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18C-048 (23) 0, ttAMPJO laf 'Wartilaillp foil z � B �xsaRCETnsctta `b U. m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'o Northampton, Mass. 01060 4 WORKER'S COMPENSATION INSURANCE &F t AVIT (Lipe=ttCC) with a principal place of business/residence at: � (phone#) J .� (streei/ci ty/stalrJzi p) do hereby certify, tinder the pains and penalties of perjury, tllat: ( ) I am an employer providing the following worker's compensation coverage for my employees worling on this job: (lasl=ce Company) (Polio Number) (Expiration Daze) O I am a sole 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Pokc,Number) (Expiration Date) (Name of Contractor) (Insurance CompanyiPolicy-Number) (Fa'pimtion Date) (Name of Contractor) (Insmance Company/Policy Number) (Expiration Date) (attach addr6oml six if ntr r,w include information perU nin to all ooatra m) (4-11 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 homeowrxra who employ p:moas to do nmir ,c ,ncr construction or tcpair work m a dwelling of not moc a than throe units in which the homeowner resides or oa the Uvinds appurt,a thereto aro not gcoa-ally ooasidacd to be employers under the worker's compensation Act(GL152,=1(5)},application by a homcowna for a lio=e oc permit may evidence the legzl dates of an employer under tho Worke t Compematioa Act I undrntand that a copy of this szatc�t may bo forwarded to tho Department of Industrial Aoc do Offioo of lrxssuince for the oovaxgc verification and that failure to secure coverago under s4,t oa 25A of MGL 152 can Icad to the imposition of a urinal penalties consisting of a fine of up to S1,500.00 an&oc irnpriso of up too=year and civil PcwItics in the focm of a Stop Work Order and a frno of 5100.00 a day agaiad tux. For dq rtmr uac poly Permit Ntlmbc� Map-# Lot# Stgnatnre of Licensee/Permittee a-if e' Version 1.7 Commercial Building Permit May 15,2000 ECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) dependent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ ECTION 11-OWNERAUTHORIZATION -TO BE COMPLETED WHEN WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT n as Owner of the subject property -.reby authorize f /YYh� to act on ,y behalf, i all matters relativ to work authorized by this building permit ap licati n. ignat re of Owner Date low— as Owner/Authorized Agent ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my nowledge and belief. igned under the pains and penalties of�perjury. _ A4 A int Name AWL0h i L �,2,h gnature o 0 ner/Agent Date ,ECTION 12 -CONSTRUCTION SERVICES 0.1 Licensed Construction Supervisor: n Not Applicable ❑ !ame of License Holder: au --tZ a / �-/6 J I License Number ddress Expiration Date 'gnature Telephone ;ECTION 13'-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6)) 'Jorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit /ill result in the denial of the issuance of the building permit. ;igned Affidavit Attached Yes....... ❑ No...... ❑ ' . . . ' ^ Version l.7 Commercial Building Permit May \j.2OOO ECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTIO14 SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO -ON$TRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) .1 Registered Architect: Not Applicable 0 ame(Registrant): Registration Number ddress Expiration Date �gnature Telephone ,2 Registered Professional Engineer(s): ame Area of Responsibility ddress Registration Number ignature Telephone Expiration Date ame Area of Responsibility ']dress Registration Number ignature Telephone Expiration Date ame Area of Responsibility ddress Registration Number gnature Telephone Expiration Date ime Area of Responsibility idress Registration Number gnature Telepnone Expiration Date .3 General Contractor Not Applicable 0 .ompany Name: �esponsible In Charge of Construction Telephone - Version 1.7 Commercial Building Permit May 15,2000 Water Sypply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: ablic 0 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: Versionl.7 Commercial Building Permit May 15,2000 ;ECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 3!5,000 :UBIC FEET OF ENCLOSED SPACE iterior Alterations fir'.} Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ xterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] ECTION 5 - USE GROUP AND CONSTRUCTION TYPE_ USE GROUP(Check as applicable) CONSTRUCTION TYPE Assembly 111 A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ A-4 ❑ A-5 ❑ 1 B ❑ Business ❑ 2A ❑ Educational ❑ v 2B I ❑ Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ Mercantile ❑ 4 ❑ Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ Utility ❑ Specify: Mixed Use ❑ Specify: Special Use ❑ Specify: COMPLETE THIS SECTION IF!EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE isting Use Group: Proposed Use Group: isting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): ECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY.. . oor Area per Floor(sf) 15t _ y St 2nd - kAj 3`d 4th ,d th y � E s 4 V0 otal Area (sf) Total Proposed New Construction (sf) I ­5 IT � fiY �yk fi )tal Height(ft) G ] Total Height ft ---- r -------- N r s 7 ��''..:,• = i,^s-� `sr�% '° r« Z '�i� P 1 .:. z = - t a , t Ir At 'i , ilk IT- Vvi tp to r. 4 - > v`_ W E f � 1 1�^ V k 1 Q 5 cv t Northampton Nursing Home, Inc. 737 Bridge Road,Northampton,Massachusetts 01060 (413) 586-3300 • Fax (413) 586-4279 March 18, 2002 DESCRIPTION OF INTERIOR ALTERATIONS Tear down old sheet rock and metal studs, add new metal studing, replace old sheet rock with cement board, and retile walls. A total of 5 walls R;�Ijj , Richard Perry, Maintenance Supervisor Versionl.7 Commercial Building Permit May 15,2000 Cit f Northampton o' - g Department . 1 ain Street om 100 rtha on, MA 01060 -. )h,l 587 12 0 Fax 413-587-1272 APPL CATION TO-C-09 TRUCT, REP ENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING 3ECTi'ON 1-SITE INFORMATION This°section to be completeby office `.1 Property Address: 3�1 Map '` Lot Unfit Zohg Overlay District y �y / Efr$,t District' CB,District . SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT' ...1 Owner of ReFord: 73 VIA !ame( tint) Current Mailing Addre s: )ign ture Telephone 2.2 Authorized Agent: U) LIL dame(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 11 f 2. Electric:.1 t�o (b) Est,n-,,ated Total Cost of Corgi:=truction from 6 3. Plumbing "S 3 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I + 2 + 3 + 4 + 5) Cs Check Number © � This.Section For Official Use'Onl Building Permit Number: ! Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2002-0784 APPLICANT/CONTACT PERSON DA Williams ADDRESS/PHONE 81 Water St. (413)586-3139 PROPERTY LOCATION 737 BRIDGE RD MAP 18C PARCEL 048 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 5e q5 —, Typeof Construction: SHEETROCK&RETILE WALLS IN DISK AREA New Construction Non Structural interior renovations Addition to Existing Accessoly Structure Building,Plans Included: Owner/Statement or License 014612 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INIFOOATION 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 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. 717ZRIDGE RD BP-2002.0784 GIs#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 18C-048 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2002.0784 Project# JS-2002-1306 Est. Cost: $10285.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DA Williams 014612 Lot Size(sq. ft.): 272685.60 Owner: NORTHAMPTON NURSING HOME INC Zoning: URB Applicant: DA Williams AT. 737 BRIDGE RD Applicant Address: Phone: Insurance: 81 Water St. (413) 586-3139 LEEDSMA01053 ISSUED ON:3120102 0:00:00 TOPERFORM THE FOLLOWING WORK.SHEETROCK & RETILE WALLS IN DISK AREA 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 3/20/02 0:00:00 3045 $150.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo