11A-058 (8) File 0 RP-2003-0695
APPLICANT/CONTACT PERSON Jeffrey Cranston
ADDRESS/PHONE P O Box 307 (413)268-3504
PROPER I Y DO GOLF
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Pee Paid
Buddme Permit Filled out
Fee Paid
"fervid Construction: CONSTRUCT T ADDITION AT SERVING WINDOW
New Construction
Von Structural interior renovations
_ Addition to Existing
Accessory Structure
Buildme Plans Included:
_ Owner/Statement or License 079531
3 sets of Plans/Plot Plan
THP: FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORVIA'ITON PWENTED:
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: § C� s5 _ ��/,t ON O/--
Finding_ f/ _"_ Special Pemut - _-. Variance--- -
Received
ariance' _—Received&Recorded at Registry of Deeds Proof Enclosed /1J0.�Cb/FenPMrrl•�
SaYc cRi�L
Other Permits Required:
Curb Cat from DPW water Availability _Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
_Pe=t from Conservation Commission Permit from CA Architecture Co mnittee
--Permit from Elm St et Commission
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 wurks 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.
in 1, I. omit NJa _
Depprtment use only
City of Northampton Status of Permit- 1 .
Building Department Curti Cut/Dnveway,Permit "fir 'n
212 Maw Street Sewer/Septic Availability
Room 100 Water/Well Availability
`Jorthampton, MA 01060 Two Sets of Structural Plans
Phone 413-587 1240 Fax 41"-587-1272 Plot/Site Plans_
Other Specify
APP
LOCATION 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
Ll Property Address'. '-"%-'`-.- ✓'"i- '/' This section to be completed by office
A-
T v Map _ Lot_�
Unitt
•- HFaIV'y/ i. /�r /5 d
— Zone V /'� Overlay District
Elm SL District_ _ _ CB District _
III---SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2 ' Owner of Rekord:
>,t..-. / ./ S� r:- t
rd 'ah
L 14L2
cprnl -'�
2.2 Authorized Agent;
Name(Pn ) Current Mailing 0.rJes,.
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 bi (b) Estimated Total Cost of
_ Construction from 6
3. Plumbing Building Permit Fee
}I:
4. Mechanical (HVAC)
5. Fire Protection
In. Total =(1 + 2 + 3 + 4 + Check Number
This Section For Official Use Onl
Building Permit Number: ,�l� '� �G� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building PeimiI May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE l
Interior Alterations Ex isling Wall Signs Existing Ground Signs Additions Roofing ❑
Ll ❑
Exterior Alterations Demolition❑ New Signs I ] Change of Use I ) Other I 1
❑ Accessory Building [ ] Repairs 1
Nk�F KTP-7- rJ: � ' fy(41,. ( "I Ge%f=>[(=r V/ ! ice' t " )4(-'(_S—
SECTION
rlr�('1 �
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) I CONSTRUCT ON TYPE
A Assembly ❑ Al ❑ A-2 ❑ A3 ❑ lA ❑
A.4 ❑ A5 ❑ 1B ❑
B Business JK 2A I ❑
E Educational ❑ _ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C El
H gh Hazard ❑
I nsthu0onal ❑ I 1 ; 2 ❑ 13 ❑ 33 _ ❑_
M Mercantile ❑ 4 ___ ❑
R Residential ❑ R-1 ❑ R-2 ❑ R3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility, ❑ Specify:
M Mixed Use ❑ bpeafy.
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 1 ':' O FICE`sU,SI L
x"a
Floor Arca per Floor(sf)
Io
"E Ai
2n° 3m
4m
Total Area (at) Total Proposed New Construction (sl)
Total Height (ft)
Total Height it - {- /-----
Vets ion 1 7 Commercial Building Permit May IS,2000
7. Water Supply (M.G.L. c. 40, § 541 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public E� Private ❑ Zone: Outside Flood Zone ❑ Municipaystem ❑
8. NORTHAMPTON ZONING
F,xisdng Proposed Required by Zoning
lTls column to bu Gllyd In by
Building De,nu"nl
Lot Size
Frontage
Setbacks Front 'S Y
Side 1.: -•li`.R. ;,n. 1. R:
Rear �7 J
Building Height
Bldg. Square Footage 1, % _ t;.�
�.{��--too
Open Space Footage °n
(IAt arca minus bldg i paced
ark'n
#of Parkin Spaces
Fill:
(volume&location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOWYES
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: ik-� Z-4 y )`%,/E/v!n f q /ru ail _
D. Are t}ere any proposed changes to or additions of signs intended for the property ?YES _
No ✓
IF YES, describe size, type and location: _ .—
Version 7 Commercial Building Penn it 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
xpuatmn IJzte
Signature Telephone _
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
—. — —
Slgr,fUl Telcoho,e Expiration Date
Nanc Arca of Responsibility
i
Address Registration Number
Signature Telephone Expiration Dab
Nam, 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 -so Not Applicable El
Company Name:
Responsible Charge of Conslt uchon
Irk
Atldress I / �
SignaV& �- Telephone
J
Ven,on1 7 Commcrclnl Building Permit May 15,2000
[SECTION 10- STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes..__.❑ No
�ECTION 11- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _ _.. _ - _ to act on
my behalf. rn all matters relative to work authorized by this building permit apphcaCo�
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the statements and information on the foregcing application are trvce ano accurate, to the best of my
knowledge and belief.
Sgned unoer the pains and penalties of perjury.
Print Na,ne
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
101 Licensed Construction Suoerv'sor: Not Applicable ❑
� a n
Name of License Holder
License Number
Access ,I il
Expiration, Date
_ .i-_.
m
SignaWre� c 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_._. ❑
a 's Critg of �azrll)aul}�tnn
g - f .Alam n dnmA le ' -
DLPART ENT OF EOIIDINC rNSPE=ONS
212 Main Street ' Muuicipnl Pu,ldmg
Northmnptoo, Moss. 01060
WORICER'S COMPENSATION INSURANCE Ali MI )AVIT
_ - (liccuseelpernitn•:.i
with a principal place of business/residence at.
1;14 O/o�
(strew(/city/stale/rip)
do hereby cei tify, under the pass and penalties of pe.jurp, ilial.
( ) I .m1 all employer providing Lire followilm .aori_c?S comp eosallon Coverage for my
employees wolidng on this job_
(Srswanm Compwy) (PoGc:Nambcr) (Expuauoo Date)
O I am a sole proprietor, general contractor or honreowne:(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Numc of Contractor) (ImSurance Compaay/Policy Numb,-) (Expimoon Dale)
(Name of Coutr2dor) (Insurance Compauy/Poficy Numbed (Fxpuaoon Dale)
(Name of Contractor) (Lns..Co. y/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comnzoy/Policy Number) (Expiration Date)
(.�nm;5_. .�iFo—y ro aft.o(.tlm pctaise5,m mma )
(✓I 1 am a sole proprietor and have no one working for me_
( ) 1 am a home owner performing all the work myself.
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legal swev ofav a�layx wdweLc Wohn'e Comp®rtjnn AA
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mv¢age aaifiotim.mnw(eilive W 15A dMGL 151 m Indo Iy:imp0ffim da mm_ al V ml
mm mti oCa fineofrgmS1300W mda®{viw®an oCup bore year end avJ pm.l6nnibc(of.SOO WaY Ude Bode
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Permit Number
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