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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 'V
WORKER'S COMPENSATION INSURANCE AFFIDAVU
I, X 0 1 0 Y-) L'-.A (':'f-4 v L_14
(licenser/permittee)
with a principal place of business/residence at:
(shret/ci ty/stater=p)
do hereby certify, under the pains and penalties of perJtlry, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worldng on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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/Poky Number) (Expirat;on Date)
(Name of Contra(:tor) (Insurance Compasry/PoEcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(attach additioml short ifnao=suy to include infonnstioa pertaining to all c dmdors)
(L)/Iam 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 whilo homeowoeta who employ pasoa:to do ma into ■n,o,cousuuetion or icPair work on a dwelling of
not morn than throe vans in which the homeowner raid=oc oa the grounds appurtenant thereto are not cax ally oDandcred to be
employ=s under the wmka's oompeasatioa Ad(GLI52,ss 1(5)),application by a homeowner for a lie ose oc pcnvd may evidenoc the
legal star=ts of an employer under thn Workoee Compensation AcL
I understand did a copy of thin statement may be forwarded to the Doputct o2 of Industrial Amide Offioe of Imw"Qm for the
oovaage verification cad that failure to secure oov=V under soctioa 25A of MGL 152 an lad to the impo oa of aimi ml penal i=
oousbtiag of a Sae of up to$1,500.00 andfor imprison of up to one ytar and civil pecaities in the form of a Stop Work Order cad a
fmo of 3100.00 a day agaia Ld me..
' For dgactmr W uao caly
Permit Number
t; [ Maps# L
ot# _
Sipab=of Li ermitfee Wte
"' Versionl.7 Commercial Building Permit May 15,2000
10 9
.�331WNWS $ W£' I
5EC 1 ° 0; 7 R P E , , X33
Independent Structural Engineering Structural Peer Review Required Yes......❑ INo......❑
SEC,TJ )N 0MPVE'T,ED
bWNER� GENT aR�GONTi2AC`TOR APP�.IES 3FpR�l�ILD1 G�PER�VII7P �.� ,
as Owner of the subject property
hereby authorize to act on
my be in II matters relativ o w rk authorized by this building permit application.
Signa 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.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SEC 1�N 12 CONST)RUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: y t .4- > -V 4 c Ft U t-A C
License Number
T e- AJ x 1--r A 1 F13 t. �)7 ,vt 3 I S. 7 ._. Y _�3
Address Expiration Date
? � 7 y
Signature Telephone
S GTl 1 'WOR 3'l >r25"COM
k PEN5AT10N 1NSUtANGE1'iDA1i'IT(M G 1, c 3152,
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
�, .;,3 � 3 r
ECT10N OFESSIONAL DESIGN D CONSTR CT,IONiSE Y�CES 10 UII.DINGS AIVpaSTRUCTURE�S BJE Vii, O�
R� NiQ1T1?OL,PURSIJANTTO .80-CMR116 COTITIIVG�MbRE'THA �OOCF F ENCLt)SED�SAC �
��., a.��.., �,,.. -4-511,;3 ��.
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
A . V P U Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
ILI
Signat Telephone
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 ❑ 1 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 r
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. AV here any proposed changes to or additions of signs intended for the property?YES_
No �/
IF YES, describe size, type and location:.
i
Version 1.7 Commercial Building Permit May 15,2000
sECTIO ��
�U- Q,
:.N Ci S to
�e� ti
ll0
s N35�OO
11� .�7 7 .e, N»:a`«a?».+�"£z:.cii .W ;,, `t?? "�S€ a s�i 3'Y *3 's..
�.:a _� ��.a'''.....°. t3lY?:
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [a--
�ESC2P�� C f�
5ECX O S 't)SE,G OUPyAN[S CO STRl1,C1"llOf��IY E
adA €„�s
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA p
A-4 ❑ A-5 ❑ 1B _
❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High 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 ❑ Specify: „
C1VIPl,E7I'THI'S SECTI+3N lF EXIST]N�G$UILDING IJNDEf2GDING RENOVATIONS;,ADDITIONS gNDlOR3C1� 1�Gi~
..6+.X'
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): _
SECTI()�I6IlII_D13' GIEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) 1St ° 1
1st 2 nd
2nd 3rd
3rd
4th
4th
Total Area (sf) Total Proposed New Construction (sf)
...................................
Total Height(ft)
Total Height ft.....................
i
Versionl.7 Commercial Building Permit May 15,2000
City of Northampton `
Building Department
a
212 Main Street :
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, 0 f<, GILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING4'�
SECTION, SITE INFORMATION ,
"T ,ssect�� a beco' p"let i off c
1.1 Property Address. "
1UrfN s i
C) 4-THA u f Aj
=z
Elm 5t D strjct Al s r cto
SECTION 2 ROPERTY OWNERS,H 1,AUTHtaRIZED AGENT
Y g,_
2.1 Owner of Record:
Name ft it)t) Current Mailing Address:
Signat re Telephone
2.2 Authorized Agent:
v _t_Q tfVq C FI Ut,A A., Lin K I1 -. 1,J- A-il r6L0 gut 015 S
Name(Pri ) Current Mailing Address: (}/o t. C
Signatu / Telephone
SECTION 3. 51'it1+lATE .: ONST2UGT10'N'C05'TS�
Item Estimated.. �...,..
Cost(Dollars)to be Offc�al 1JeOniy
completed by ermit a lic nt
1. Building (a)Buildrng Permit Fey 3
2. Electrical (b) stirhfed 1t�tal Gat of 3
Cann tucttor from, 6
3. Plumbing Building-Per*t�Fe� 3 33
4. Mechanical (HVAC) ,
5. Fire Protection
6 Total (1 +2 +3 +4+ 5) 6'0 "Oh SKOR ' w �, .�.
3 Hi 1 N"j
�"3�h 3 33.' J S T' 3b'h S ,� -F F.b '✓ J�'k m°$ .::
: � rfTh�IS�Sedt�onirffical� Qnl � � a f33
,g girr
s.
�I�Q�♦� Pi ���-.. � 8 "� � WW�� P �' 13.a�u.� k1339 3>i� 4 t P �.��,�-;�3A.
333
y
File#BP-2002-0074
APPLICANT/CONTACT PERSON David Vachula
ADDRESS/PHONE P O Box 112 (413)247-9459
PROPERTY LOCATION 285 NORTH KING ST
MAP 18 PARCEL 004 001 ZONE SR
THIS SECTION FOR OFF ICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE 6 X 14 PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049846
3 sets of Plans/Plot Plan
THE FqLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF3MMATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR _Special Permit and Site Plan
Major Project: Site Plan OR _Special Permit and 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 Stree ommission
/7(o
Signature of Bui g OfIlicial Da e
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.
I.1..
BP-2002-0074
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2002-0074
Project# JS-2002-0115
Est.Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: David Vachula 049846
Lot Size(s4.ft.): 8407.08 Owner: DULONG DAVID I&PAUL A LABBEE
Zoning: SR Applicant. David Vachula
AT: 285 NORTH KING ST
Applicant Address: Phone: Insurance:
P O Box 112 (413) 247-9459
N HATFIELDMA01 066-0112 ISSUED ON.71201010:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 6 X 14 PO R C H
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 7/20/010:00:00 2625 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo