _.._. _ _
Total Area (sf) Total Proposed New Construction (sf)
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
Versionl.7 Commercial Building Permit May 15, 2000
,„ / " -- � flefZartmell# usa orfl �f
n a City of Northampton St&ti o i z 4 V
cJ
11- q �' 10, Asa � ` a
C-5-3 H en Building Department •rt ewayyt7rt
` 6, 212 Main Street S we rCp iu i5i�� ;,� k
Room 100
9 a wk,
afe' ��ira�i t ��
e rr o Northampton, MA 01060
°� phone 413 - 587 -1240 Fax 413 -587 -1272 Plotl�t� F ns ��
APPLICATI • • 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
30V fk t TM (x / ,i _ _ Map Lot Unit
tC� / 71,e3V4--
i Zone Overlay District
Elm-St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address: c /06 Z
Signature Telephone
2.2 Authorized Agent: �` _ __.._ _.__
Name (Print) Current Mailing Address _ ._._,_. _,_
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION 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 -(6) .___
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _:..
6. Total = (1 + 2 + 3 + 4 + 5) 2. 0 Check;, Number
This, Section. For Official Use Only
Building Permit Number Date
Issued
A 150 foe— Pe AA-
Signature: (27/ 3 z_
Building Commissioner /Inspector of Buildings Date
� F
300 NORTH MAIN ST - LOOK PARK BP- 2012 -0855
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A - 002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -0855
Project # JS- 2012 - 001502
Est. Cost: $2800.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WAYNE YOUNG 31539
Lot Size(sq. ft.): Owner: NORTHAMPTON CITY OF LOOK MEMORIAL PARK
Zoning: URA( 51) /WP(20)/URB(2) /HB(0) /WSP(0)/ Applicant: WAYNE YOUNG
AT: 300 NORTH MAIN ST - LOOK PARK
Applicant Address: Phone: Insurance:
2171 ROARING BROOK RD (413) 512 -0601 0 WC
CONWAYMA01341 ISSUED ON:4/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO TRAIN STATION
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 4/3/2012 0:00:00 $0.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner