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DEPARTMENT OF BUILW NG INSPECTIONS
212 Main Street a MWiteipat Building '
Northampton, Mats, 01060 �+
WORICER'S COMPENSATION INSURANCE A.FMA.'VIT
I, �a Ibd� l.m�.., �ti� .�'oti �v►G'.
(license pelmittee)
with a principal place of business/residence at ;
Q i of phone#) Y/3` 6 -�j/3 O
(stzre-t/city/ zip)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
i 1 W k[ S-q 333 )5- oa /° 3
adsumuce Company) (Policy Number) (apiration bate)
(0 I am a sole proprietor general co�te t or honieowner(circle one) and have,hired
the contractors listed beloww o tide following orket's competisatioti pohctes�� �, a+ 4 n w
RD 71
ame of Contracto S
(N ) (Insurance Com parry oi
cY Vtiuibtr) (Expitutioii b te)
► a f t
�Valmeolf C tractor) (Insurance Company(Policy Nutuber) xplrahon 17ate)
(Name of Contractor) (Itmtrance Compahy/Pollcy t�ltitnber) (Expiration bate) NY�,l
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Ante)
(Adach addi60"theet if lwc uy to in"inf�oa pertaining to an ooalcadws)
t
( ) I am a sole proprietor and have no one working fot`men '
O I am a home owner performing all the work tnysel � � f`` ...
NOTE:pleash 6 Aware that whHa hoaxowne s who employ petsoed to do uctlod tlt ' wotlC od 1
not more tben dzro6 ttnit i in which the honfeowncr t'elides or on the grounds apptlrtaeeat thecnto ete hot toaiWeted to tit
employers under ttse work, comp=ssAca Act(GL152,ssi(5)�aMUcation by s homeowner for a liaaio or permit may evldenoc thus
legit status of en employes under the Woctce ee Compensdion AcL
I understand that oopy of this that emeat MAY be forwarded to the betlettmeut GfJn&L3hW Axideoh'bffiob oI tnst4inad for
oover*gc ve i&catlon dad that fidure to secure cove mp under tbcdoa 1S A of Mot,t 32 sae teed id tbe'6p--i Io►of tximidel pedalltld , x
coaustmg of a fine of up to St,Soo.w and/or 6gx6oaavcat of up to om year!ed avh pemttiei to the 166-1 of it Slop�tlorlc OrdM and! a . ,,+,y
fine of S100.00 a day agniwl tad
&P'l`'tW �i'only
Lot# t `•.
e
Si of LiccnseelPerluittee
• Version 1.7 Commercial Building Permit May 15,2000
`ET� ) 10i STRI� URA� ktEi ��. fl(Fiii
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
OI�h11N1E 5 Al J" T' ' �PL ES ' IT I-, ,l3 N
r�a.ilN _, �I I>,£',YA2bs2'. "'it �7.3tl3
._.£.3rxt.1
cv� , �j2v.G�� G'� �c�r� j�n �i3����, as Owner of the subject property
hereby authorize SG-� C)C)%,'Ae ✓ c Y,, `Aq .7C_lCkA to act on
my beha , in all matters relative to work authorized by this building permit application/.
- r a> (0 I
Sig cure of Owner Date
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 pains and penalties of perjury.
Print Nanr
Signat r o(Owner/Agent Date
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder:�!�-c—<_ 1 .4.J-+r--A + C�_ 0(-) )--2
WV License umber� 01a�� zs' Off.
Address Expiration Date
ignature Telephone NO
ill"di
AA
41' 11"1',"
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...... ❑
• Version 1.7 Commercial Building Permit May 15,2000
SE ib , r � ►i�y � � � �rt��` �� �y icy �SERV
.F...�... .,;� ,.....
"> Nc
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
Sct 1 n do/L*-% o .a c u e- ` vtC . Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Li�5�
Address c,
nature 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 FloW Zone ❑ Municipal 40n site disposal system ❑
8. NORTHAMPTON ZONING e.i✓�cck ,l.t
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 DON'T KNOW_ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 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: Z,x 3 ! 1A to f �0-j t-d f a nc 'e—
D. Ar there any proposed changes to or additions of signs intended for the property?YES_
No T
IF YES, describe size, type and location:
Version 1.7 Commercial Building Permit May 15,2000
��.{{ 0rJ/+5`r R91U�r�`Jaif�� _�
Cif � Y'T CLOS SFS �� 3 5 13
x�rya.=un!w ..d:c, 1 .. - • :�t En x�i3,. . �w ; ij s,� ear '33 ��,�.3� 1'3� Id��;»�i,.�i
.,r as U
a � �x.u,�, nz:; ;�•;J§�' 1G.. ..�?;i.: ;fi;is3:' ,�3.,;�i.. t r:i1a<
,.�t.,;x, ., $i lP hka.�,.3
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [
❑ Accessory Building ] Repairs [ ]
�u '+ia00ul�arllvrl�l"
u a.� xr��ti. w�:x'rt rrxr.�a °�asx�xz. n z'9 u,al,v� 33x x.ft 11"71'�3 33�a1�„>a.�., t
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 ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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:
s�9 rat: m �;i �� 3 n� u��,. .� I;�N°x 91 ��� � r '� 'a•
NP4
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
'i��f VI ��i,i,l � •I'.,BSI 4 �i�,%
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) 1st
Ii G 2nd
1st `� X �.5�!�
�
2nd 3rd� X. �5 } ���
4th
3'd ttJ
W
Total Area (sf) Total Proposed New Construction(sf)- &) A
_
...................................
Total Height(ft) A!A
Total Height ft--------------------
F '
Version 1.7 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
}V �.
APPLICATION TO CONSTRUCT, REPAI RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
0 HER THAN A ONE OR TWO FAMILY DWELLING
DEP t Villu 1.1jr,
N�RTK�MRT�N,�� Oi060
5E+ 71ON 1 rSITE i OR ATI(M
1.1 Property Address:
111-f ,c c- 14c 4-q /)a u%" .us e"t5
r 10J z IQMi ct � . �— ii lyp
jt4 Q i o (v
3. z �, s. S 'wr y .,
SEW'16N IN,, it r��r:R �1�33, T ►+� , 3
u ate; ,x'm,'
� a, a.; k., 33,:
2.1 Owner of Record:
�► �r; y� OIL) So..yn 5j:
Name(Print) Current Mailing Address:
S�sy- `l X30
Signature Led, Telephone
2.2 Au horized Agent:
Name(Print) Current Mailing Address.
q 1 -3 ac'
S' re Telephone
Item Estimated Cost(Dollars) be
WE
(Dollars) �
/ 3£M3�3I�'��� ,3�PsW.� � 4• �� Y 3 OEI�1� '� � ' 3 ����( r� ,
completed by ermit applicant
1. Building
dF�,d,� V MY�S,iA'I :'`•, ) � �`dpi
1 73 f a 3�
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection §
6. Total =(1 + 2 + 3 +4+ 5) �, `{ o •
F R 1
r 3 rr �` NO
t ta,
6 f
„ qtr
is G#r ,. ox.Cl'i>r ,r Useh
�
�3urldr P�r�rrrt.�lu�r►ber� � �, � „ .�r. ,s�, Date l�su�c�f� � ���, � as � �
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File#BP-2002-0547
APPLICANT/CONTACT PERSON SALOOMEY CONSTRUCTION
ADDRESS/PHONE P O BOX 1203 (413)269-4360
PROPERTY LOCATION 178 FLORENCE RD-FLORENCE HEIGHTS
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: INSTALL BASEMENT REPLACEMENT WINDOWS&FIRE PROOFING WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accesso Structure
Building Plans Included:
Owner/Statement or License 065275
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 mission
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 R��: � ;, BP4002.0547
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Bai1g l 1!30010:(10:00 15202 $214{Q
212 Main Street,Phone(413)587-1240,Fax:(413),587-1272
Building Commissioner-Anthony Pat llo