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32A-146 (2) I 1 -I ' CI. r 6 liv c tn' A ill : n . i 1 Tif w, 1 1-"---6"—I 1 .--1"..‘" a a 4 Ci Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 Dear Mr. Hasbrouck, April 2, 2013 I request that you grant a modification to waive the requirement for construction control of the project at The Foundry Restaurant, 24 Main Street, Northampton, MA 01060. The proposed work, taking down two partition walls, is of minor nature, will not affect health, accessibility, life and fire safety, or structural requirements. The cost of control construction would be considerable when compared to the cost of the proposed work. Thank -you for your consideration. Respectfully, Claudio Garrido 140 Nash Hill Road Haydenville, MA 01039 (413) 268 -9052 (H) (413) 219 -5906 (Cell) F w M1 3 j "�t '411 k ' s I . r 4 #ti i ■ 441 .P ; " � � � ik II. yv w I- , 1 7 „M1 F'w d The Commonwealth of Massachusetts ,,,...„,„„, . Department of Industrial Accidents 0 Office of Investigations *. • .� 600 Washin Street • Boston, MA 02111 w www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly ell -- ---- // /A� ' c)® Name (Business /Organization/Individual): U T --- Address: A. S - t ` a .-� City /State /Zip: jig& - t F V(' fi t t 4 • Phone #: (lig) .26 l © 5,2, Are you an employer? heck the appropria e box: Type of project (required): 1. ❑ I am a employer with 4. 0 I am a general contractor and I ❑ employees (full and/or part-time).* have hired the sub- contractors 6. New construction 20 I am a sole proprietor or partner- listed on the attached sheet. 7. D Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' g 0 Building addition [No workers' comp. insurance comp. insurance,$ required.] - 5. 0 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. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.0 Other employees. [No workers'. comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ( Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 thep , + S andalties of perjury that the information provided above / is true and correct. � -_ '� ` Date: ��Si• nature: . Phone #: (l • r Al - r 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) ... ..,- cL Independent Structural Engineering Structural Peer Review Required ' Yes 0 No 0 .. 4.., SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN .,,I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT a / ( 1, iz as Owner of the subject property I hereby authorize ,. Zb CA2 "V ......L.2,(c 0 .........._____ _ ___„ ____ _ ______. _ _ _ ..._ ' to act on my behdf, i all matters relative i ts work authorized by this building permit application. - , A. IiiiivirINI, - 411 ' ' o4 : --- — ------: igna (Ire of *wner Olpr F Date b - 6. - Oe., . < P -- , ., , 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. '' • o Signed under the pains ands_anales of perjury. _ Print Name '//,.---"-1-1-'7 -- -------- .'' c...) Signature of Owner/Agerit Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: . Applicable El —7- -7 Name of License Holder : C-- id (iii)...th ,,...............6....f.±L( . 2 ( A c7 __ ...., _.1 Lcis013), Ic( ---- 5" License Number _ aC2_ (44 .0 (1 qd„L tc).. 1-I el K611 «v ' /4. c lo.21s or57:7710 i ,(/ — - Address / Dfite 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 Version1.7 Commercial Building Permit May 15, 2000 J 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 EILOSED SPACE) 9.1 Registered Architect: Not Applicable O Name (Registrant): _____ __.. Registration Number Add ress ---------- _..___ Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name • Area of Responsibility Address Registration Number t Signature Telephone Expiration Date Name Area of Responsibility Address • Ristration Number Signature Telephone Expiration Date i Name Area of Responsibility _... _.,.�.._. _. ..._..._.,_w w___.. . ( - _ -___. _...__....__. _. Address Registration Number I i Signature Telephone Expiration Date Name Area of Responsibility T i Address _ Registration Number Signature Telephone Expiration Date 9.3 General Contractor C I N m fb . _ : ` _. __._ , • Not Applicable ❑ J Company Name Responsible In Charge of Construction_ 6. l6Q () k' .19 _.. t � mm ..._.__ .._ ~w Addres-3 _ /�r� _ f �( 4 f� z 14 t° i4� `s'k�(/f ,1i!" t f %!G°�" en o - 1 � Signature Telephone Version1.7 Comrnercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING ., Existing Proposed Required by Zoning , This column to re filled in by Building Department Lot Size 1 ' j , , \ — ' Frontage ' ..._ . \ - Setbacks Et2fl T 7-1- Side L: ; R: . , L:; , i — 1 , Rear 1 - - --- 4 1 Building Height / / ....._ I i / r - • ,, Bldg. Square Footage I i : /' 1 ---- 1 1 , Open Space Footage % i ,, ! -- - (Lot area minus bldg & paved ' i t , J / i. ' --- — parking) ,, # of Parking Spaces . ' \\ Fill: (volume & Location) / A. Has a Special Peri:Mt/Variance/Finding ever been issued for/on the site? NO 0 / DONT KNOW 0, YES 0 , \ IF,YES, date issued/ i , IF YES: Wasidie permit recorded at the Regis of Deeds? NO „O DONT KNOW 0 \ YES 0 , \ IF YES Book / enter 1 Page ; and/or Document # : / \ B. Does the site contain a brook, body of water or wetlands? NO 0 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 (3 \ , Date Issued: , 1 , \ C. Do any signs exist on the property? YES 0 NO\ 0 \ I \ IF YES, describe size, type and location: \ \ D. Are there any proposed changes to or additions of signs intended for t e property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 ace or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 .. .. SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS. LESS THAN 35,000 • t , CUBIC FEET OF ENCLOSED SPACE • '— Interior Alterations X Existing Wall Signs 0 Demolition 0 Repairs 0 Additions 0 Accessory Building 0 Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use 0 Other 0 I Brief Description IEnter a brief description here. 1 y S-Pd Of Proposed Work: SECTION 5- USE GROUP AND CONSTRUCTION T-Iref i USE GROVP (Check as applicable) CONSTRUCTION TYPE A Assembly A A-1 Oa i ilk A-2 0 A-3 0 1A 1 0 A-4 0 A-5 0 1B 0 B Business 0 2A 0 E Educational 0 2B - r 0 F Factory 0 F-1 0 F-2 0 2C 1 0 H High Hazard 0 __ 3A 0 I Institutional 0 1-1 0 1-2 0 1-3 0 3B _, M Mercantile 0 4 U R Residential 0 R-1 0 R-2 0 R-3 0 5A 0 S Storage 0 S-1 0 S-2 0 5B 1 U Utility 0 Specify: r M Mixed Use 0 , Specify: r — S Special Use 0 Specify: ; I . COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group: _. _, 1 Proposed Use Group: Existing Hazard Index 780 CMR 34): __ , 1 Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA / . BUILDING ARE PROPOSED NEW CONSTRUCTION : , OFFICEUSE , ONLY , Floor Area per Floor (sf) ^...., ,,,,,,' -,.., 'N.., 7 '‘,... l , - 2 __i / --' , --- 3" , / 1 , - ; ..............._ —_....._...........-....._.., / - ^- , ,, --- -- . / th , •,, 4Th ,/ 4 ...,,., .-...- ------ , I •,.„, / Total Area (sf) ,' Total Proposed New Constructioit(sf) Total Height (ft) _ Total Height ft _ . 7. Water Supply (M.G.L. c, 40, § 54) 7.1 Flood Zonq Information: 7.3 Sewage Disposal System: Public El Private El Zone Outside Flood Zone0 Municipal 0 On site disposal system0 — • Version1.7 Commercial Building Permit May 15, 2000 ? u`? ©.xarfrste : (i$ # ;.,W '" c, '� ' ' a ±- City of Northampton • Building Department �,. . 212 Main Street 1, Room 100 Northampton, MA 01060 W , W ; � .: a * , 4 phone 413- 587 -1240 Fax 413- 587 -1272 • r I _ ,, � � s A APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY uvv ii�ye� /C SECTION 1- SITE INFORMATION ,"iGt✓C V G 1 3? 4 _/ u T is r rrtanplted by office ' 1.1 Property Address: 9 l ( r(1`1/ 5 _ Map D e n BUILDING G i NsPE r O N S NORTHAMPTON, MA 0 060 Unit ,G ! i" " �. j Zone Overlay District ,trvr 4T i f 'e/t1- ©0(0 1 Etrn S District CB District SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 5411 -. :' �. _ O Name (Print) __. Current Mailing Address J' Signature Telephone OF Authorized Agent: C7/{ ( ��{/ �// � I� S, -E 14(,)) r� (41-10 - - -" - — °' - ( ..g• �'"'- -___�. ...,. . 1� . ._. ___�.._...,...__._._.. Name (Print) / ? Cur ent aiiin Address: _ --- — g 1 L� -- — G 3� � ,h e (o S2 Signature W Telephone [ C SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i (a) Building Permit Fee T O ' b Estimated Total Cost of 2. Electrical I Construction from (6) 3. Plumbing _ _ Building Permit Fee 4. Mechanical (HVAC) -- ° 5. Fire Protection p 7 _ . . . _ — , 6. Total = (1 + 2 + 3 + 4 + 5) i 0 ( ) Check Number This Section For 'Official _Use Only Q (,J Building Permit NumbereP / 3 a' !� 7 [ Date Issued Si• = Age ,ee67/, 7- //Id° 4 ?" -- 5 — / : ng ommissioner /Inspector Buildings Date 24 MAIN ST - THE FOUNDRY BP- 2013 -0884 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 146 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- 2013 -0884 Project # JS- 2013- 001520 Est. Cost: $1000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CLAUDIO GARRIDO 89458 Lot Size(sq. ft.): 1481.04 Owner: NOBLE SALLY Zoning: CB(100)/ Applicant: CLAUDIO GARRIDO AT: 24 MAIN ST - THE FOUNDRY Applicant Address: Phone: Insurance: 140 NASH HILL RD (413) 268 -9052 HAYDENVILLEMA01039 ISSUED ON:4/3/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE WALL POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 4/3/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner