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32A-097 (2) • O e c ;, ° $ ( xt o£ Nazf1pampfcn * * _1 �. � a saacI1ttsctla = * __� _ DEPARTMENT OF BUILDING INSPECTIONS � c' =1'�� 3 212 Main Street Municipal Building Northampton, Mass. 01060 r' WORKER'S COMPENSATION INSURANCE AITIDAVIT Pioneer Contractors • (liceasedpermi twee) with a principal place of business/residence at: • • • P.O. Box 1144 Nnrthampton, NIA 01061 (phone°) 586 5491 (st t/city /staiddnP) do hereby certify, under the pains and penalties of penury, that. (V I am an employer providing the following worker's compensation coverage for my employees working on this job: • Wcc 500595701 2D01 Associatrad Rmployerc Ins -- -- - 6 /1naL (lnsurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contactor) (Instuance Company/Policy Number) (Expiration Date) • (Name of Contractor) (Insurance Company/Policy Number) (Bxpiradon Date) (attach additional shcci if nn .. to include information pertai.ning to ell contractors) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. • NOTE: plot= be asrue that while homeowner, who employ persons to do r*+e mutt, cnasmution or repair work on a rt ;shag of not mere than throe units in winds the homoowocr resides oc oo the grounds appurtenant tbetcto arc not gone ally considered to be employers uoccr tbo worker's compeasatioa Act (GL152,ss 1(5)), applirupon try a homeowner far a liccasc cc permit may evidence the legs/ ;talcs of an employer under the Wodccer Compensation Act_ I understand thsi a copy of this euscmcr t may be forwarded to the Dcpartrocns of Industrial Aecideate Of oo of ltatusnoe for the coverage vcriftatioa and that failure to emu covcrago under section 25A of MOL 152 can lead to the imposition of penalties coatis: Ling of a foe 'etc to S 1,500.00 ardor insprisoomaxt of up to one year and civil pea/tics in the form of a Stop Work Orrin' and a fine of 5100.00 a day against were_ For dcpsstm cal u.c only Z. c. Permit Number � ' LDat " v m,apli -- Lot 14 Situ tort of Licc see/Pcrmi • . - • 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 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Paul Brown as Owner of the subject property Pioneer Contractros -David Claxton hereby authorize to act on my behalf, in all matters relative to w rk authorized by this building permit application. 06/07/2012 Signature of Owner 4 Date Pioneer Contractors -David Claxton , 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 and penalties)of v Print Name 06/07/2012 Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder David Claxton 017890 License Number P.O. Box 1145 Northampton, MA. 01061 01/19/2014 Address 77 /1 /1 Expiration Date f t .7( ,r i (413) 586 -5491 Signature f 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 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: N/A Not Applicable ❑ Name (Registrant): N/A 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 Pioneer Contractors Not Applicable ❑ Company Name: David Claxton Responsible In Charge of Construction P.O. Box 1145 Northampton, MA. 01061 Address �Q L (413) 586 -5491 Signature //19,1- Telephone Version!.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 Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q ,Date Issued: C. Do any signs exist on the property? YES NO 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, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 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 0 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. Install vent fan for basement bakery area 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 E 1 A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 1 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 1 2C ❑ H High Hazard ❑ 3A El 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: A_3 Proposed Use Group: Same 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) 1 st 1 2 nd 2 3rd 3rd 4 th 4 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 p Private ❑ Zone Outside Flood Zone 12 Municipal p On site disposal system 0 Versionl.7 Commercial Building Permit May 15, 2000 � rtme t u se r „ i ° pity of Northampton uilding Department ffar�cC?Wrer Fr „ % „� a„ 2 212 Main Street � 0 � ” �sr d� aa,t �r, .U p tblit Room 100 �� „t r OF BULD , NSPECTION "s No ° hampton, MA 01060 +t �e f ur l NORTHAMPTON ,,;,+.,■,!.'• • - .87 - 1240 Fax 413- 587 -1272 F 'tt/Sif Pla s ,u i 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 1 Market Street Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 'Paul Brown 1 Market St., northampton, MA. 01060 Name (Print) Current Mailing Address: (413) 535 -9885 Signature 4i1j/1 ` Telephone 2.2 Authorized Agent: Pioneer Contractors -David Claxton P.O. Box 1145 Northampton, MA. 01061 Name (Print) Current Mailing Address: (413) 626 -7267 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $550.00' (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of $225.00 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection $1,650.00 6. Total = (1 + 2 + 3 + 4 + 5) U14 -1,S'i Check Number ACV‘ m`s This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -1092 APPLICANT /CONTACT PERSON PIONEER CONTRACTORS ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586 -5491 PROPERTY LOCATION 1 MARKET ST MAP 32A PARCEL 097 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / 'l / / Fee Paid / c� `7 C , 6l ss Typeof Construction:_INSTALL VENT FAN FOR BASEMENT BAKERY AREA New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 017890 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 -molii :...Dela ( S mature of Buildi : Of ial ' 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. I 1 MARKET ST BP- 2012 -1092 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 097 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -1092 Project # JS- 2012 - 001879 Est. Cost: $2425.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PIONEER CONTRACTORS 017890 Lot Size(sq. ft.): 3876.84 Owner: BROWN E PAUL TRUSTEE Zoning: CB(100)/ Applicant: PIONEER CONTRACTORS AT: 1 MARKET ST Applicant Address: Phone: Insurance: PO Box 1145 (413) 586 -5491 Workers Compensation NORTHAMPTONMA01061 ISSUED ON:6/19/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VENT FAN FOR BASEMENT BAKERY AREA 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 6/19/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner COMMONWEALTH OF MASSACHUSETTS + DIVISION OF PROFESSIONAL LICENSURE • BOARD OF E e rtYSSFACH(USETTS DRIVER SHEET METAL W ORKER a AS A�:MASTER UNRESTRF TES i r G i�1�n LICENS SSA " . � . 1 MA ', =. H 9F Mq ISSUES THE ABOVE 1 �CENSE TO: - = t SS d �s ea erlu as rnx�eea F AARON S MORIN t = lf� NONE 19862961. MI 10.14-1971 .: • , v - c 1 ,_ p ,. ..:�. _ 15 SEX M: 10 t 11 140 WEST' ST w E ' oe l es s �� HATFIELD . MA �,01088 — 954 f t*Y. a HA MA 01088.9500 533 10/28/13 64680 t - f 5 DO 10. 10.2010 Rev 07.15.2005 LICENSE NO. EXPIRATION DATE SERIAL NO. 1 i °t The Commonwealth of Massachusetts Department of Industrial Accidents I _ ` Office of Investigations t. w V14...,,, ;� 600 Washington Street ' - �. `1so "s Boston, MA 02111 � , =_- , - "' www.mas &gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information t Please Print Legibly f4 © Name ( Business /Organization/Individual): M n k.. , Se- e4e- / ea _ Address: ' / 7 0 (-' S -Pi7 City /State/Zip: ea , W-14....- , ' Dlo f$aP.hone #: yf 3 — .2y7 "'O 55 Are you an employer? Check the appropriate box. Type of project (required): E 1. 1 am a employer with 1 4. 0 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 onthe attached sheet 7. ❑ Remodeling ship and have no employees These sub have 8. 0 Demolition working for me in an ca employees and have workers' g Y capacity. aci tY comp. - in $ _ 9 - ❑ Building addition [No workers' comp. insurance • d. 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions - - - -. _ re m ] :.� 3. ❑ I am a homeowner doing all work : Officers have exercised their 11.0 Plumbing repairs or additions - -- myself. [No workers'_ rom ,.__:. right o_f exemption per MGL .._ . 12.0 Roof repairs insurance required] t c. 152, §1(4), and we have no �/ Qv��./a rk employees. [No workers' 13. 1J Other V 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: 1 * bil:a , ( c.-4 ,. ( _ 0 . • — Policy # or Self-ins. L /(1�-S7 #: & / © < O G / Expiration Date: 3 D —/ 3 I Job Site Address: V/] S, 9&t City /State/Zip: 1016 60 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 theviolator... 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& t4 e pains and penalties ofperjury that the information provided above is true and correct - - Si: . attire: _A/WAN/ i Date: Phone #: `- (73 q) 7_ l Z t Official use only. Do not write in this area, to be completed by city or town officiaL Town: Permit/License # Iss or Authority (circle one): - I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. ___ . Contact Person: Phone #: INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes rlfrWo ❑ If you have checked Yes, indicate the of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee rinPS not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waivPsthis requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxes, I hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Prngrecs Incpertinnc Date Comments Final Incrtrtinn Date Comments Type of License: B y ❑ Master Title ❑ Master - Restricted City/Town ❑Joumeyperson Signature of Licensee Permit # ❑Journeyperson- Restricted License Number: Fee $ ❑ Check at www matt gnvk1pl Inspector Signature of Permit Approval �G;:�`: _ Commonwealth of Massachusetts I _ 8 2012 City Of Northampton L______.__ _ (- S heet Metal Permit �// — 3 g oep r F r r; , Permit /� ' N F r. Estimated Job Cost: $ ( C7 c 00 Permit Fee: $ 451' /er) Plans Submitted: YES NO (/ Plans Reviewed: YES NO Business License # 5 Applicant License # Business Information: Property Owner / Job Location Information: Name: Al � . Whorl Name: p,„,fG C , Street: / D t A tes S Street: / ,ern o 51 City /Town: (,J&5 / (.',lam l City /Town: /16 r th-i"go-/ Telephone: C{5 —. - / ({ t & Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES ( 740 Staff Initial J -1 / M- 1- unrestricted license J -2 / M- 2- restricted to dwellings 3- stories or less and commercial up to 10,000 sq. ft. / 2- stories or less Residential: 1 -2 family Multi - family Condo / Townhouses Other Commercial: Office _ Retail Industrial Educational _ Institutional Other 5 ware Footage: under 10 000 s . ft. V over 10 000 s . ft. Number of Stories: 9 Footage: q q Sheet metal work to be completed: New Work: Renovation: / HVAC Metal Watershed Roofing Kitchen Exhaust System t / Metal Chimney / Vents Air Balancing Provide detailed ( description of work to be done: // f WIA-f- oe,,, 1-..b. - 1- - t , e ka.,(4( trtio( ( fr ak--rYV-&r ,,,wa, Fees with Building Permit: $25.00 Residential, $50.00 Commercial. Fees for jobs without a Building Permit $6.00 per $1000 Minimum fees for jobs without Building Permit $50.00 Residential, $100.00 Commercial File # SM- 2012 -0038 APPLICANT /CONTACT PERSON AARON MORIN ADDRESS/PHONE 140 WEST ST (413) 247 -0550 0 PROPERTY LOCATION 1 MARKET ST MAP 32A PARCEL 097 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / ( / /� O Fee Paid Typeof Construction: VENT BASEMENT OVEN UP & OUT TO BACK WALL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 533 3 sets of Plans / Plot Plan THE FOLL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 ' Elm Street Commi ion Permit DPW Storm Water Management j� ' 9 Signature o 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 the Office of Planning & Development for more information.