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32A-255 (26) x e , O O° l'LX � x.11 x.111 �IIIt BfI?lasaacflnsctta DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 wom,CETS COMPENSATION INSURANCE AFFIDAVIT (licenserJpermittee) with a principal place of business/residence at: P• (�, 61L�,(_(phone#) q/3' S% I (street/ ty/sYafrJzip) do hereby certify, under the pains and penalties of perjury, that: (/I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) p f�� (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired w the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E)piration Date) (attach additioml shed ifaecesssry tv include ittfocmation pertaiaiug to eJi coattnctors) ( ) 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 awaro that while homeownm who employ pe som to do ma d•,,a,,,e,o=nly dioa or repair work on a dwelling of not more than throe units is which tht homeowner resides or on the grounds appurtenant therdo ate not eaxtally ooarick c to be employeta under the worka's comp=s4ot Act(GL152,ss 1(5)),application by a homeowner far a liccase cc P-nd may evidence the legal cia- of an employer under the Workcet CooepamaLion Ad. I understand that a copy of this uatemeat may be focvea ded to tho Dcpettmm2 of Ia&Ldrid A=&n&Offioc of Insunnoe for the coverage verification and that failure to aeaue covmmp=dor sectioa 25A of MGL 152 can lead to the imposition of criminal pemlties consisting of a fine of up to S1,500.00 and/or imprison of up to one year and civil pez d6cs in the form of a Stop Work Otda and a fine o(5100.00 a day against mc. -� „� Foe dgNUtmr�sl oy t Numbr� eL 'Lot# f_.. Si tare ofLiermittee Version 1.7 Commercial Building Permit May 15,2000 ECTI0N A S'[RUCT `R L��EE REVIEW 780 CR1011 i3 � '. Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION 11��CWNER AUTHORIZATION TO�BEtCOMPLETEDIINH,EN � QWNERS`AGEN GR CONTRACTOR APPLIESFt1�tJCD1NGiPERMIT «�..�..a -�;. E�2t �� ,,: r,,,,•�.,�L ,?. (y�Y- of � (M�'n� 3y , 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 iof Owner Date 1�A' C/�(�j� , 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 unde a pain and naltie er ry. s Print Name ��, !� • �h>c;6►'� �I31 103 Signature of Owner/Agent Date SECTION 2�C�tbi0G SON SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 6.x - License Number �� 0 �, 1 wj 1`�6r° fw • , rat o�( l I Iq4 Address Expiration Date Signatur Telephone #... vk -� )'� N fi N l '' � _WY 33 'A0 L t . fi 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 f the building permit. Signed Affidavit Attached Yes....... No...... ❑ Version 1.7 Commercial Building Permit May 15,2000 � 1'-�` rc :Y:ev+ay"� 3-'• }m�' pf i v � a2-;s: F$3 • .: � ,,,.,E,,,.r t ,<>. ib -.:M�Aa+` s<?-ifh��'9 .,,.,ice a3 y �s ; SECTI01��9PR0 ESSION"AL��ESIGNAND CONSTR[lCTI,OfV SERVICES �'�OR 8U1LDI GS AND- TRUCI'�RES�SUBJEC'1Q COIVSTRUG,T�rbN��ON;TROL'�P.URSUANT�f�°7$©€�CMF2;1�:6'':(GONTI�1NINGMORE�THAfVS��OQ�C�f�b�"��E��,LO�E�D�SPACE)x'�..,.' 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 92 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 Not Applicable ❑ Company Name: iV)l�.U,1 Responsible In Charge of Construction P, i I%- Address A ruAd Signatur Telephone Version 1.7 Commercial Building Permit May 15,2000 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 ❑ 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/Fin'diinng ever been issued for/on the site? NO DON'T KNOW V YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW V YES IF YES: enter Book Page and/or Document# B. 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: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D.No Are ere any proposed changes to or additions of signs intended for the property?YES IF YES, describe size, type and location: j Version 1.7 Commercial Building Permit May 15,2000 SECTON4'"COVSTRUCTION3 ERV(C�S�FOR '�OJE`C7S�LESS! HA 5000 �CUIG� ETNC� SEDgSF�ACE E + � 'E.N, �, a.,'�rr.3,'u�, ur. ,a �3i k:�>x Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing Exterior Alter ions Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] I Accessory Building[ l Repairs [ 7 �iMtrv� , .c"� i k ,w SE3fiROUp AND GONS7Rl�C �aa'3~s ._"5 x„ ism�a'=?�. a a�3tllan , USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1.1 ❑ 1.2 ❑ 1.3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential 10 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: , , rr NfiFL ,E TEAS � AVtD33C IN ERGOING N S CT10y 1F EX TNG UD lONS ADDITION ;' Existing Use Group: Proposed Use Group: SC+-"e— Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SfG6aU110ING HEIGHT A01 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St 1st 2nd 3 2nd rd 31d 4th 4th Total Area (sf) Total Proposed New Construction(sf) _................................... l Total Height(ft) kt y Q k9 1 Total Height ft -------------------- Versionl.7 Commercial Building Permit May 15,2000 City of Northampton Building Department 212.Main Street Room 100 ;Northampton, MA 01060 phone 413.587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECT QN 1' SITE 1N�fORM}ATI�ON._� -his e+c. 1.1 Property Address: SECTiONg2 'PROPERTX QWNERSHIPIAUTHORI2ED AGENT 2.1 Owner of Record: st"av- lyvc Name(Print) Current Mailing Address: 43- Sgt-�lo� Signature C Telephone 2 2 Authorized Agent: Pk oV�e t?�- C H^ c D j 1 ►u I`1v �,c� w n�(n� ,_ C71 D(o Name(Print' Current Mailing Address: Signa re Telephone ECT OI 3� 57 tMA7 CONSTRUCTION CO5TS � ARM.< s.- ?., ,��- .tea,_ ._,_. �' i3w�`jl t k t Item Estimated Cost(Dollars)to be �� ,31_ �f� ! ��s� � completed b permit applicant �. .'' - 1. Building _ J7_W (�J�_ a)liidtg1?e1tt e � f a 2. Electrical te�t3 3. Plumbing Bu�ttitngPermi# 4. Mechanical(HVAC) 3, , si 5. Fire Protection ' ' ` 6 Total (1 + 2+3 +4+ 5) �� i A r .3 ;, 3 a t �" 3 '; F` a. a 3 �. �f ThISISedtiti �'o �t fftc�al� se o '�, �,�. S ,. iM a gy Bu1dln �Prrt�u b � Y , , ate(sstl�d� '0 3 < s4 r OR-dre *3 3 y 3 k 3 9 3 i $triature ', " iril,„ingCrrtruss�pnr„Jlnspect_gt,olBcTilings, e`3 Da owim- ST BP-2003-0827 GIS#: COMMONWEALTH OF MASSACHUSETTS ZVI CITY OF NORTHAMPTON Lot:-001 Permit: Buiidina Category: BUILDING PERMIT Permit# BP-2003-0827 Project# IS-2003-1352 Est.Cost: $45000.00 Fee: $225.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin Pioneer Contractors 017890 Lot Size(sg.ft.): 72614.52 Owner: STAR NORTHAMPTON INC Zoning: CB Applicant: Pioneer Contractors AT: 36 KING ST Applicant Address: Phone: Insurance: PO Box 1145 (413) 586-5491 Workers Compensation NORTHAMPTON MAO 1061 ISSUED ON:413103 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING RUBBER ROOF 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: Receipt No: Date Paid: Check No: Amount: Building 4/3/03 0:00:00 8138 $225.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo