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38B-073 (2) R a + + I� id 7 /t p , s + .,,,nt L" x I 4� x a ! 1+lY�is + A� z` ti•I�',y,AiS 1t++{+ ,F da I, �: , kv ; kF .. is d � + w;l "SM q I { + r wl rc y i e' i k ° _ � + tl t 'slid ME VA Pq k p k J. 'k^1s MI v " + OPEN BELOW 13'-6"x 4'-3" W3630 W3030 W7836R W3030 c°n id BATH 6'-11"x 6'-1" 11'-7" C) '-11 5/8' M 00 ,'$ I B58 II m m � I � � DCB36R B57 9068 LIVING AREA 382 sq ft 1 p 0� 1 Vo p, / f, March 8, 2014 Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, Ma. 01060 1 Request you grant a modification to waive the requirement for construction control of the project at Northampton Veterinary Clinic 227 South street Northampton, Ma. because the work is of a minor nature,will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of construction control is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, Mark Sarafin Sarafin Builders 42 Pomeroy Meadow Road Southampton, Ma. 01073 'r The Comrnonwealtll ofMassacitusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston, MA 02111 www.nzass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ` Address: plv�� City/State/Zip: c,w. w Phone#: 3 -5 - -.19)1 Are you an employer?Check the appropriate box: Type of project(required): 1.X I am a employer with _ 4. ❑ I am a general contractor and I � y er 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.ED I am,a sole proprietor or.partner- listed on the attached sheet. 7: Remodeling These sub-contractors have ship and have no employees 8. E]Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$-- required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions �.❑ I am a homeowner doing all work ❑ myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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: 0,U1(L co \J-\ _ Policy#or Self-ins.Lic.#: v\\Pt kip Ll©(V0_1 Expiration Date: �Q' �`�j — 1 y Job Site Address: City/State/Zip: Q\ou 0 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 against the violator. Be.advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for surance cover ge verification. I do hereby certify d th a' nd pe Itie of perjury that the information:provided above is true and correct Si nature: Date: Phone#: "11�j- Official use 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#: r Version l.7 Commercial Building Permit May 15,2000 t SECTION 10—STRUCTURAL PEER REVIEW,(780,CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 11 -OWNER:AUTHORIZATION-TO BECOMPLETED.WHEN . OWNERS AGENT OR CONTRACTOR'APPLIES FOR BUILDING-PERMIT ._.. __ _ ---.._-----_ 7 # 1tn t1ot.._.:.._.:..�.. _:._._a_.� ,.._._.. w e.. _._,....____� _. .... as Owner of the subject property hereby authorize SG�rGIC� L�G .._.r.e �. ..,._ _ .. _ ..._a. _._.._._.. . _ - -w ._w_._ _ _..__._ _.'.to act on my behalf,in all matters relative to work authorized by this building permit application. _ Signature of Owner Date trVLlq — — - I .... .. __..............�,.,._._..__.... ..._..,.__ _....w ......,�..._:___._;' ,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 s pen ti s offer _ _ .� Print Name - __,__ _ _ ._ __ __� w...._,.._ Signature of Owner/Agent to SECTION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ t Name of License Holder:1. .. . s � (� 1 License Number Address \(l �6cpiration Date Signature Telephone SECTION 13--WORKERS'COMPENSATION'INSURANCE AFFIDAVIT(Nf G L c'.152;§.25C(6)),. t 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 Version 1.7 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 G.F.OF E LOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): ,......_...._,_..__.._.....__._._.._._.:...._..._.».._.._....__..___.._..__,r_,__.._.__.,._.-,..._._.,..._._.,-.,_.._....�._...�,,�.�.......�..�_...-..._..�...�_.._.., Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility ............... ..__. __._.�. _ __..w,.n_W.__ . _ _ _____. __�.___v___ _. _._ __. __ __ _. .. ...._. .... __. _, _. _._..............._.... ._.__. ._,__._.._.. ..._. ... Address Registration Number Signature Telephone Expiration Date £ ��......_«.........,..................:._....,._..... ....E Name Area of Responsibility ........ ....._._...W._........._.._ ` Address Re�istration Number Signature Telephone Expiration Date ._.�._....__d..�.0_._..._.._�.._._. _._,..�_....�....___..___ .,_.,���..�.-v...�..._.�,r........._,._w..�,.._.._,..._ Area of Responsibility_.-...._w. ...,._r..T _.._�.,_... � __.- Name Address Registration Number 1 Signature Telephone Expiration Date { Name Area of Responsibility Address Registration Number t , Signature Telephone Expiration Date 9.3 General Contractor ------- Not Applicable ❑ Company Name: Responsible In Charge of Construction ..............._...._._.. _._.. - ._ w_.. ..__...._._._._...._._. ........ . : .._._._. ,_...,__.._..__.. _.._...._.._ a___.. ..... Address_ _ _ i Signature Telephone Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTOMZONING , Existing Proposed Required by Zoning . This column to b e filled in by Building Department LotSize _.,...,......_..�....�.._.,; .....,...` .� �.......��, f w..............�_._.__�._...,w.�w.. Frontage f.:..._....._._..:.�_,.._...,.� .._................� � .-..�._.m....�..._� Setbacks Front _- - � Side L•?___---__ R• _ - ! L R: ...._ 1 Rear Building Height "- j i _ Bldg. Square Footage Open Space Footage _ % —_- of 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 DONT KNOW YES 0 IF,YES, date issued: , IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 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 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 0 NO _ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation, or filling)over I 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. 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 X Existing.Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description !Enter a brief descri:ption here. , ov mo C3. Of Proposed Work: \"\C,\ 4CDes 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 Cl A-5 Cl 113 ❑ B Business 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 Cl F-2 ❑ 2C H High Hazard ❑ 3A ❑ Institutional Cl 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑ 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:-T S Special Use ❑ Specify: COMPLETE THIS SECTION IF.EXISTING BUILDING UNiDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN-USE Existing Use Group: Proposed Use Group. __ .—.. __ Existing Hazard Index 780 CMR 34) ,_ .._. _. �M, _., 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(so 1 St 2nd 2nd, 1 ....._....._.... _.___ ... . ....__... 3rd `..._. 3' 4th 4th Total Area(so 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[] Alp Versionl.7 Commercial Building.Permit May 15,2000 ©epartme t use ont�f City of Northampton statu 0,f s Ci Permit` rrkt t f " 2� i Building Department y Curb-Cut/Q�vetnra Permtt.�- , MIP►R t 2Q14 �! 212 Main Street �� 3= ` SewerlSept►cgvatfattlity i � Room 100 1lUaterlUlfelt Rvattaka'i}rfyw � R '.x" 3 >. ,.. orthampton MA 01060 ` � �_ Two�SeFs oStracturaf Plans; e' tions ` cone 13-587-1240 Fax 413-587-1272 h latl�lte�Ptans Other Specify _4 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 1.1 Property Address: This section to be completed by office C.)J................ _ _ _._.__._._...__...._._ `5 F Map Lot Unit O 2 Overlay District - - ---�- °° - Elm St District` CB District SECTION 2-:PROPERTY OWNERSHIP/AUTHORI2EDAGE NT . 2.1 Owner of Record: k- Name Print r ( ) Current Mailing Address: U"t(jip� Signature Telephone 2.2 Authorized Aaent: Name(Print) Current Mailing Address Signature Telephone SECTION 3-:ESTIMATED:CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Offcial UseQnly completed by ermit applicant 1. Building (a}Building Permit Fee , 2. Electrical b Estimated Total Cost of w... Construction from- 6 _._... _._.__._._.__..._. _... 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection :_......._....:�_ ..... ...._-._......._.,_. ......__�..- 6. Total=(1 +2+3+4+5) � (p,9 L(`�, _ .Cfteck Number 1776-1/ This Sectionr For Official Use Only. Building Permit Number Date issued __-- -Signature/" ildin ommis inner/ p ctor of Buildings Dat e 227 SOUTH ST BP-2014-0952 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-073 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-2014-0952 Protect# JS-2014-001653 Est. Cost: $16900.00 Fee: $101.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK SARAFIN 053434 Lot Size(sq. ft.): 23217.48 Owner: NORTHAMPTON VETERINARY CLINIC REAL ESTATE TRUST LLC zoning:URB(100) Applicant: MARK SARAFIN AT. 227 SOUTH ST Applicant Address: Phone: Insurance: 42 Pomeroy Meadow Road (413) 527-7812 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:311712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE WALL, INSTALL DOOR & NEW CABINETS & COUNTERS 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 3/17/2014 0:00:00 $101.00 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner