37-018 (9) 722 FLORENCE RD BP-2017-1273
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-018 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BASEMENT RENOVATION BUILDING PERMIT
Permit# BP-2017-1273
Project# JS-2017-002122
Est.Cost: $350.00
Fee: SI 00.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: ALEX KOMLEV 103055
Lot Size(sq.ft.): 432550.80 Owner: BIBLE BAPTIST CHURCH THE
Zoning: Applicant: ALEX KOMLEV
AT: 722 FLORENCE RD
Applicant Address: Phone: Insurance:
15 SARAH LANE (413) 586-4739
BELCHERTOW NMA01007 ISSUED ON:5/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:remove 30 feet of existing sheetrock & insulation
and replace
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 Occu a anc Si•nature:
FeeType: Date Paid: Amount:
Building 5/5/2017 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1273
APPLICANT/CONTACT PERSON ALEX KOMLEV
ADDRESS/PHONE 15 SARAH LANE BELCHERTOWN (413)586-4739
PROPERTY LOCATION 722 FLORENCE RD
MAP 37 PARCEL 018 OOI ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM ALLIED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TypedConstruction: remove 30 feet of existing sheetroek&insulation and replace
New Construction
Non Structural interior re tvations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103055
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
I/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 EP ay
Signatu - of Building 0 ictal 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,
F Version1.7 Commercial Building Permit May 15,2000
Department use only
Med ,. A City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
1 212 Main Street Sewer/Seelig Availability
c .:.. ..
: -
Room 100 WatafM/ell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloVSite 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
1.1 Property Address: This section to hen completed by office
!22 FlPre..e1C '� IZ� -_. -_-.. Map 37 1 Lot 0/2 Unit
itkrrII^n.ea f 1-ca /✓M9 OiO.f z Zone Overlay District
-- - - --- -- Elm St.District CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
B:ble r ya/: C' aj1 i 7/0 Fore.icCA?P Yx,.-e:rccMP »bz
Name tannl) �� Current Ma l ng Address
ti" Ko1,, I (evi3) 384 Li73`J"
signature r _ — A' ev Telephone
2.2 Authorized •gent:
6 Ao 411 t• 710 17 (tot 7 /-/vie.te1'1P Or*.Name(Prznt) _ Current Mailing Address
(4U 3)_Jib V75?
Signature / y. r�Oeu.- Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /2 _ 7 U. (a)Building Permit Fee
2. Electrical ? (b)Estimated Tole!Cost of
Construction from (6)
3, Plumbing Building Permit Fee
4. Mechanical(HVAC) ( / t
5. Fire Protection .. y�, 44/rens
.--
6 Total=(1 t2+3+4+5) Check Number hal gq/
This Section For Official Use Only T
Building Permit Number Date
Issued
Signature_
Building Commissioner/Inspectorof BuBdings Date
Version] 7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED✓ SPACE
Interior Alterations 9 Existing Wall Signs 0 Demolition 0 Repairs Additions 0 Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other 0
Brief Description Enter a brief description here.
Of Proposed Work:• gam 90 30 ode e/05],/,b, ...517te01hocCd �5,9/lQp/5f_VAC e-
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 0 1A 1 0
A-4 0 A-5 0 1B 0
B Business d Ci.xi.C✓k 2A 0
E Educational 0 2B I ❑
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 0 1-2 0 1-3 0 30 0
M Mercantile 0 1 4 0
R Residential 0 R-1 0 R-2 0 R-3 0 5A 0
S Storage ❑ S-1 0 S-2 0 50 0
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(sf)
.s
1st
3rd _. _..
4I
4th
Total Area(sf) Total Proposed New Construction(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 0 Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
Vermont 7 Commercial Building Permit May 15, 2000
R. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
Eau comma to be fined 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)
#or Parking Spaces .. __ _
Fill. _.. _..
(volume&Location) . . ._. .. _. _
A. Has a Speciat Permit/Variance/Finding ever been issued far/on the site?
NO 0/ DONT KNOW 0 YES 0
.. ........... . ....... ....
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO CI DONT KNOW Q YES Q
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW lFJ' YES n
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained a Obtained 0 , Date Issued-.
C. Do any signs exist on the property? YES 0 NO O
IF YES, describe size, type and tocation: qt
SY L.�lwirell Ely
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO of
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exca tion,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.
Version 17 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 0
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
4W COA)/yaC J,0./) __. Not Applicable ❑
Companyyr Name
Responsible In Charge of Construction
71 ° 179rtne , P norm ce_ h OIO6L
Address
Signature Telephone
Version1.7 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
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. _.... 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 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
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:;. /0/est_XO,'i/mow_.. _.... /O30S5--
License Number
1/0 j/oven« PD fJoter/ce 7/7p �ig � /z/sa/�3
Address Expiration Date
gnature
r/- 1/474-- /3 e 973?
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 0 No 0
The Commonwealth of Massachusetts
,.� Department of Industrial Accidents
Office of Investigations
i—Ll—rr 600 Washington Street
Boston, MA 02111
www.rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
k /2 f
Name(Business/OrganizatiotJlndividual): L.9/r5�/c.0✓. �� _
Address: 7)0 119r ence yED
City/State/Zip: f2. -t4«- i,/i DIO6Z Phone#: (y/3� 35b- ol73Y
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ram a general contractor and I
6. ❑New construction
—ateemployees (full and/or part-time).* have hired the sub-contractors
2.yJ I am a sole proprietor or partner- listed on the attached sheet 7- Remodeling
ship and have no employees These sub-contractors have g, Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. F We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11.❑Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
q ] employees. [No workers' 13.F.-1 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information-
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 none 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.
L am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
lob 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 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 certify under the pains and penalties ofperjmy that the information provided above is true and correct.
Signature: Date: 6 3 77
Phone#: l3)/ 38G —����73 y
Official use oonly. 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 MGL 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: 7Z2 R-47Ile-4 ICC /C /19.47fricre,ice /�G Z
The debris will be transported by: X1/ 4& S4-
The debris will be received by: /// -k /&
Building permit number:
Name of Permit Applicant Pe/
et /Kv
Date Signature of Permit Applicant
CC'
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,.S
111 \