11A-058 (2) lot
`\ The Commonwealth of lassachusetts
Department of Industrial Accidents
Office of Investigations
600 ttashinaton Street
Boston,MA 02111
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41ww.masS.g0v1dia
-Workers' Compensation Insurance_-Affidavit: Builders/Contractors/Electricians/Plumbers
ADDIicant Information Please Print Legibly
dame usiness/Organim ion/In dual): d--i t t- 0.
�4 T I
Address:
City/State/Zip: c-/0 v ,LL t Phone.T:
Are you an employer?Check the appropriate box: Type of project(required):
1.[E 1 am a employer with Z- 4. ❑ I am a general contractor and I
employees(`ull and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on are attached sheet. 7. ED R.-modeling
ship and have no ellTlo ees These sub-contractors have S. ❑Demolidon
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp.ms-ura„ce comp.insurance.+
required-] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have°-exercised.their 11.0 Plumbing repairs or additions
myself. [No workers'corm. right of exemption'perMGL I2.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance req=ed.]
'Anv applicant that checks box#1 must also fill out the section below showing their worles'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.
tcontractors that check this box mast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their'woik-m'comp-policy number.
I am an employer that is providing workers'compensation Lnsurancefor my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #r: Expiration Date:
Job Site Address: City/State/Zip:'
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 fire
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 DU for ihsur nce coverage verification.
I do hereby c fy pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 2G l,!1
Phone
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: PermitlLicense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City!Town Clerk 4.Electrical Inspector 5.Plumbin:Inspe],ctor
6.Other
Contact Person: Phone r:
Version].7 Commercial Building Permit May 15, 2000
[SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
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 �� l,nar ► '�cet1 _ 4 �w�Q / �L�M�- to
act on my behalf,in all matters relative to work authorized by this building permit application.
All
Signature of Owner ai, V i Date
i, 3•fAnl- ��t�W`S �aJ d r 4 ��U --- ✓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.
Signe under the pains and penalties of perjury,
rrin Name
Signature er/Agent Date
SECTI N 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 0
r .
R
Objective: to move ice cream service from current "food" side to
other side where golf balls are currently handed out.
Projects: fixing up "golf' side cosmetically including putting up
wall coverings conducive to food service, floor tiles, remove
partition, and paint.
i
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
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address RegistrationµNumber
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 \
J � ` rT rL�)✓ �w*er-�C .,. - Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signa Telephone
r
Version 1.7 Commercial Building Permit May 15,2000
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 0 DONT KNOW � YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued: 41A
JI,t Ins i C. Do Do any signs exist on the property? YES rc�' NO 0
IF YES, describe size, type and location: .� }> �5 �0��1 ��:tr1r)U \ -t5t���
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
MENEENEENOW
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 ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ,
Brief Description Enter a brief descrintion hP*-p
Of Proposed Work: 13ee ttt ej7V ,�;i.��_;;�
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business JK 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I 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 ❑ 513 ❑
U Utility rm Specify:
u
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)
1 St
2nd 2nd
3rd
3`d
Total Area (sf) Total PrnpnsP.Cl NPw Constnictinn(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 IRI Private ❑ Zone Outside Flood Zone❑ Municipal� On site disposal system❑
s
Versionl.7 Commercial Buildine Permit Mav 15,2000
_ Department.use only
City of Northampton
Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/SepticAvailability
NOV ' ul`i Room 100 WaterLWellAvailability'
Northampton, MA 01060 Two Sets of Structural Plans
- ptoTre 413- 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
This section to be completed by office
1.1 Pro a Address:
ca'.�6-eir 411 _ Map Lot Unit
j j� 3 Zone Overlay District
t,c�.Zc�S
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-go l Ss'c"n/ 416 AkI4 J LL f24 _I (A-61 S
Name(Print) Current Mailing Address:
Signature �Z' Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building4C_
(a)Building Permit Fee
2. Electrical �J (b)Estimated Total Cost of
-3 Construction from 6
3. Plumbing -2`, Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection poq
6. Total=0 +2+3+4+5) Check Number
This Section For.Official Use Only
Building Permit Number Date
_ Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2008-0548
APPLICANT/CONTACT PERSON Jeffrey Cranston
ADDRESS/PHONE P O Box 307 WILLIAMSBURG (413)268-3504
PROPERTY LOCATION 124 HAYDENVILLE RD-MEADOW CREST GOLF RANGE
MAP 1 I PARCEL 058 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction:_RELOCATE ICE CREAM SERVICE TO GOLF BALLS SIDE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 079531
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Permit DPW Storm Water Management
Demolition ay
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.
BP-2008-0548
GIS fi: COMMONWEALTH OF MASSACHUSETTS
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-2008-0548
Project# JS-2008-000827
Est. Cost: $700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Jeffrey Cranston 079531
Lot Size(sq. ft.): 616374.00 Owner: BRISSON PIERRE R&SUSAN H
zoning,,: UIZA Applicant: Jeffrey Cranston
AT. 124 HAYDENVILLE RD - MEADOW CREST GOLF RANGE
Applicant Address: Phone: Insurance:
P O Box 307 (413) 268-3504
WILLIAMSBURGMA01096 ISSUED ON.121412007 0:00:00
TO PERFORM THE FOLLOWING WORK.-RELOCATE ICE CREAM SERVICE TO GOLF
BALLS SIDE
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 12/4/2007 0:00:00 $50.001698
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo