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18C-048 (22) 0 4.(tiAa1 FAO Gr ifs 1af wart 11allyf olt � B �xsaRrfTnsrtts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal. Building 'a Northampton, Mass. 01060 'J�y WORKER'S COMPENSATION INSURANCE AFM' AVIT I, (Ii censer/per�v tree) with a principal place of business/residence at: (phone;#) (streucity/staidzip) 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) (Expiration Date) ( ) I am a sale proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Com-pany/Policy Number) (Expiration Date) s f. (Name of Contractor) (Insurance Company/Po(icy Number) (Expiration Date) (Name of Contractor) (Insurance Comparr/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E)piration Date) (Attach additionl sheet ifnexxrury to include information pertaining to all oocrttaaotz) ('Il—am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ person:to do maiai�consbn t oa or repair Warr;on a dwelling of not Moro than throe units is which t e homeowner nudes or oa the grounds appurtenant thereto are not generally ooasidacd to be employ=under the workcrls oompc as4oa Act(0L152,m 1(5))�application by a homeowner for a license or permit may evidcooe the legal ctstua of an employer under the Worlceea Compensation Ad I unAawAnd du l a oopy of thin ru tcmmi may be forwarded to the Dcpa tmo v of ln&L rial Aoadm&Offioo of Iffiur,anoo for the covet age vai&catioa and that failure to securti coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to S 1,500.00 and/or imprisormxnf of tip to one year and civil penzWcs is the form of a Stop Work Ord--and a lino of 5100.00 a day against uric. For departroa 3w ua1�_ Permit Numbe © Maps Signature of Li etmit�ee Versioni.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES'FOR BUILDING PERMIT I, 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 of Owner Date l 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 Name Signature of Owner/Agent Date SECTION 12—CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date 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...... ❑ 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 C.F. OF ENCLOSED SPACE) 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: Responsible In Charge of Construction Address Signature Telephone x 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/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: D. Are there any proposed changes to or additions of signs intended for the property ?YES _ No IF YES, describe size, type and location: 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 Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building [ ] Repairs [ ] SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ 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: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,:ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): 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(sf) St t.. 2nd 1st 2nd 3rd 3rd 4th 4th Total Area (sf) Total Proposed New Construction (sf) - - „ Total Height(ft) Total Height ft -------------------- .,t 1 Version 1.7 Commercial Building Permit May 15,2000 City of Northampton, Building Department 212 Main Street Room 100 Northampton, MA 01060 a, phone 413-587-1240 Fax 413-587-1272 3 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 P Y f3 n r � . „ fin. Map `Lot Unit Zone, ;. Overlay District-,,',-,'-,- .�4 O J c L 7f 4 iEim'St'District CB Distuct� SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Q CN 1.1 3 7 k3 nJao 'YY�►►�`,,� Name(Print Current Mailing A dress: f i ig Telephone 2.2 Authorized Agent: r "' Name(Print) Current MailJng AdWss: Signa u Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building 0 ..00 (a) Building Permit Fee _ 2. Electrical (b) Estimated Total Cost of Construction;from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 1 3, 60' Check Number s- This Section For Official Use Only Building Permit Number: d Datelssued: Signature: Building Commissioner/Inspector of Buildings Date u = BP-2002-1086 G1S#: COMMONWEALTH OF MASSACHUSETTS ::. CITY OF NORTHAMPTON Lot:-001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2002.1086 Project# JS-2002-1748 Est.Cost: $413.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): 272685.60 Owner: NORTHAMPTON NURSING HOME INC Zoning:URB Applicant: NORTHAMPTON NURSING HOME INC AT. 737 BRIDGE RD Applicant Address: Phone: Insurance: 737 BRIDGE RD NORTHAMPTON MAO 1060 ISSUED ON:617102 0:00:00 TO PERFORM THE FOLLOWING WORK.-ROOF 20 X 20 PAVI LLI ON 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/7/02 0:00:00 3200 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo