38B-008 (10) 126 WEST ST-PHYSICAL PLANT BP-2001-0654
GIS#: COMMON EALTH OF MASSACHUSETTS
14p:Block: 38B-008 ITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations B�ILDING PERMIT,
Permit# BP-2001-0654
Proiect# JS-2001-1184
Est.Cost:$3000.00
Fee: $50.00 PERMISSION IS JHEREB Y GRANTED TO:
Const.Class: Contractor. License:
Use Group_ ALBERT PROKOP 073299
Lot Size(sq.ft): 14461 .92 Owner: Smith Colleize
zoning: ApyUcant. ALBERT PROKOP
AT: 126 WEST ST PHYSICAL PLANT
Awlicant Address: Phone: Insurance:
6 SUNSET LN (4�3) 585-2412
MONTGOMERYMA01 085 ISSUED ON.•11301010:00:00.
TO PERFORM THE FOLLOWING WORK: ONSTRUCT ROOF OVER EXISTING SAND
STORAGE
004,P2OST THIS CARD SO IT IS VISIBLE FROM THE ITREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footin s:
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 CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy i signature:
Fee Type: Receipt No: Date PaW: Check No: Amount:
Building 1/30/010:0:00 482588 $50.00
212 Main Street,Phone(413)1587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0654
APPLICANT/CONTACT PERSON ALBERT PROKOP
ADDRESS/PHONE 6 SUNSET LN (413)585-2412
PROPERTY LOCATION 126 WEST ST-PHYSICAL PLANT
MAP 38B PARCEL 008 ZONE SI j
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: CONSTRUCT ROOF OVER EXISTING SAND STORAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 073299
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
pproved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § —w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of D eds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of HealthWell Water Potability Board of Health
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Permit from Conservation Commission Permit from CB Architecture Committee
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Signature of Building Offficial Date
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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 aut orities.
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Version 1.7 Commerci 1 Building Permit May 15,2000
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587.1240 Fax 413.587.11272
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
Thrs sectib��p���t�hnplete� Jy ff��a J� '=
1.1 Property Address: M ��r
/ L/ J/ ` map, y J UC1
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111 St Q.s"'T t ,CB District.... :..........j„„,,yw,,,�...«.r,..
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Ca C 00,04a
me(Print) Current Mailing Address:
�J ^ Zyi7
Signature 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
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing BuildingPermit Fee
4. Mechanical (HVAC)
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5. Fire Protection
6. Total =G + 2 + 3 + 4 + 5) Check Number '
This.aection For.Official Use(,Only
uilding Permit Number: ate Issued:
Signature:
Building Commissioner/Inspector of Builcli ags Date
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f ' Versionl.7 Commercial Building Permit May 15,2000
'ION � VT U SIDP CES � 3�'i=` THAi5; 0
t p
.-,,,,,
74—
Interior Alterations Existing Wall Signs Existing C iround Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Sign [ Change of Use [ ] Other [ ]
❑ Accessory Building[ ) Repairs [ ]
DESC'2�P�� DD d1z sd N D Z
S�CTBN USEI20UP ANA CONSTI)CTIT SPE
„{ry-.. ..,,, ..,,. ?:.. .. ! 7>>r��-zr,. lw,7v> Nva-0, .W .v.3r.. a .- ._
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1 F ❑
A-4 ❑ A-5 ❑ 1 g 11B Business ❑ 2A ❑
E Educational ❑ 2B I El
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 1F EXi;STING BUIL4lNG ]UNDERGOING RENOVATIONS,ADDITIONS AN,D/OR GHAfUGE°1N:.USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT ANDr4REA
BUILDING AREA EXISTING PROPOSED NE CONSTRUCTION
Floor Area per Floor(sf)
St
a
1st
2nd " �
� �
2"d
3rd
I r�
t'9
3rd
4th
4 t
,r
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Total Area(sf) Total Proposed NeConstruction (sf)
Total Height(ft)
".
Total Height ft ------a-------------
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Version 1.7 Commercial Building Permit May 15,2000
L7.Water Supply(M.G.L. c.40, § 54) 7.1 Flood Zone Info mation: 7.3 Sewage Disposal System:
iblic ❑ Private ❑ Zone: 0 tside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Iv 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
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Fill:
volume&Location
A. Has a Special Permit/Variance/Finding e�er been issued for/on the site?
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NO DON'T KNOW YES
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IF YES, date issued:
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IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW I YES
IF YES: enter Book P�ge and/or Document #
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B. Does the site contain a brook, body of water �r wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be ob ained from the Conservation Commission?
Needs to be obtained Obtaine I Date Issued:
C. Do any signs exist on the property? YES NO
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IF YES, describe size, type and location:
D. Are there any proposed changes to or aditions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
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Versionl.7 Commercial Building Permit May 15,2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION S' RVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO'780 CMR 116(CO TAINING MORE THAN35,000 C.F. OF ENCLOSED SPACE)
1 Registered Architect:
Not Applicable ❑
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Name(Registrant):
Registration Number
Address
Expiration Date
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Signature Telephone
92 Registered Professional Engineer(s):
Name ! Area of Responsibility
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Address Registration Number
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Signature T lephone Expiration Date
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Name Area of Responsibility
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Address Registration Number
,nature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
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Signature Te ephone Expiration Date
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Name Area of Responsibility
Address Registration Number
Signature Te ephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
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-!dress
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Signature Telephone
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Version 1.7 Commerciz I Building Permit May 15,2000
CTION 10-STRUCTURALPEER REVIEW(780 CMR 110.11)
.dependent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTION 11-OWNER AUTHORIZATION -'TO BE COMPLETED `I YHEN
OWNERS AGENT'OR CONTRACTOR APPLIES"FOR BUILDINGPE RMIT'
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
I, , as Owner/Authorized Agent
hereby declare that the statements and information on the foreg ing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name j
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gnature of Owner/Agent Date
SECTION 12 CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable a❑
Name of License Holder : �� `✓� '4 3 2 /,
(,� �,( License Number
a
Address /� !� r- Expiration Date
i CJ J
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c,152, MOD,
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...... ❑
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Y 1iAMP
•�o�-�To° �x � �ll����.11t��IIIt
� B �lasaaclinsctts`
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DEPARTME4T OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Norf iampton, Mass. 01060
WORKEW S COWEN ATTON INSURANCE AFFIDAVIT
(1.i permittee)
with a principal place of business/resid nee at:
(phone#)
(b,rceucity/staid2ip)
do hereby certify, under the pains and enalties of perjury, that:
( ) I am an employer providing the folowing worker's compensation coverage for my
employees working 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) ce Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) ce Company/Policy Number) (Expiration Date)
(anal additioml shed if neoessary to include informatio i pertaining to all coat re )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing aLl the work myself.
NOTE:please be awam that while homeowners who lay pasom to do makicaanc,consuuctioa or rzpair work on a dwelling of
not more thea throe uatu is vAnch the hamowncr rtst& or m the grounds appurteamt thereto acs not Scoaally oomidaed to be
employes under the work ees oompcnsation Act(GL15 1(5)�application bry a homeow=for a Berne or permit may evidcaoe the
legal o-w ofanomptoyorunderthewodcoescompawlioaAcL
I understand that a copy of this uatemmi maybe for wwdod to the Dtpartcwnt of Industrial Accidents Oifioe of Iasursaoa for the
coverage vaificatioa and that failure to sw=covoeages under section 25A of MGL 152 can lead to the impar Oa of mminal penalties
000lLemg of a$x of up to 51,500.00 andlor' of up to one year and civil penalties in the form of a Stop Www Order and a
find of S100.00 a day agniost mt-
gPermit
tmental��y
Number—Lot#
Signage of Licensee/Permittee
0041
111 Colo��
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