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32A-088 (3) .. .-.. 1 07/22/2009 02:49 14135401959 WESTERN MASS MASONS PAGE 82/02 5. WEST WING SOUTH EAST CORNER. CUT OUT BRICKS THAT HAVE CRACKED AGAINST CORNER OF WINDOW. BACKER ROD AGAINST WINDOW AND CAULK THE GAP. TOTALS 1550.00 WE HEREBY PROPOSE To FURNISH MATERIALS AND LABOR - $ IN ACCORDANCE WHINE A� SPECIFICATIONS, FORT SUM OF: This quote may be withdrawn born u$ if not accepted wf fin 30 days. '61144011014em . Quote Prepared By: David Dsiedd TINS: Any albrsfon or derided tram above extra axes Alba executed ady upon roman orders, ended become as adfre chew Dior aed above the eeimab. B!' Aping Oft quote yvu agree and u d sbr+d a4l4ha above Mows and cony oastIv tappy b Wob Argr dlage& tan mete be soda, must be tbscutSed peer to combustion and agreed upua by contractor and may 1490 aunt toIts * tete. m A C C E P T A N C E OF M.:TbaAbovePrices, Speakebene AndCo are Are Sa oeyAndHerebyAccaptad .YouMsAubloixedToWho Work As SpedledalinalliMenalieWal sqnrature of / / J �± ' gc'etu"e tie: .� fj • Thank You For Choosing Western Mass Masons! UCENSED REGISTERED INSURED E STERN MASS :1\4AS oNs 383 COLLEGE HVYY, SOUTHAMPTON, MA 01073. (413) 527 -1800 WWW.WESTERNMASSMASONS.COM QUOTE To: SCOTT JOHNSON Date: 7-224009 COOLEY DICKENSON HOSPITAL Quote 1 67431 111111111.1111111111111111111111111111 Pmject tLISL PROJECTS Description of Wodt To Be Done: 1.1 AM R ST VC" HE • � E - REMOVE AND DISPOSE OF VENEER THAT IS PULLING AWAY FROM E BUILD THE VENEER WILL BE TAKEN DOWN TO THE GRADE LEVEL AND REBUILT WITH NEW BRICKS, MATCH AS BEST AS POSSIBLE. TOTAL$ 4650.00 2.GRAVES AVE NORTHAMPTON MA. St+ THE FRONT TWO CHIMNEYS MUST BE TAKEN DOWN TO THE ROOFLtNE AND REBUILT, THE CHIMNEYS WILL BE REBUILT WITH NEW BRICKS AND LEAD FLASHING. THE REAR CHIMNEY MUST ALSO BE TAKEN DOWN TO THE ROOFUNE AS WELL $ 3250.00 NOT INCLUDED IN THE TOTAL PRICE. TOTAL$ 6775.00 3, SHEPPARD BUILDING. REPOINT SOME LOWER SECTIONS WITH RED DYE IN THE MORTAR AND RELAY A COUPLES BRICKS. • TOTALS 850.00 4. WRIGHT BUILDING SOUTH SIDE. REPOINT LOWER SECTIONS WITH RED DYE IN MORTAR. RESET BROWNSTONES AS BEST AS POSSIBLE. RELAY ANY LOOSE BRICKS, FRIDGE LINES AND ELECTRICAL WILL HAVE TO BE MOVED, TOTALS 3785.00 Thank You For Choosing Western Mass Masons! _ _ __ .. Jc -n1,1 AM'1CA17 J 1Ff 1M-1-1 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City _of Northampton _ wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations The inspection.processrequires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour). a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper -- --- - - - - -- is -i-n- conjunction. to_ the_building._permiLissued,. and - that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date _ ..� Address of work location .‘"4 P : The Commonwealth of Massachusetts � — Department of Industrial Accidents ' 1 1.= f' Office of Investigations w= 1_ �, g 600 Washington Street Boston, M4 02111 ` www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization /Individual): LUC S i < `4 4i �.-2'ss 7a<2 --/ Address: 3p c J( /X..7 City /State/Zip: J.4 12/ Phone. #: PCl Are yo employer? Check the appropriate box: Type of project (required): /„ 1. I am a employer with OZ 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have. no ,- loyees These sub - contractors have. 8. 0 Demolition working for me in an i employees and-hhave workers' Y capacity. t 9. 0 Building addition [No workers' comp. insurance camp. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. [Q I am a�omeowaer dd a Q aII we 1c cersilave` xcr_c ed their _-1-1. Plumbing r epairs 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' 13.0 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 it ft ormation. Insurance Company Name: 64 n , / , —S/of / e Policy # or Self-ins. Lic. #: 7y / �'t� y Expiration Date: - Job Site Address: Kra its Ac City /State/Zip: 4Ff . A >a( Cl/C Attach page h acopy of the workers compensation policy declaration pa (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. 15e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do herebycerti der the pains • penalties ofperjury that the information provided_above_is true autcorr-ect _ _ Si • a • ture: �IW sate . ... d Phone #: t c L) -di UU - 1 N ffiC11 use only. Do not write iii tkic area, abe completed by city or town officiaL City or. Town: Permit/License # Issuing Authority (circle one): --I. Board of R itth 3. Building .Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbino Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : O i CJC. �,/J / ec / < e3?‘ License Number 3,p3 6.640 /-7-4 Addres ✓ J/ Expiration Date Si t r Telephone 9.. Registered ;kme°Improuerrient:Coritracto , , .., ..w .... ! x ... Not Applicable ❑ des (e r,,, '1r1 � z�e✓1C /33 Company Name Registration Number y — mac Address Expiration Date Telephone .� SECTION 10- 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 bu2g permit. Signed Affidavit Attached Yes No ❑ ffi p La (� The_current_exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of nit amptdn r inance5: °S'Iae "' a -Lost s_Genemil aws- Annotated. Homeowner Signature j • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other [p] Brief Description of Proposed ") i / Work: a, be ..4.'w c---/- / /0. c h e e%I Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa' I`f NeW house and: or addition to ezistiriq housing; complete -the fol lowing: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , 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 . .. TD _ 11 c,' (...../ cC (4 i , 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 ,—/— Signat o wner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage .__._.._._.__ Setbacks Front Side R: ..___ Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: ._.� � .H_ .........._. �_ ... , (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 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 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 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 NO 0 IF YES, describe size, type and location: ## D. Are there any proposed "c ianges to or ad lfions `o ' signs intended -for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. W+II the construction activity disturb {Gearing, 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. it { r ' D�partmbFitu oily 6: City of Northampton S ta s P r r - tq Building Department trb w a 2 aj� its , k . 212 Main Street , Pe r§ kril ty wit 5r c Room 100 �a1 , i �- 0V, A� r�felT��a1�1 x i Northampton, MA 01060 * o � trt c P, �� r \ phone 413- 587 - 1240 Fax 413 - 587 -1272 � • I 8 to taWt fir: z � � ` Qt� ` pI� O* APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING .SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 0 f Cr ^ v PJ Ae Map _ Lot Unit 4 Zone Overlay District ' EIm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ _‘..:, Di k_Cis..1(4.4..._ Ap.: _(._ Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: A. j_ /(446.1 /v 3P3 c i r C LT 1 Name (P ' ) Current Mailing Address: C S" re 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 /fa/5- 6. Total = (1 + 2 + 3 + 4 + 5) ,. cy cJ Check Number i i 4 This Section ForOffic se Onljr D ate Building Permit Number: 'Issued: Signature: Building Commissioner /Inspector of Buildings Date I_ -- BP- 2010 -0246 GIS #: COMMONWEALTH OF MASSACHUSETTS * CITY CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pei Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0246 Project # JS- 2010- 000310 Est. Cost: $6775.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WESTERN MASS MASONS 089376 Lot Size(sq. ft.): 5880.60 Owner: COOLEY DICKINSON HOSPITAL THE Zoning: URC(100)/ Applicant: WESTERN MASS MASONS AT: 25 GRAVES AVE Applicant Address: Phone: Insurance: 383 COLLEGE HIGHWAY (413) 540 -1959 WC SOUTHAMPTONMA01073 ISSUED ON:9/2/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD CHIMNEY 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 9/2/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo GANDMEN -01 ROM2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 -S (7/97) GANDMEN -01 ROM2 --ACORD,„ ACORD B ATE (MM /OD /YY) CERTIFICATE OF LIABILITY INSURANCE 6/16/2010 PRODUCER (413) 733 -3131 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION FieldEddy Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 96 Shaker Road HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 709 East Longmeadow, MA 01028 -0709 INSURERS AFFORDING COVERAGE INSURED Gandara Mental Health Center Inc INSURER A: Philadplphia.IndemnitrInsurance CompaktiPIIC!_._._ 147 Norman Street INSURER B: National Union Fire Insurance Co of Pittsburgh, PA West Springfield, MA 01089- INSURER INSURER 0: �^ I ` INSURER E: !� COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ��— POLICY EFFECTIVE POLICY EXPIRATIONj' LTR TYPE OF INSURANCE POLICY NUMBER DATE IMM /DDNYI DATE fMM/DONYI I LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X . COMMERCIAL GENERAL LIABILITY PHPK437756 7/1/2010 7/1/2011 FIRE DAMAGE (Anyone fire) $ 100,000 CLAIMS MADE rid OCCUR MED EXP (Any one person) _ $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ — 3,000 000 GEN AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 3,000,000 X�I POLICY n JECT F LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ y AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ 3,000,000 A X OCCUR , CLAIMS MADE PHUB276416 7/1/2010 7/1/2011 AGGREGATE $ 3,000000 DEDUCTIBLE $ • X . . .. $ .._. WORKERS COMPENSATION AND X WC STATU- 1 OTH- EMPLOYERS' LIABILITY L7S)RYLMITS 1 �F(3_ B WC006 -42 -9930 7/1/2010 7/1/2011 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER A General Liab. - Simplified PHPK437756 7/1/2010 7/1/2011 Occurrence /Aggrega 1,000,000/3,000,000 DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Proof of insurance coverage issued per request. CERTIFICATE HOLDER } 1 ADDITIONAL INSURED; INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION "Proof of Insurance Coverage Sample" DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE - r ACORD 25 -S (7/97) © ACORD CORPORATION 1988 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper jermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made * � _ understand the above. y (Ho ', ' ;r�' . 'gnat e ri;questing exemption) I will call to sche . ule all required building inspections necessary for the building permit issued to Date vg---V/6 Address of work location 25 Graves Avenue , Northampton, MA T The Commonwealth of Massachusetts t Department of Industrial Accidents • fl Office of Investigations r . _._ _ 600 Washington Street =:-.1_4....... _ a Boston, MA 02111 - www mass gov /dia • • -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print LegibIv Name ( Business /Organization/Individ „ at): G A/4A -i' 0 A-4 eP r • Address: / V 7 /Vor m o, Ai 'S-t • City /State/Zip:(J)est` cpeuv f e kcf Phone. #: V/3 — 73 6 `?aR Are you an employer? Check the appropriate'box: . Type of project (required): / 1. [ij I am a employer with275 /50 4. 0 I am a general contractor and I 6. ❑ New consttnction employees (full and/or part-time).* have hired the sub- contractors listed on theattached sheet. 7. 0 Remodeling 2. .0 I aril a sole proprietor or partner- ship ond have no a loyees These sub - contractors have 8. [] Demolition • working for-mein any capacity. eaAlloyees and_lhave workers' II dtug a diti n f/ workers' comp insurance . -. comp. mcttranc a #- - required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have xercised their 11. Plumbing repairs r ❑ g or additions myself [No workers' comp. rig of exemption per MGL 12. Roof airs .c: 152 and we have no insurance required] t ' 1 4 e ()' 13.0 Other K/ rd e' /epA 11 - employees. [NO workers' comp. IDSt1Iance regUirid.J. . Any applicant that checks box #I must.also fill out the section belowshowing theirworkers'- compensation policy information: t Homeowner; who submit this affidavit.indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether-or notthoseentities 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 andjob site information. Insimee Company Name :? h .1. a A e l (31, .:c.- Sh cf em. A :4 n s LcP a • e. a t, .;pa * • Policy # or Self-ins. Lic. #: 1.-t.{ P K 5 9 a c.. 3 I Expiration Date: - 1(0 t 1.2. o ii. Job Site Address: 25 Graves Avenue , C , /S Northampton, MA 01089 Attach a copy of the workers' compensation policy declaration pege'(showing the policy number and expiration date). -_ Failure to secure coverage_as required under Section t25A ofMGL c. 152 can lead to the mipos tion'of crin3inel penalties of a fine tip to $1,500.00 and/or one- year imprisonment, as well as civil penalties is the form of a STOP WORK -ORDER and a fine of up to 5250.00 a day against the violator Be advised that a copy of tins statement may be forwarded to the Office of Eire the DIA fcif insurance a verification ,.. _....7. Ido her$ rt e cei under the arms and penalties o . , - 'ray ... f p and correct - -- �' ..f' P P � the in ormatron rovrded.abavp �c� S_gnatu /� . 1 ate Phone ii: 413 - 736 - :329 ext 206 _ . • ' ' O sal use onl . Do not write in this area, to be Completed by city or town offrciaL City or Town: Permft!License # Issuing Authority (circle one): .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricaljnspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: D_ � Not Applicable ❑ Name of License Holder : gobe , r' O/ A37/7 License Number 3/7 avid sr el iCY v w 010 101 Addres Expiration Date x/D c ,h a / /3 - � 9S =5" Signature Telephone 9. Registered tHfrfei`isitiirO4iiil ti cn c b .„ : 'f;71,Et Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- 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 ❑ 1b - l tltYll � ll �'; The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the buildine permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement indows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [114 Other [at Brief Description of Proposed Work: St) p p o d I ` i tc / Roar ii 5`oArovril s New Stic�� 3 t- a -U. vrvelr 3 Alteration of existing bedroom Yes N No Adding new bedroom Yes / No Attached Narrative Renovating unfinished basement Yes _ '*" No Plans Attached Roll - Sheet = 1Wr ctr'.° Xretin :`daa eit + fiti: a. Use of building : One Family _ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Henry J .East — Trou /Gandara Center , as Owner of the subject property hereby authorize Robert Arnhold to act on my behalf, in all matters relative to work authorized by this building permit application. .41111 1111111111 / 111111111r ...„rIg --4 11111111119° Sign. !- `■ NI■' Date Ami lrArer 1, I Julio Fact -9'r ^u , 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 penalties of perjury. Henry Julio East —Trou Print Name 01. — _ - Sign -< of 1,0E Ag Date X1/7-1 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department 3; �7o SFr Lot Size i Frontage I 75 Fr 1 i { ' - Setbacks Front ± I Side L:= R: —_.. • 1 L:' 1 R:# _ 1 ? ' Rear 1 I i Building Height i , �-- L __ _J I .. Bldg. Square Footage ME En % f I Open Space Footage r % i (Lot area minus bldg & paved _ _ ®, 1 1 parking) i( # of Parking Spaces i Fill: I l (volume & , Location) ti -- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO (Si) DONT KNOW 0 YES 0 ri 1 IF YES, date issued:I l IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book , Page and /or Document #: . B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES i IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: , C. Do any signs exist on the property? YES 0 NO 7 . 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: l i 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton _� � Building Department � 212 Main Street S p 9 Y Y (1 ��l l'vJ Room 100 Northampton, MA 01060 �� � E 4 phone413 -587 -1240 Fax 413 - 587 -1272 �,�� � APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 0 2S . (5 r A veS 4v Map Lot Unit Noe,/4 em 7 / / Zone Overlay District Elm St° District CB.Dlstrict SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 6A)vcfA ,'n /11t?l/rid1 !IeA/b' Ce4v7tr I - Z ,1/OfMA/v 5l /)esi 'SrikygelJ Name (Print) Current Mailing Addres : V/21' 3 & -g3a.4 Telephone 2.2 Au orized 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 !oz e'r (a) Building Permit Fee 2. Electrical 0 (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) Check Number /1) This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0319 APPLICANT /CONTACT PERSON ROBERT ARNHOLD ADDRESS/PHONE 317 GOLD ST BELCHERTOWN (413) 695 -5404 PROPERTY LOCATION 25 GRAVES AVE MAP 32A PARCEL 088 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Y Fee Paid g70 Typeof Construction: INSTALL KITCHEN FLR SONOTUBES,SIDING & 2 WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 23717 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 Demolition Delay �/ I Signature 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. z ; GRAVES AVE BP-2011-0319 GIS #: COMMONWEALTH OF MASSACHUSETTS b,Blockx 32A 08:8 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-2011-0319 Project # JS- 2011- 000522 Est. Cost: $7000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARNHOLD 23717 Lot Size(sq. ft.): 5880.60 Owner: Gandara Mental Health Center, Inc. Zoning: URC(100)/ Applicant: ROBERT ARNHOLD AT: 25 GRAVES AVE Applicant Address: Phone: Insurance: 317 GOLD ST (413) 695 -5404 WC BELCHERTOWNMA1007 ISSUED ON:10/8/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL KITCHEN FLR SONOTUBES,SIDING & 2 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: 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 10/8/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner • KESU '4c °12° CERTIFICATE OF LIABILITY INSURANCE DATE 7 /7 /2 DIYYYY) 717/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER (413) 733 -3131 NAME: Mary Lou Rosner FieldEddy Insurance iA °O , " N , Ext): (413) 233 -2122 FAX Noy (413) 733 -3191 96 Shaker Road ADDRESS: mrosner@fieldeddy.com P.O. Box 709 PRODUCER East Longmeadow, MA 01028 -0709 CUSTOMER ID # -01 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Gandara Mental Health Center Inc INSURER A :Philadelphia Indemnjy Insurance Company 147 Norman Street INSURER B :Atlantic Charter Insurance Company West Springfield, MA 01089 INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER (MM /DD /YYYY) (MM /DD /YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 1 PHPK741925 7/1/2011 7/1/2012 A E�RENcED 100,000 PREMISES (Ea occurrence) $ i CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGG $ 3,000,000 X POLICY PRO- LOC $ _ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO — — BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 3,000,000 A PHUB351211 7/1/2011 7/1/2012 — DEDUCTIBLE _ $ X RETENTION $ 10,000 $ WORKERS COMPENSATION X ORS LIMITS O ER AND EMPLOYERS' LIABILITY B ANY PROPRIETOR /PARTNER /EXECUTIVE Y I" WCV00968000 ' 7/1/2011 7/1/2012 E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below l i E.L. DISEASE - POLICY LIMIT $ 500,000 A Misc.Professional Liability PHPK741925 7/1/2011 7/1/2012 Occurrence /Aggregate 1,000,000/3,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Proof of insurance coverage issued per request. with regards to location: 25 Graves Ave. Northampton MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty p ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 - AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations fi t' - 600 Washington Street 1/47' Boston, MA 02111 www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Gandara Mental Health Center, Inc. Address: 147 Norman Street, City /State /Zip: Northampton, MA 01089 Phone #: 413- 736 -8329 ext 204 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 listed on the attached sheet. 7. ❑ Remodeling 2. El I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3. ❑ I am a homeowner doing all work right exemption per ht of ti MGL myself. [No workers' comp. 12.0 Roof re airs [ rt insurance required.] t c. 152, § 1(4), and we have no i� A P� employees. No workers' 13. Other CrFr c }^ comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. r 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 certify under the pains and penalties of perjury that the information provided move is true and correct. Signature: � e I`r'a Date: 7 — 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 #: . , • . 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 el SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 7r1 1 0 • ,-, „ AirGar A d t/ ...." Asid fir 'I 0 , as Owner of the subject property 7 hereby authorize e6p — 7 — • 4 ivied I d act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Own Date 1 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 .. , , _ .. .... ... . „ _. Print Name Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : Abe-r L A t &Aoki ( ddress s. Geb `2 Address geZA 7 -6, L i/ ' 1 1411 ' nature /0 / 4 IP" Telephone °) a 7 , 3 _ 0 41 i•- Y/ ---Sy License Number /7 - ;•311 Expiration Date 9/y/i2- 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 s- 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 ,.,. ...... __ _ ___._ _. __._ _. ._„ __. _ _ _ _ .- ._n. 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 Version1.7 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. _w .._. 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 DONT KNOW 0 YES 0 IF YES, date issued: ' IF YES: Was the permit recorded at the Registry of Deeds? NO CY DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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, excava '•n, 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. 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 ❑ Access ry Eltiilding ❑ , � Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ 0 I -r • I Brief Description Enter a brief description here. Of Proposed Wor : i SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 El A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B , r ❑ 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 t ❑ 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: Existing Hazard Index 780 CMR 34): _ ..___. _. Proposed Hazard Index 780 CMR 34): . r...._ .. .. SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1st 1 s t 2nd 2 nd 3rd 3 4th "., 4th Total Area (sf) Total Proposed New Construction fsf) 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 Zoneo Municipal ❑ On site disposal system • Version1.7 Commercial Building Permit Ma 15, 2000 Department us or }y 3 RE City of Northampton Building Department curtaCutiDnvew y Pe ji B O 2 12 Main Street S ewer /Septw atlabtltt �uL y t w 3 Room 100 • N. hampton, MA 01060 °Trivia Sets of Structura' Pteas a? •1•., • m - • 3 -587 -1240 Fax 413- 587 -1272 `Plot/Site Saris 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 This section to be completed by office 1.1 Property Address: 6'rA v eS Map Lot Unit Zone Overlay District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 614 ov:n/97,3fi 0 Name (Print) / ji . Current Mailing Address: 141 6., Signature � /J�� Telephone 736' — �, ! 2.2 Auth • rize gent. 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 S 000. o 6 (a) Building Permit Fee 2. Electrical _., C 7 (b) Estimated Total Cost of J , Construction from (6) „ . _ 3. Plumbing f i Building Permit Fee 4. Mechanical (HVAC) �/ 5. Fire Protection AfC) / 6. Total= (1 +2 +3 +4 +5) Check Number AD X35 "— This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissionerllnspector of Buildings Date File # BP- 2012 -0027 APPLICANT /CONTACT PERSON ROBERT ARNHOLD ADDRESS/PHONE 317 GOLD ST BELCHERTOWN (413) 695 -5404 PROPERTY LOCATION 25 GRAVES AVE MAP 32A PARCEL 088 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ? lb A Fee Paid �' Typeof Construction: REPAIR PORCH FLOOR,RAILING & POST New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 23717 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN_ F9RMATION 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 7/g/ I Signature of Building Of icial 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. 25 GRAVES AVE BP- 2012 -0027 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 088 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 -0027 Project # JS- 2012- 000049 Est. Cost: $3500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARNHOLD 23717 Lot Size(sq. ft.): 5880.60 Owner: Gandara Mental Health Center, Inc. Zoning: URC(100)/ Applicant: ROBERT ARNHOLD AT: 25 GRAVES AVE Applicant Address: Phone: Insurance: 317 GOLD ST (413) 695 -5404 WC BELCHERTOWNMA1007 ISSUED ON:7/13/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR PORCH FLOOR,RAILING & POST 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 7/13/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner