22B-041 (6) Initial Construction Control Document
* r To be submitted with the building permit application by a
vrll Registered Design Professional
for work per the 8th edition of the
IkAlr
me . Massachusetts State Building Code, 780 CMR, Section 107
Project Title: CafbvPsliN orussi J ` R J A i Date: 112—(1-I?)
Property Address: IJp PN1 S L gEfeE MA oluo
2
Project: Check one or both as applicable: ❑ New construction /Existing Construction
Project description: . I X1( o `s, i.I i� ii it ! , !/t
Pd./. . nr / r'i. f' r31
001 D ,
4/, MA Registration Number: 17 J` � Expiration date: Tef/� P, , am a
registered desig rof,1�'ional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
[ ] Architectural Structural [ ] Mechanical
[ ] Fire Protection [ Electrical [ ] Other
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a`Final Construction Control Document'.
Enter in the space to the right a"wet"or
electronic signature and seal:
Phone number: (`T(")) 3.�c - (-CR Kd Email: 7j(,y(k oL corn
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06_11_2013
The Commonwealth of Massachusetts
- Department of Industrial Accidents .
: :-0— Office of Investigations
11' 600 Washington Street
-r t a
— Boston, MA 02111
/,,.
`w 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. ❑ I am a general contractor and I
6. 1=1 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or_partr>er- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contactors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
g Y P h'• $ 9. ❑Building addition
[N workers' comp.insurance comp.insurance.
quired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.LJ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
g
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.
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 age., t the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D • for • surance coverage verification.
I do hereby ,er '►`,�cnd•r the gins and penalties of perjury that the information provided abo is tru and correct
Sianatur:& 1 'W/� . s` Date: i 3 I
Phone#:
Official irsa 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) h
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION 11 -OWNER'AUTHORIZATION-TO,BE:COMPLETED WHEN. ':
OWNERS AGENT OR CONTRACTOR APPLIES FOR=BUILDING PERMIT. .:
1, l tk `+' .,as Owner of the subject property
herebyauthorize,._._.___..._.__...__..._._._.___.___..._.__ __.w__.__.. __w_ .._ -._., ._� ,.._ ._w.w._. ...__._____._.__m.._ .___}..._ .... .to
act on my behalf, in all matters relative to work authorized by this building permit application. __ __
Signature of Owner Date
I,: _ .. .. _..__m_ ____ ________ _, _ .._.,._.._.._.-....,_._, ,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 painsandeenalties of pear ury. ,,., ___ _ ___________ ..w,_ ._..� _r._.,
i
Print Name g t, W r4'"N P i471,1- ,—_..__..._._..._. ____.._._..........__.,._.
Signature of Owner/Agent � _ —.1.-.. i Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑ _.
License Number
,.,_.. - _ __._...._. ___. .____.._...._... _ ....M...., _........._____.,.__.__ ..____.__
Address Expiration Date
l
_
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
Version1.7 Commercial Building Permit May 15,2000
J
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF EIJSLOSED SPACE)
9.1 Registered Architect: _
- ' Not Applicable ❑
i
Name(Registrant): --- -
Registration Number
Address l _ __. ._..___..,..._.__.....-.:
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
i
Name . Area of Responsibility
Address Registration Number
J _
Signature Telephone Expiration Date i7'4 i-f__ ea-O 1 r-
_ __ ,..--I
Name Area of Responsibility
i
_
Address Registration Number ___._____ __
Signature Telephone Expiration Date
Name_._ �-.._ _ . `
._ , .___.._._._ Area of Responsibility_..
Address . Registration Number
}
Signature Telephone Expiration Date
i
Name Area of Responsibility
i i
_ __ _
Registration Number
Address _
____._._,...._._._.,-�.__..
i
Signature Telephone Expiration Date
9.3 General Contractor
\ `'S.--C- ',:).1 .-1,..,__ �-" V.fin.. u--1..,._... _, ____ Not Applicable ❑
Company Name:
v-_ C-4k ,Q__ 1,y■
Responsible In Charge of Construction
kY dAe
•
T�:
r • i 1
Si nat �` " Telephone
Version1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING ..
Existing Proposed Required by oning .
This column e e filled in by
Building partment
Lot Size _. _ ..._, _ .. --,_ ---
Frontage _ § _____ __..
Setbacks Front .„ a j
Side L: ' R:,. ,� , L:[ 1 ,_r�_.� .., L .
N.
Rear ....- --
Building Height /////
jm
S
Bldg. Square Footage `” t ' f;✓/"°o i------7 f Ni
Open Space Footage ,./
---------=--:- (Lot area minus bldg&paved ��„j-;/I „l i I L ;
parking) f.
#of Parking Spaces --- '
i
(volume&Location) .......... ------- ----- --°. ----- . ",
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued: 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 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: M1µ
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location _ ,,__,,,.
D. Are there any proposed changes to or additions of signs intended for the property? YES -1'4 ,i
IF YES, describe size, type and location: ? 4n 1 j rip LA j tZ
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15,2000
J
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE •
Interior Alterations CO Existing Wall Signs ❑ Demolition❑ Repairs 0 Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other j2' KAI, ,,'ti
Brief Description #Enter a brief description here.
Of Proposed Work:? c"�� r. \\i P -.'�c -�L
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 JA 2A ❑
E Educational ❑ 2B r ❑
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 ❑ R-3 ❑ 5A ❑
s Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U Utility ❑ Specify:` ________________
M Mixed Use ❑ Specify:r
S Special Use ❑ Specify: 1
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS;ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: 3 �.5 t. - Zi TN --I Proposed Use Group: ----1-____—
___ Wµ•-- µ ...._ . _,1
_
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)
1St . 14; d9 - V ' -�P °.n"
1_ . __ Nj
1 -_
..._._._ - _ -; 3,�
4th 4th `_
-------__ __ ____ _ _
Total Area(sf) 3c)c)c_, F• — Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft :..._
7.Water Sup .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❑
•
• ,
Version1.7 Commercial Building Permit May 15,2000
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212 Main Street t''Idv■tews'oiitio'A4rkiitity,..m-,r;,Mm.f. ,ciyK,.m2v,i.vx„..,. .y:'t:
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orthampton, MA 01060
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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:
!
tlQ, -- 04Ne_ _._C-- : Map Lot
i.,-. :-..... Unit
V\,---e"...._
-Zone Overlay District
' 1 Gi....i.......
zu -_--1,17:-,...7,..7.....„.-........„.;........7.... .......... .j"g^ .............................1'5 Elm i St District : CB District
.,.., ....•
SECTION 2-PROPERTY OVVNERSHIP/AUTHORIZED,AGENT....
. .
.
2.1 Owner of Record:
.,.._.7... ,....zi_.._..1,-..„-...,..i._ __. \ cl'".t _,....___J i
L.. _ .. ..,,....._,........__________.._......-
Name(Print) Current Mailing Address:
Signature.\ "4.----* ' -c-----y- - Telephone
2.2 Authorized Agent:
Name(Print) Current maiiing,Address:
Signature Telephone
.: .. : .
SECTION 3-ESTIMATED.CONSTRUCTION-COSTS.- :. ....:.
Item Estimated Cost(Dollars)to be -- Official Use Only
. - ....
completed by permit applicant
. -. - . . - --f.---- - . ----7- 1
1. Building ! '.(a)-Building Permit Fee
30-60
2. Electrical - -"-- ri (b)EstimateclTotal.,Cost of
_26otri;) - .ConatrUct.on fom(6) i•
i---- __
-- - .
, Building Permit.Fee
-
3. Plumbing ! 1 C-T___ i
4. Mechanical(HVAC) 'lt—Qp.,--- ----- - '
5. Fire Protection i _,„4.... -
6. Total=(1 +2+3+4+5) li / Olt check.Number
This Section For Official'UseOnly
. . . '...
Building Permit Number . Date.
. .Issued
Signature:
Building Commissioner/Inspector.of Buildings Date
File#BP-2014-0727
APPLICANT/CONTACT PERSON LEVINSON ARNOLD G&
ADDRESS/PHONE 14 HANCOCK ST NORTHAMPTON (413)320-6982 Q
PROPERTY LOCATION 176 PINE ST
MAP 22B PARCEL 041 001 ZONE NB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out g S.Fee Paid
Tvpeof Construction: FABRICATE BASEMENT STAIRWAY /_ '
New Construction a. /t�
Non Structural interior renovations )Llll%iar
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 BASED ON
IN`F 1�IATION 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
r /s /f
Signature o :uilding •'ficial 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.
176 PINE ST BP-2014-0727
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22B-041 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-2014-0727
Project# JS-2014-001223
Est.Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 64904.40 Owner: LEVINSON ARNOLD G&
Zoning:NB(100)/ Applicant: LEVINSON ARNOLD G &
AT: 176 PINE ST
Applicant Address: Phone: Insurance:
14 HANCOCK ST (413) 320-6982 O
NORTHAMPTONMA01060 ISSUED ON:12/17/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:FABRICATE BASEMENT STAIRWAY
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 12/17/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner