35-270 (3) R�tv}r�T r
A2 ecc3.o 3 Of �\Turfljalivpjol1
Ala>>nthncclla' _
u DEPARTMENT OP DUILDrNG INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, ATass. 01060
`VORICER'S CON'MENSA"IION. MSURANCF AFFU)) �T`J-
(:_C
I
(li ccDSCxJpermi t tcc)
- lQ� �' • (phone') ?��S�
(suit/ci tylscatcra P)
do hereby certify, under the.pains -,ad penalties of perjury, :hat
( ) I am an employer providing the followine \�,orkcr's comocnSZ don cove aft: for lny
eluplovices wortDing on Oils job:
(1aur--n=Conn:L') (PoUc:Nu--,ib--r) --- (r:-pirrion Dztc-)
( ) I am a sole proprietor, general contractor or homeowner (curie pee) znd have hired
the cocuactors listed below vgho hive the following worker's raopensztion policies:
(i+IIIDe 0" Con nap-) (n umnc:. ColnoanyrPouc-; ?"1l1IILC) (i-_?::) -o:nn 1111C)
(Name 01 CooQaaor) (Insura.nc; COMDanv/Pohl Mincer) (Ekpir,.uon Date)
(Name of COnII-aC10T) (La u.ranc: Compjoyfpolicl' N.dmbu) (Expui z6on Dale)
(NaMC of Contractor) Unsuranct— Company/PoUcy Numb:.r) (Expiration Date)
(nair� �oc31`'_CCt ifnoocsiry to aicu<SC uafoczuaon pc jZjaing to all oodr-_G..o-s)
I am a sole proprietor and bave no one woridng for me.
( ) I atn.a home owner performing all the work myself.
NOTE:plc s be ewwt thz M'I ]o �TJ K'60 CCaPIQy P<rlaW Lo C1J Mx ",--,.,,.-, ocr—,Ww,0 c repair work oa.d,,ci-z of
apt more th n t'sw--in"'bleb the botaoawacr realty--a oa the pouacS zppurtcaw= -c pot any oc(=..dmd to be
catploycz%I c the"-_k-t oc �_ y'm Act(GL152ss l(S)� NVU=6cro by n bomcoa-oa fm c Gc=x cc pamh r=y c idmrx trc
Icg21 n,n,,of ea eaPloyer under tlw Works 'c C.oatpomaLion Ad
I un4crfL od that a oopy of thin�my bo forw+ ded to tba Dcpatmc d of lndurrid Accdo=&Offioo of 4�irz000 for Lbw
cove'Se V=ificxt10°°rA t!r t LiJum to tmuc)c�o`mn,�&c trades soetioa 23 A of MGL 152 can Icsd to the i=pas-bon of aimiasl pcoa- (=
oohs—g of a rrac of up to 51-500.00 artdtor m��- of up to one year rod a%iJ pmaltio in LS-form of a Stop Wort Ordu and a
frnn of S 100.00 t day rgaima tnc
For d '.—,r u,c only ---------
permit Number
Y
Lot K
Si�Zturc of Licrnse&permittcc e
Versionl.7 Commercial Building Permit May 15,2000
SECTION 1"0=STRUC,TURAL.PEER REVIEW 1780 CMR 110.11)
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 properly
i
hereby authorize !to
act on my behalf,in all matters re i to wnrk au t zed b this building permit application.
Signature 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.
Si nq ed under the pains 2nd enalties of peon . r^
3 `
Print Name —
Signature of Owner/Agent Date
SECTION"12 CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder:
License Numbe
_3
Address Expiration Date
Signature Telephone
SECTION 13'-WORKERS'COMPENSATION INSURANCE AFFIDAVIT,(M.G.L c.' 1152,1,25C(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
r
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND GON,STRUCT[ON.SERVICES=F,OR BUILDINGStAND$TRUCTFJRES IUB,IECT TO
CONSTRUCTION CONTROL PURSUANT`70 790 CMR 116{CQNTAINING MORE THAN 35;000 C.F.OF ENCL' , SPACE)
9.1 Registered Architect:
i Not Applicable
Name(Registrant):
Registration Number
Address
Expiration Date
Signature I Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
I
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
I
Signature Telephone Expiration Date
i
Name Area of Responsibility
I _ i
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
I Not Applicable❑
Company Name:
}
i
Responsible In Charge of Construction
r �
} i i
Address
I
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
>L� fl
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size I
Frontage
Setbacks Front
Side L:' R:= L:= R:=
Rear
wilding et
Bldg.Square Footage % —
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
i
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel 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 , 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 ® ` NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
i
SECTION 4-CONS,TRUCT10N SERVICES fORPROJECTS CESS:THAN 35;000
CUBICFEET OF'ENCLOSED SPA CE
q .
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other pt
Brief Description Enter a brief escriptio ere.
Of Proposed Work:
I � '
'SECTION 5-USE GROUP-,AND CONSTRUCTIQN TYPE
USE GROUP
Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
❑ A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi h 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 0 Specify:
COMPLETE THIS,SECTION 1F EXISTING BUILDING,IPubDERGOING RENOVATIONS;.ADDITtONSANDJORCHANGE IN USE
_.
Existing Use Group: I Proposed Use Group: I
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):F i
SECTION 6 BUILDING HEIGHT-AND,AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) .n
t s'f
St
1st
2nd �. —�j .w. ". �. Z, s 0-190 yg �, x-
3rd
3m iT
4th 4t' I
Total Area(sf) , Total Proposed New Constructions
Total Height(ft) E
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[t Municipal ❑ On site disposal system
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Versionl.7 Commercial Building Permit May 15,2000
1 _..'.._ orthampton
Bull i Department
21 1�1gin Street
'100
Northaimpto , MA 01060
;.. -p". -124 Fax 413-587-1272 .
APPL1CAflON TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION, SITE INFORMATION
fit Property kddres Ttus section to be compre#ed iaYoifice�
(.lJ- T ��5 (lapS of Za Unit
�1 tv
es
joie °Oerl�ay Duct Di
SECTION2.-PROPERTY,OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorize en _ _
77
Name(Print) Current Mailing Address:
1AC__1 _i -- 3 3 �
Signature 0-,4 Telephone-7 SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
m leted by ermit applicant
1. Building ,` j '(a)-Building Permit Fee
s "[ i
2. Electrical n (b)Estimated Total Cost of
(� Construction from(6 — '
3. Plumbing f Building PermftPee
4. Mechanical(HVAC) ___
5. Fire Protection
6. Total=0 +2+3+4+5) -Check Number /P7;2
ThisSection For Official Use Only.
Building Permit Number- Date4
Issued.
Signature:
Building Commissionertinspectorof-Buildings Date
File#BP-2005-0712
APPLICANT/CONTACT PERSON Paul McCutcheon
ADDRESS/PHONE 77 FOREST GLEN RD FLORENCE (413)584-3352
PROPERTY LOCATION UNITS D&E- 27 WEST FARMS RD
MAP 35 PARCEL 270 001 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid __ 70
Typeof Construction: INSTALL DRYWALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 062544
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91MATION 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
o-e _ /////a 0
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.
UNITS D&E- 27 WEST FARMS RD BP-2005-0712
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -270 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0712
Project# JS-2005-0978
Est.Cost: $6750.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GroML Paul McCutcheon 062544
Lot Size(sa. ft.): 29359.44 Owner: MCCUTCHEON DEVELOPMENT LLC
Zoning:NB Applicant: Paul McCutcheon
AT. UNITS D & E - 27 WEST FARMS RD
Applicant Address: Phone: Insurance:
77 FOREST GLEN RD (413) 584-3352
FLORENCEMA01062 ISSUED ON:1111105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL DRYWALL
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 Occupangy Si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 1111105 0:00:00 6172 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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UNITS D&E- 27 NN .ARMS RD BP-2005-0712
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-270 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Bulldina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0712
Proiect# JS-20,105-0978
Est.Cost: $6750.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grout: Paul McCutcheon 062544
Lot sizg(sy. ft.): 29359.:44 Owner: MCCUTCHEON DEVELOPMENT LLC
Zoning:NB Applicant: Pad P%. -utcheu
AT: UNITS D & E - 27 WEST FARMS RD
Applicant Address: Phone: Insurance:
77 FOREST GLEN RD (413),584-3352
FLORENCEMA01062 ISSUED ON:1 111105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL DRYWALL
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: lC`y / House# Foundation:
C` _ Driveway Final:
Final: Final:
Yj//, r, A 9
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation-0h l
Final: Smoke: Final:4 3.01 f:p�VQi
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certi i to of Occu an Sip-nature:
FeeTyue• Receipt No: Date Paid: Check No: Amount:
Building 1/11/05 0:00:00 6172 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Conunissioner-Anthony Patillo
A , ',