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DEPARTMENT OF BUILDNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. D1060 "
WORKER'S COMPENSATION INSURANCE AFk'IDA.VTT
`_-�`(1-oeuxurJpermlG.ee)
with a prYncipal place of business/residence at:
do hereby certify, under the pains and penalties of perjury, that:
(- 1 am an employer providing the following wolkt;r s compensation coverage for my
=s
employees working on this job:
(Iusurance Comfy) (Policy Number) (kxpira on arc)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and hay..hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) ansunanx Company/Policy? wzb.r) (Expiration Date)
t..
(Name of Contractor) (jASU==Conipany/Policy Number) (Expiraton Date)
(Illame of Contractor) (Insurance Company/Policy Number) (Expiradon Date)
(Name of Contractor) (faszuanx Compaq/Policy Number) (E:xpiraton Date)
(Attach adci4tioaal eiseat irneonsary to include inforauiioa peetaiaia6 to ev coaseRsoc,)
( ) I.am a sale proprietor and have no one working for me.
( ) I am a home owner perfonming all.the work myself
NOTE:please be awzm that%U10 homrownas trho+=Ploy P=s;a=to do Lim wmlrttaion or rtPas Work oa s dv eT=of
nit mom thaw&'&0 units iu wlrich the bomoowocr raid=oc an*4 gru=el&appttctemat ti>Atetn are a0l gtarally oomidarod to be
amPloyers undo dw wa1'.a's OOmP=d icn Ad(GL152,ss 1(5)k apPtimd=by a bO=W,Yr fcr a&cem oc P-rak nay evtaeme Ike
legal stabs of as*=ptayw uodar the Wockoes Compematjm Act
I undwzaad dud a copy of this stsicmmt may be fawwdad to tba Do*anti:of Ldautial Aoeidmid Office of Lnsm w for the
oovrza ge v aificidoa sad that W=to smut:covctW twckr section 25A cf MM 152 c n kid to rho imPw—of aimi u Pc-WO
oomiuiag of a fne of up to 51,500.00 and/or iaXbO=W=d of Up to tine ysar sad Civil pemtl4=m the fain of a Stop Wotic ada sad:
firm of S1 04.00 a day&piad tnc.
' Pot use oaty
Permit Number
Mao
of i ermittoo
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Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
fDr-
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
as Owner of the subject property
/dam
hereby authorize A.. LiY?. _L.�lif.1 `a �f�( I`Q/U. / h • to
act on my 4in fters rela'v e to work authorized by this building permit application.
_Signature of Date
Ter- ii y, ..T,* . Ca,✓t� �u�1
as gwner/Authorized
A
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 pains,and penalties of periury._,,
/? S. -T 4... Q_.._. . ...
Print N
Signature of Owner/ t Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable I�
Name of License Holder:
,r
License Number
r) 1AP
�..
�7-
Addr Expiration Yate
0( C'._S .
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 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 ity
_._ 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
Company Name:
Not Applicable ❑
Responsible In Charge of Construction
Address
Signature
Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
NO
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/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES C)
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
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
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
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 NOJj
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 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 ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brie/tdescription here. ��L/tCP
Of Proposed Work: _ Df}Agj#
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 ❑
E Educational ❑ 213 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential 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:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS A H E
E posed Use Group:
Existing Use Group: ._..,,.. _. .,
Existing Hazard Index 780 CMR 34):`. Proposed Hazard Index 780 CMR 34): _......
SECTION 6 BUILDING HEIGHT AND AREA VO if 1 A1 91 6 11)
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
sc
2nd _. ,._. ..,_ .. 2nd
3rd 3rd
4`" 4 th
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 ❑ Zone Outside Flood Zone[:] Municipal ❑ On site disposal system❑
Version 1.7 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/SepticAvailabibty
230$ Room 100 Water/Well Availability "
Northampton, MA 01060 Two Sets of Structural Plans
phone,*$3-5871240 Fax 413-587-1272 Plottsite Plans
Other,Speclfy .
\APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
U - OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
� �j ....` �N Map Lot Unit
A, FIC rear c R Zone Overlay District
__..,.._.. _....,,..., Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
C p .
�.x _ 013P (a4
Si g nature Tel phone 1...
2.2 Authoriz ent:
(7C!lgl Te NC..t/teS i-004 A,0 midr .7�/• a���' „ !/iC�'�j� S`'� /�<st�teri'�� .�rr�/`ei,,,ctu
Name(Print) ° Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
S'7f.�(1
2. Electrical (
b)(b)Estimated Total Cost of
�t o- Construction from 6
3. Plumbing C(� Building Permit Fee
4. Mechanical(HVAC) • G Ci
5. Fire Protection 3
6. Total=(1 +2+3+4+5) Q 00 Check Number y �"
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
t A
File#BP-2008-1118
APPLICANT/CONTACT PERSON Teagno Construction Inc
ADDRESS/PHONE P O Box 2054 AMHERST (413)549-0803
PROPERTY LOCATION 178 FLORENCE RD-UNIT 9D
MAP 29 PARCEL 001 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid_
Typeof Construction: REPAIR FIRE DAMAGE APPARTMENT-UNIT 9D
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 034716
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN,F99MATION 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
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.
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178 FLORENCE RD UNIT 9n 8P-2408-1118
its : COMMONWEALTH OF MASSACHUSETTS
k 29-001 CITY OF NORTHAMPTON
t: I PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
QO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
AU10L
.,&oJNG UWT
ED TO.
PERMSSIONLY HEREBY GRANT
• , R�'��04�-111�
CQUSt. : : Contractor; License.
Tsragiva Cvnstructjgn Inc _ Q3471§
Owner: hV&JUAbU24LN MX OF
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Ar� nr. no Constru n tnc
co s
AIVIRERS1, 04
OR REE 1RE�}AMAGE AF 'ARTMEHT UN17
IWO
l t aft " f PC # : '.�V, lihling�eefor
Fastlags
Rougb Free: $
Fireplace/Chi er
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Waal,
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AM
Ago
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212'M SMC4 Phone(413)S 4240,Fax:(41�)587-1272
Building Commissioner-Anthony Patillo