32A-267 Version!.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I - \' @$ as Owner of the subject property
hereby authorize d ��5`.. C ' v�ti.l \ _ .� ,;•••3\-_,_ ,,..L. a k's, 'S! to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 penalties of perjury.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : .� �s _ __' (_si \ ��,
��� License Number
•3 {
Address . �] Expiration Date
Signat e 4.4....e_ �� 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 Eli No
Version 1.7 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):
1 2 - " (A 1 , - ) t - 7 L-L.vJ G - rr 2 - '14*- 0 f L..•
Name Area of Responsibility
Zia __A 2 kc�-14 5 r N `1 i. rato 1 3 - - s
Address Registration Number
s'. 1 7 ,/
y
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
A ° G1m F. _y_f• - ctv 1'U&4-1 T Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addr � G�C�
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 L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: _ .__ __,........
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 0 Obtained
, 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 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 ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. AN ,.x- - Pi sr . r
Of Proposed Work:
`Pt*- 5Pv1nevt - r --tom rVlE.-
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
NI 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: 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 CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1 st
1 st
2nd 2 nd
3 rd
3rd
4 th
4th
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 El
Versionl .7 Commercial Building Permit May 15, 2000
Department use only',
City of Northampton Status of Permit:
Building Department Curb Cut/D*away Permit -
212 Main Street Sswer /' ccAa�Eabrllty
Room 100 Water /Well Availability
Northampton, MA 01060 Two Sets of Structural Plana
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site P lans
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 ''�
Map 3 d4 Lot `7 (? Unit u
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
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) Lw L) Check Number '`?' / 155--
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
9 /8/0
Building Commissioner /Inspector of Buildings Date
4 GRAVES AVE BP-2011-0200
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 32A - 267 CITY OF NORTHAMPTON
Lot: -003 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0200
Project # JS- 2011- 000349
Est. Cost: $3800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KARL FERGUSON 60171
Lot Size(sq. ft.): Owner: 2 -4 -6 GRAVES AVENUE CONDO ASSOC
Zoning: Applicant: KARL FERGUSON
AT: 4 GRAVES AVE
Applicant Address: Phone: Insurance:
92 BEAUREGARD TERR (413) 563 -3355 0
CHICOPEEMA01020 ISSUED ON:9/8/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD STRUCTURAL POST FROM BASEMENT
TO ATTIC
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 9/8/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner