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,_ The Commonwealth of Massachusetts
,. Department of Industrial Accidents
Office of Investigations
4 `. ` 600 Washington Street
Boston, MA 02111
www.snass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
GERRY SHATTUCK
Name ( Business /Organization/Individual): 53 Clark Avenue #11 _
Northampton, Massachusetts 01060
Address: (413) 584 -6265
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required): I
1. ❑ I am a employer with 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-
x listed on the attached sheet. 7. ❑ Remodeling
hip and have no employees These sub - contractors have g_ ❑ 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
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.
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 DLA for insurance coverage verification.
I do hereby certify cs er the a t• of perjury that the information provided above is true and correct.
Signature:
Date: hi )
Phone #: 4J 1 '-'C7
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 #:
VersionI.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
1 , (.141 k .. as Owner of the subject property
'�
hereby author _ -. to
act on my beh ;;;.. all ma ?s rel- : • - to work authorized by this building permit application
Signa of Owner ® Date
, 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 perjury. _...
__ a
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
.._ ._
, _�
GERRY SHATTUCK License Number
53 Clark Avenue #11 6
._ ..__.._ ._Northamttn+ -....Massaehnsetts01 } _ ___..... .._... ...
Address (41.3) 584 -6265 Expiration Date
Li
_,, u_
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(S))
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 uilding permit.
Signed Affidavit Attached Yes No C
Version1.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _., _
Frontage
Setbacks Front �' t
i
Side L: .. R: " : 3i ,
Rear L
d 9
Building Height i
Bldg. Square Footage
Open Space Footage N , % '
(Lot area minus bldg & paved ,`,. 0 2
parking)
# of Parking Spaces 11
Fill: . .-�
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ijj 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 Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
�_ ___
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and 14,,,ej
D. Are there any proposed changes to or additions of signs intended for the property ? YES ti+ NO 0
IF YES, describe size, type and location: 54,h- AA— 4 _ .'t_ k ,._r ITT/
1r� 1-At q N
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.
Versionl.7 Commercial Building Permit May I5, 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
K..w ._ .
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
..���
Not Applicable ❑
Company Name:
63 Clark- Avenue 44L1
Northampton, Massachusetts 01060
Responsible In Charge of Construction
Address
; 51 fte
Signature Telephone
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 1
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. i d )11 -- A-
L.
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 1A ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A I ❑
E Educational ❑ 28 I' ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1 -2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 0 R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
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):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
st .._ .. 1 st -_ „4. ott m
2nd 2-
.
3rd _._ ., ._ _ .__. .._ _ �_.._. .a
3 ,..
_ _
4th m
4
Total Area (sf) ' �.. Total Proposed New Con truction (sfl._. -
a
Total Height (ft)
Total Height ft
t
I
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 17.3 Sewage Disposal System:
Publi Private ❑ Zone Outside Flood Zone Municipal On site disposal system ❑
--\ Versionl.7 Commercial Building Permit May 15. 2000
•, Department use only
Northampton Status of Permit
Butt i De a rt me nt Curb Cut/Dnveway Permit
p
� e� 21` ,1a�n Street Sewer lSepticAvaifabt3rty
Room 100 1lllater/V ell AVadabiiity
` 0 Northa ton, A 01060 Two Sets of Structurar Plans
U one 4 24 ax 413 -587 -1272 Piot/Srte Plans
\` ;c,` ' N' ' OtherSpecify
APPLICATION TQ STR,' EP
- ', - REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
■ V- . :''`' - OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SI INFORMATION
This section to be completed by office
1.1 Property Address:
Q� Sr- 1 (\\ ,e Ma P Lot Unit
S/ Zone Overlay District
--- -- -_ ..w..�_.,, ,— .. .. El St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address
Signatures ;'', / 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 2 (3 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing l.�,` Building Permit Fee
4. Mechanical (HVAC) "
5. Fire Protection I,
6. Total= (1 +2 +3 +4 +5) ��) " Check Number f if 4/17 6 v
This Section rFor Official Use Only /
Building Permit Number Date
Issued
Signature:
I
1
Building Commissioner /Inspector of Buildings I Date
File # BP- 2008 -1188
APPLICANT /CONTACT PERSON Gerry Shattuck
ADDRESS/PHONE 53 CLARK A VE #11 NORTHAMPTON (413) 584 -6265 ee
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out // f o7/17, 5-v
Fee Paid cJ
Typeof Construction: CONSTRUCT SEASONAL PATIO DINING
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/ Statement or License 058422
3 sets of Plans / Plot Plan
THE FOLLOWING AC ION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION l � NTED:
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* Al x36 /
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required: 423 3g) Q a s g,1
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health ��Welll�l Water Potability Board of Health
Permit from Conservation Commission 1/Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
....... /.... , "q 1 tV-..... - ZOO a
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.
,
si pia
EaistingRailraatl
��� �_ � Embankment
a IInhu hT1777TT7 T
15 19 13 12 11 70 9 s T 6 5 9 3 2 • ousting Building. Ip l
Parking lot N C
.----Restaurant L Dumps.. \,\
S�'a I N
2 story brick 2 story brick �� -� = �. ea..... �a
building building _- T . ��∎ s=...... —� .._
3 story brick 1
III building '
NEW rnna AM as
.Di
Hawley Street
Parking Access
•
a „.. ,,.
II V
O
0 10 20 30 40 50 FT
q.1 Q
SXJ '.. r.:"%,........ C/4 V, 4 a
af kb
a3
/ ct4
AM", 1.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
•
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. 11:1 I am a general contractor and I
have hired the sub - contractors
employees (full and/or part- time). * 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
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
3. ❑ I am a homeowner doing all work
officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ 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.
1. 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 above is true and correct
Signature: Date:
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 #:
` Apo.
Version 1.7 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 O
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
I, LJ I (. a O ft 3 , 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 undert - •ains and •- nalties • .erju
,addill11
�...
Print •,r
L AM
Signatu of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
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
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
,
Number
Address Registration Numb
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._._.. _.,. 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 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 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 (:) YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES (3 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 C)
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 (3 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w f .-
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 0 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs El Roofing ❑ Change of Use ❑ Other N
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as • pplicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 0 A ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -^ ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 • 2C 0
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 0 1 -2 ❑ 3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R- ❑ , R -2 M ' R-1 ❑ 5A ❑
S Storage ❑ •-1 ❑ S -2 M 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ ' .ecify:
S Special Use ❑ Spe :
COMPLETE THIS SECTION! ‘ ISTING BUILDING DERGOIN& 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 AR
BUILDING AREA EXISTING 1, PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
15
1 5t
2 nd
2
3rd 3 rd
____ _ ,..__.... 4w
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 ❑ Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system
•
r -
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer /SepticAvailabHity
�
\- Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
'; 47, k _ Map Lot Unit
`` ` 101 Otbef,C) Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address
q_(3 -6-C? - .
Signature _ . Telephone
2.2 Authori ed Agent:
IM _. t.► v■ "'tJ- ..c
Name (Print) Current Mailing Address:
`' 3 .� . 5 . .
Si / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building D/�p'} (a) Building Permit Fee
2. Electrical i (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) #96(;)C) Check Number This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
,
File # BP- 2009 -0666
APPLICANT /CONTACT PERSON GUERRA CLAUDIO
ADDRESS /PHONE 82 INDUSTRIAL DR UNIT 3 NORTHAMPTON (413) 586 -6323 0
PROPERTY LOCATION 1 BRIDGE ST
MAP 32A PARCEL 271 001 ZONE CB(48)/NB(52)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out q /�
Fee Paid ��! W
Typeof Construction: ERECT 10 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Signature of Building • fficial 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.
AGE ST„ BP- 2009 -0666
GIS #: COMMONWEALTH OF MASSACHUSETTS
ap:Block: 32A - 2/t 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- 2009 -0666
Project # JS- 2009 - 000966
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14113.44 Owner: GUERRA CLAUDIO
Zoning: CB(481/NB(52)/ Applicant: GUERRA CLAUDIO
AT: 1 BRIDGE ST
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR UNIT 3 (413) 586 -6323 0
NORTHAMPTONMA01060 ISSUED ON:1/30/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 10 X 12 SHED
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 1/30/2009 0:00:00 $25.002095
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
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�, Pla m ust be fl `d wi Irthe Bu Inspector,
Repainting ( )
• . ; grar Removal ( )
NORTHAP7I. 71060
Qt Titv of North Atass.
Application for a Permit to Place or Maintain a Sign
or other Advertising Device
(Application to be filled out in ink or typewritten)
FEE PAGE PLOT......,...
Northampton, Mass., 6-/Z z 01....
To the Building Commissioner:
Application for a permit to place or maintain a sign or other advertising device, or marquee.
1 1
BUSINESS NAME 1 a : t,S
om*
1. LOCATION STREET and, No
2. Owner's name C414 c i G errs J
3. Owner's address s a1.!1..... .�'....... 1
,j 0,- 0`'� -�
4. Maker's name C t i 5 /
5. Maker's address . (Z - r; 1 kr.Z
6. Erector's name
7. Erector's address
SIGH t ft Sw rku . oti: - KIND OF SIGN
d (Designate)
1. Sign will be (check one) illuminated non - illuminated
2. Will sign obstruct a fire escape, window or door? AN
Marquee
3. Lower edge will be ' ft. 8 ins. above the public way. Projecting
L
4. Upper edge will be .(,2 ft. V ins. above the public way. Roof
5. Height Z ft 0 ins. Width 3 ft 8 ins. Tempor y
6. Face area 6 sq. ft. Wall 1 4/h
fi) ...
7. Inner edge will be O ins from the building or pole. Ground
8. Outer edge will be 3 ins. frogs the building or pole. Other
9. Face of building or pole is j/ re. back from the street line.
10. Sign will project. O ins. beyond the street line.
11. Sign will extend 0 ft C' ins. above the building or
12. Of what mate 'al will sign be constructed ? Frame l�lska' Face Y d �
13. Estimate cost..�<..
The undersigned certifies that the above statements are true to the
best of his knowledge and belief.
» » » » »» (Signature or wncr or Agent)
NOTE: In order that this application may be accepted, the data called for above must be set forth
CLEARLY and FULLY.
10. Do any signs exist on the property? YES NO ■/ IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO
A
IF YES, describe size, type and location: Zs-hi-5( ' W
.>•I . 11l — * , o 4 ' ot(br.i r i U
11. ALL INFORMATION MUST BE COMPLETED, or PERM T CAN BE DENIED DUE TO
LACK OF INFORMATION.
This column to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved parking)
# of Spaces
# of Loading Docks
Fill:
(volume -& location)
13. Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge
DATE: , `C 1 APPLICANT 's SIGNATURE �-- -�'
—
NOTE: Ise ano at a zoning permit does not relieve an a lioa
pp n burden to comply with all
zoning requirements and obtain all required permits from the and of Health, Conservation
Commission, Department of Pubiio Works and other applioable permit granting authorities.
FILE #
R ECllWE —. .;
JUN - 4 2001 File No.00 / /M
DEPT OF BU G PERMIT APPLICATION (§10 . 2)
NORTNA
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: Al At . (4f r4,i,td" 7r
Address: 6r 4 e 45 Telephone: 5 ‘ 6 6 (4 3 1 3
vv �
2. Owner of Property: C. c c / 4 CPI
Address: 5/ I t Pt Pt ^(/3 Telephone: ,c8C. 6 31
3. Status of Applicant: V Owner Contract Purchaser Lessee
Other (explain):
4. Job Location: /0 k r & (j2 ) r
Parcel Id: Zoning Map# ' /� Parcel# ,7/ District(s): C
(TO B ILLED IN BY THE B UILDING DEPARTMENT)
5. Existing Use of Structure/Property iR QI G
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
Sit
7. Attached Plans: �/ Sketch Plan Site Plan Engineered /Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special PermitNariance/Finding ever been issued for /on the site?
NO N Pe DON'T KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book _ Page and /or Document #
9. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW • YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , date issued:
(FORM CONTINUES ON OTHER SIDE)
File # BP- 2001 -1001
APPLICANT /CONTACT PERSON GUERRA CLAUDIO
ADDRESS/PHONE 50 MAIN ST (413) 586 -6313 0
PROPERTY LOCATION 1 BRIDGE ST
MAP 32A PARCEL 271 ZONE CB/NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out gj d -
Fee Paid 00 / /
Typeof Construction: ERECT ILLUM FRONT WALL SIGN 6 SQ FT - DEL RAYE RESTAURANT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
�enied as presented:
r+i c 4 S. /Ca z
// f S pecial Permit and/or Site Plan Required under: §z2 '�"'3 -49 19 2 -I3 , Tj/ v f ecc, a�J/
PLANNING BOARD 1/' ONING BOARD 9
Received & Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w /ZONING BOARD OF APPEALS
Received & Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w /ZONING BOARD OF APPEALS
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 Co ion Permit from CB Architecture Committee
mss/ % o sS
Signature o : uilding 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.
File # BP- 2001 -1001
APPLICANT /CONTACT PERSON GUERRA CLAUDIO
ADDRESS/PHONE 50 MAIN ST (413) 586 -6313 0
PROPERTY LOCATION 1 BRIDGE ST
MAP 32A PARCEL 271 ZONE CB/NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin . Permit Filled out _ ,i / , -
Fee Paid d , l w
Tvpeof Construction: ERECT ILLUM FRONT WALL SIGN 6 SO FT - DEL RAYE RESTAURANT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THELLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received & Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w /ZON1NG BOARD OF APPEALS
Received & Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w /ZONING BOARD OF APPEALS
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
Signature of Building Offi al 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.
City of Northampton Map L q1 Zone CB/NB
Massachusetts Date issued 6/14/01 0:00:00
Inspector of Buildings Permit # BP- 2001 -1001
Permit Fee$30.00
SIGN PERMIT
Business DEL RAYE
Address 1 BRIDGE ST
Applicant Installer INDUSTRIAL SHEET METAL
Applicant Installer Address HATFIELD
Work Description ERECT ILLUM FRONT WALL SIGN 6 SQ FT -
DEL RAYE RESTAURANT
Estimated Cost $400.00
Building Department
Approval by:
, :si f. b City y ot• Northampton REQUIRED INSPECTIONS
g =r"-1 Footings 1. Footin s and Walls
=� -•� -� �• ��` e BUILDING DEPARTMENT 2. Structural e :;!� Components iln Pike*
z...0.9 3. Complete Building*
No. 1102 Office of the Building Inspector
Zoning Form No. 961656 Da 11/18/96 Fee $520.00 Check # 2108 & 1003
front back
Page, ' 2A Parcel 271 , Zone CB / BU;: NB Section 127 ❑ PERMIT
Yes L❑ No
* Plumbing and Electrical Inspections required
THIS CERTIFIES THAT John Lebhar o 0 j<: before Building Inspections
has permission to construct 1,200 S.F. Addition ;c v im , � Al- `" Inspection on Site—Foundations i -52 `3 - '-/- _ "� _
situated on One Bridge St - One Bridge St Inc Inspec don of Plumbing —Rough
Inspection of Plumbing— Finish •S
provided that the person accepting this permit shall in every respect
- 9 , 6
conform to the terms of the application on file in this office, and to the Gas Inspection '
provisions of the Statutes and the Ordinances relating to the Construction, "" 5 i-a/ r X I.4. -i.
p g Inspection of Wiring —Rough r' � ' " " •
Maintenance and Inspection of Buildings in the City of Northampton. �,,3�� c ,, 7s c(a'- -- , ��
Any violation of any of the terms above noted is an immediate revocation S Ins )ection of Wiring—Finish S `l� /y>
of this permit. Expires six months from date of issuance, if not started. 3 ` 5 ` ~ ` i 7 `�" Y AC; i../ Z"' < 3 - ' 3 a 7 1
P Build.uig Inspection —Rough 0 i'+ -. - •• ' 7 -
Note: A certificate of occupancy will be issued by this office upon retum ,/ In In spect i on d■ )-3 • .
of this card signed by the Plumbing, Wiring and Building Inspectors.
* *30 DAY TEMPORARY OCCUPANCY - 5/5/97 - EXPIRES 6/5/97 Building Inspection— Finish X `' ' 9 7 - e
Electrical Incomplete Smoke Detectors (Fire Department)
Other
THIS CARD MUST BE DISPL D A CONSPICUOUS PLACE ON PREMISES
Certificate of Occupancy ,,,e;":7 �" .0 , jro!( ,
Building Inspector
r edit liif ;110'd'
°� `��: City of Northampton REQUIRED INSPECTIONS
_ t' 1. Footings and Walls ._
�� ' e - B UIL DI NG DE PARTMEN T *
2. Structural Components in Place
3. Complete Building*
No. 1101 Office of the Building Inspector
Zoning Form No. 961627 Date 10/28/96 Fee $120 Check # 2069
Front Back
Page, 32A Parcel 271 , Zone CB NB Section 127 ❑ Yes ® No
BUILDING PERMIT ,
* Plumbing and Electrical Inspections required
THIS CERTIFIES THAT John Lebhar before Building Inspections
has permission to demolish & renovate interior Inspection on Site — Foundations
situated on One Bridge St - One Bridge St Inc Inspection of Plumbing —Rough i &A-
provided that the person accepting this permit shall in every respect Inspection of Plumbing— Finish �5'C 9
conform to the terms of the application on file in this office, and to the Gas Inspection , s CA' Cr
,3:,./.
provisions of the Statutes and the Ordinances relating to the Construction, S i i Insg�licui of Wiring—R g ym U/ tee, c < ,
Maintenance and Inspection of Buildings in the City of Northampton. � �Y
Any violation of any of the terms above noted is an immediate revocation 512e/ // Inspection of Wiring — Finish > pmy.1 -L 1e
y
of this permit. Expires six months from date of issuance, if not started. .0-9-1/ ° '� -1 ' �? - `! 7 1' p,
Buildniz Inspection —Rough 0 n, 9 :11 - 1' 7.1&.,,,
Note: A certificate of occupancy will be issued by this office upon retum insulation Inspection o i< 2 › - / 1 - 1 - c77_, -,
of this card signed by the Plurting, Wiring and Building Inspectors.
Building Inspection— Finish c ri' 5 5- q - , „
* *30 DAY TEMPORARY OCCUPANCY - 5/5/97 - EXPIRES 6/5/97
Electrical Incomplete Smoke Detectors (Fire Department)
Other
THIS CARD MUST BE DISPLA D A CONSPICUOUS PLACE ON 1. PREMISES
./
Certificate of Occupancy ��
-.
B ' • ng Inspector f ( 1:.l;If Sil;1
,