23A-038 60 MAPLE ST BP-2016-1363
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-038 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-1363
Project# JS-2016-002344
Est. Cost: $1200.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TYLER BERGERON 080274
Lot Size(sq. ft.): 11412.72 Owner: KSM PROPERTIES
Zoning: GB(100) Applicant. TYLER BERGERON
AT. 60 MAPLE ST
Applicant Address: Phone: Insurance:
730 GULF RD (413) 427-8034 O WC
BELCH ERTOWNMA01 007 ISSUED ON.512512016 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT INTERIOR WALL TO EXISTING
OFFICE SPACE
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 5/25/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2016-1363
APPLICANT/CONTACT PERSON TYLER BERGERON
ADDRESS/PHONE 730 GULF RD BELCHERTOWN01007(413)427-8034 Q
PROPERTY LOCATION 60 MAPLE ST
MAP 23A PARCEL 038 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid /irk
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT INTERIOR WALL TO EXISTING OFFICE SPACE
New Construction
Non Structural interior renovations
Addition to Existinc
Accessory Structure
Building Plans Included:
Owner/Statement or License 080274
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Delay
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.
Version 1.7 Commercial Building Permit May 15,2000
Department use only
RECEIVED ity Of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
MAY Room 100 Water/Well Availability
o hampton, MA 01060 Two Sets of Structural Plans
�pOpTM�ILDING 1 - 87-1240 Fax 413-587-1272 Plot/Site Plans
PIr
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
1.1 Prooerty Address: This section to be completed by office
(„ mq� b`l t r,c Map Lot Unit
vv✓✓ I�`��� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) K6 mV tc,f m5 �� Current Mailing Address:Ip� �p SlT�� ��le:^•� �ll�
Signature )GAI Telephone
2.2 Authorized Agent:
73
Name(Print) / let- UeCoPco✓1 Current Mailing Address: 730
30
044 01"0'7
SignatureTelephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by permit applicant
1. Building .
� ODP o 0 (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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number bate
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS�HAN 35,000
CUBIC FEET OF ENCLOSED SPACE
i
Interior Alterations EfExisting Wall Signs ❑ Demolition[] I', Repairs[] Additions ❑ Accessory Building[]
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use Other❑
Brief Description Enter a brief description here.
Of Proposed Work: �„ ��f ( ✓1 r;0-r- .QJQ A/- 10 bec,c ;h s� WSt 5 i Yl
SECTION 5-USE GROUP AND CONSTRUCTION TYPE O+
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ 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 ❑
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(so
1 St 1 St
2nd 2nd
3rd 3`d
4th 4th
Total Area(so Total Proposed New Construction(so
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 ❑ Private ❑ Zone Outside Flood Zone[-] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
S. 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 O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,rextion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SE VICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CON INING 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 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
Company Name: Not Applicable ❑
Responsible In Charge of Construction
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
KSM Rwisi t Y5 a L as Owner of the subject property
hereby authorize 11I1er- etb✓1 to
act on myll//behalf, in all matters relative to work authorized by this building permit application.
1`C"l(()II i
Signature of Own4r Date
1, �V lrrr2,cn 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.unndider the pains and penalties of perjury.
1 tl let'
Print Name
Signatur of ner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: e �d��o rV Y� C`S — 0 9O)L"7 Lt
f n License Number
7 ,30 (, �.� Q � BcI��� ri �1/T 010o.7 7- 20-1 -7
Address Expiration Date
X113 ya7- 003
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIIT(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 bui ing permit.
Signed Affidavit Attached Yes 0 No Q
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
l Congress Street,Suite 100
Boston,MA 02114-2017
SV' , www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: 73 0 &LA( f &d
City/State/Zip: &It Le-s (L—i M A- Phone#:
Are You an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 3 4. ® I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub-contractors have
8. ®Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.:
9. ® Building addition
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 1 I.® Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[3 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.®Other
employees. [No workers'
comp. insurLoce required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'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.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: M7r &tAr--rCA .1-yt c-,
Policy#or Self-ins. Lic. #: 6 F 0 L �716 13 7 Expiration Date:
Job Site Address: City/State/Zip: F61ot-c
Attach a copy of the workers' co pensation 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 fine
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 DIA for insurance coverage verification.
I do hereby ceIDat
nder the pains and penalties of perjury that the information provided above is true and correct.
Si ature: ��aa e: "
Phone#: " /)' t/)7- 9 03 t'(
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of IV1GL c 40, S54, I acknowledge that as
a condition of the building permit all'debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: ��
The debris will be transported by:
The debris will be received by: �� � ��c (,�
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
I
i
�1o�tKc�O /v1 �
C
L9
Pioneer Post and Beam
Div. of Bergeron Builders, Inc.
730 Gulf Road Belchertown Mass. 01007
Phone. 413-427-8034 1 www.pioneerpostandbeam.com
I request that you grant a modification to waive the requirement for control construction for the
interior wall construction at 60 Maple street in the Florence section of Northampton because the
work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural
requirements and is impractical in that the cost of control construction is considerable when
compared to the cost of the proposed work. Thank you for your consideration. "Mass
Amendments, sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
Tyler Bergeron
Bergeron Builders Inc.
730 Gulf Road
Belchertown MA 01007