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DEPARTMENT OP BUILDD'iC INSPECTIONS __t—
212 Main Street • Municipal Building
Northampton, Mass. 01060 quo"s
WORKER'S COMPENSATION INSURANCE A Iff_DAVIT
Pioneer Contractors
(1►censeeipermittee)
with a principal place of business/residence at:
•
P.O. Box 1145 Northampton, MA 01061 (phone) 586 5491
(stmx t/ci ty/staleJzi p)
do hereby certify, under the pains and penalties of perjury, that:
(0/I am an employer providing the following workers compensation coverage for my
employees worming on this job:
Wcc 50059570120C12- 6 30
• - • u • • - nshrance r'o — -
(Insurance Company) (Policy Nu filer) (Expiration Daft:.)
( ) I am a sole proprietor, general contactor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (E).-pirntion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
•
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Laub additions!sheet ifnc scary to Sochudc information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
•
NOTE:please be aware that while homeowners who employ persons to do maitetcaarice,construction or repair work on a dwelling of
not more than three units in winch the homeowner raid=or on the mounds appurtenant thereto are not generally coceidaod to be
employers unekr the warku's.co¢zpciasatiou Act(GL152,au 1(5)),application by a homeowner for a tissue cc permit may cvnicnoe tuts
legal'status of an employer under the Worlca'a Cotnpomation Act-
t understand that a copy of this cutemeat may be forwarded to the Dcpartmcar of Industrial Aocidcsn'Offioo of besot-Loco for the
coverage vcrificanion and thst f:.ilurc to sec=covct aga under section 25A of MOL 152 can lead to the imposition of criminal penaflics
consisting of it fine of up to S1,500.00 and/or imprisonment of up to one year and civil pcaaltics in der fonn of a Stop Work Ordr and a
fine of 5100.00 a day against mc.
For cicpsrtoomeal use iy
___ 4(1. 1 a
t. Permit Number
�� `3//!✓_�_QX.? maP4 Lot
•_,
Si tore of Licccsee/Permi•• e
Versionl.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
Unique Lodging, LLC. . as Owner of the subject property
hereby authorize Pioneer Contractors to
act on my behyin all - atters relative to work authorized by this building permit application.
. 05/17/2013
Signature/ Own-• Date
David Claxton/Pioneer Contractors , as.+®vs '/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 th ainssaand pe altie prury.,
Print Name
05/17/2013
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: David Claxton CS 017890
License Number
P.O. Box 1145 Northampton, MA. 01061 01/19/2014
Address Expiration Date
,(413) 586-5491
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 ❑
cfz
.. 1QL'LCGS » ICGS / a
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
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Pioneer Contractors Not Applicable ❑
Company Name:
David Claxton
v� .
Responsible In Charge of Construction
P.O. Box 1145 Northampton, MA. 01061
Address
//19140'' L' ,(413) 586-5491
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 DON'T KNOW 0 YES 0
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 Q 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 Q NO ®i
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 0 Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. Selective interior removal of wall& floor coverings
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ID 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 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 1111 R-2 2( R-3 ❑ 5A El
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: R-�� 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 5t
1 Sf
2nd
2nd`
3rd
3rd
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 p Private ❑ Zone Outside Flood Zone 12 Municipal p On site disposal system❑
Versionl.7 Commercial BuildingPermit May 15,2000
Department use my !'
City of Northampton tas of Permit A " i l %
.
� f Building Department G tCut/Onv ayPermitgti , i °
e , 4/ '', tk
'
212 Main Street SewerSp Avai(lbil M// � i ,,
Room 100 1NaterMt-e11 Availab>lrty iti � � ���r �
Northampton, MA 01060 T'wo Sets o S�ru tiral Pla is� ;,�4� '' vol
phone 413-587-1240 Fax 413-587-1272 Pl'oil itG i lan's i,
"�4r `'� , ', i
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE •- O( : R_l!!1 s' r ■ OLIiSH ANY BUILDING
OTHER THAN A ONE OR TWO FAMI D ELLING '
MAY I ? 2013
SECTION 1 -SITE INFORMATION
1.1 Property Address: T t GSr SPECTi sted by office
NORTHAMPTON:MA 01060
74 Bridge St. Map Lot __ Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 17)2 J 2 am pi atA
2.1 Owner of Record:
Unique Lodging, LLC. 74 Bridge St., Northampton, MA. 01-060
Name(Print) Current Mailing Address:
(413) 237-5555
Signature !A_, Telephone
ir
2.2 Authorize- •wi!
`Pioneer Con ract.rs P.O. Box 1145 NOrthampton, MA. 01061
Name(Print) Current Mailing Address:
(413) 586-5491
Signature ( Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $5,000.00' (a)Building Permit Fee
2. Electrical , (b)Estimated Total Cost of
Construction from (6) -
3. Plumbing i Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /,
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature / % j' 6—//7/ 3
Building Commissioner/Inspector of Buildings Date
oK, -rd esst4E DE,AAO PE2T wt, : ,2 t--- F66
MA-0-4--
74 BRIDGE ST BP-2013-1114
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 177 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2013-1114
Project# JS-2013-001834
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 22999.68 Owner: UNIQUE LODGING LLC
Zoning:URC(100)/ Applicant: PIONEER CONTRACTORS
AT: 74 BRIDGE ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers Compensation
NORTHAMPTONMA01061 ISSUED ON:5/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:SELECTIVE INTERIOR REMOVAL OF WALL &
FLOOR COVERINGS
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 5/20/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner