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22B-041 (25) 176 PINE ST BP-2019-0207 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:22B-041 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv:Zonine Permit BUILDING PERMIT Permit# BP-2019-0207 Proiect# JS-2019-000300 Est.Cost: Fee:$100.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LEE BROWN 066993 Lot Size(sq. ft.): 64904.40 Owner. PUN FAMILY LLC Zoning:NB(100)/ Applicant: LEE BROWN AT: 176 PINE ST Applicant Address: Phone: Insurance. 555 UNION ST (413) 504-9441 SOLE PROPRIETOR SPRINGFIELDMA01109 ISSUED ON:8/2412018 0:00.00 TO PERFORM THE FOLLOWING WORK 14X14 DECK•"NOTE - DECK MUST BE FREE STANDING AND MEET 521 CMR 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 Occuoancv signature: FeeTvpe: Date Paid: Amount: Building 824/20180:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File 4 BP-2019-0207 APPLICANT/CONTACT PERSON LEE BROWN ADDRESS/PHONE 555 UNION ST SPRINGFIELD (413)504-9441 PROPERTY LOCATION 176 PINE ST MAP 22B PARCEL 041 001 ZONE NB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENC OSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin p Permit Filled out Fee Paid _ Be FREE $TANOhq TweofConstruction: 14X14 DECK rVV It New Construction AND M66T '5 11 CML Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066993 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 Now 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. 4 Versimi Commercial Buildin Permit May 15,2000 Department use w* ity Northampton Status of Permit: AUG 16 2018 uildi gDepartment Curb CuVDnveway Peron 212 Main Street - SewetlSeptm Availability Om 100 WatedWell Availability oFPT OIHAMPTOUIL MAO' W_Hg a ton, MA 01060 Two Sets of Structural Plans NOS tl HAMPTON.MAOId�fill e - 87-1240 Fax 413-587-1272 Piot/Sne Pians 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 7-SITE INFORMATION 1.1 Property Ad/dress: �`This section to be completed by office / es�r Map o Lot b 1l// Unit (/ Zone Overlay District '- - ---- - - -- Elm St.District OB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow(n"er�of Record: 14 mo toe 'a Name(Print) Current Mailing Address. r Signature Telephone "7,t)3 d 5-6 ,:; 2.2 Authorized Agent: Name(Prnt) LB >; 2J Current Mailing Address SSS 'tf/VI q.•*� JI ft�;y! (dl ✓ . 0/ Signature 1C Telephone t -5-p ' SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only Com le ed bV Denrit applicant 1. Building D ® (a) Building Permit Fee 2. Electrical v- }NrdA ,gJ'8e-K' (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection -- 6. Total=(1 +2+3+4+ 5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building CnmmI55100erila5pe41or of Buildings Date Versionl.7 Commercial Building Permit May 15,8000 SECTION4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs Additions Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use❑ Other❑ Brief Description Enter abrief description h@re "7CK Of Proposed Work: Gf'tµ`Q-G2((yF- SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A AssemblyE-1A-1 1:1A-2 C3A-3 El 1A ❑ Al ❑ A-5 ❑ 12 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 1 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ 5-2 ❑ 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 let) 1:, 1s 3rd 3m _... 4,h Total Area(sf) Total Proposed New Construction(so Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,S 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private El Zone Outside Flood Zane❑ Municipal ❑ On site disposal system❑ Version)7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be Glued in by Building Departmwl Lot Size Frontage Setbacks Front Side L .. R: . U R Rear Building Height Bldg.Square Footage Open Space Footage ILot area minus bldg&paved ,. pullung) #of Parking Spaces — Fill- _ . volume&Locatiov) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO o DONT KNOW O YES O IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES 0 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 O NO O 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(cleanng,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. V4 Version l.7 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 ❑ 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 Data Name Area of Responsibility Address ,. Reg stration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Data Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone 00 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 © No Q 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 pequry. Pr nt NamF k� � �R 20 Signature of Owner/Agent Date (m / SECTION 12-CONSTRUCTION SERVICES 104 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder: License Number T�o 066 cj93 Address Expiration Date mssy/v, no S?` 171 nature Telephone / r r r 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 O No O City of NorthamptonVW 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: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date /�(p//D Signature of Permit Applicant The Commonwealth ofMassaehusetts Department of7ndustrialAceidents 7 Congress Street,Suite 100 Boston,MA 02114-2017 wrvw.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: ��.'e' ou�— Address: � 1.) eco S,7— City/State/Zip: � Phone d'o't C�9, Are you an employe "Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail part-time).- 6. ❑Restaurant/Bar/Eating Establishment 2. nm a sole proprietor or partnership and have no y. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We arc a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,¢1(4),and we have Hi Manufacturing no employees. [No workers'comp.insurance required]* I I 11 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.❑ Other "Any applicant Nat checks box 01 must also till out the section below showwg their workers'compensation policy isnavotion. "*If Ne coryorele officers have exempted Nemselves,bol Ne mrpomtion has other cmploycc,,s worker,'eumpmevatiun policy is mgWmd and such an oBar vats should ehcckbox#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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. ldoherebycert' ndr�' mn, tdpenaldes ofperjury that the informadonprovidtedabove is true and correct lenam —�' Date: CJS hope 4: — / Offteial 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone ft: www.cone,.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,p25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements oflhis chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Han LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Pone 1r,--x102-13-15 Y � 0 --1 - a 7r. nye 1 ivl3rJ j^I 1"'- 3tI i f7 K Z p y � >> N t�] Iu City of Northampton Massachusetts m' s DEPARTMENT OF BUILDING INSPECTIONS r 212 Main Smoot,ROOM 100 Northampton MA 0io6o (413)587-1240 Plot Plan Drawing To be submitted with permit applications for 1- or 2-family additions, decks, porches, pools, and detached accessory structures. / J Property address: //�7L ,&ze —` !�' /L Sn- ✓YI/1 , / O // Proposed work: SlY£ zz�/X'/7 Information/detail requirements: • Septic system tank and drain field (if applicable). •Street(s) by name • All existine structures including decks, pools, • Front of house detached garages,ca rports,,sheds,etc. • Driveway ✓ • All proposed additions,decks, porches,pools, • Easement(s) detached garages,carports, sheds,etc. • All property line dimensions • Distances of existing and proposed structures to lot lines and other structures. 3 iID ; rv'2 po v v �N asr �y�X 'Ltd� � If"I ,sa.0 art(W o 5 q ev 9 r/k 11 Fay �i5e =� occk I'�oieK is Ir � Fp.ati— d-o s.�'s w✓fi< i's U s�6c.,,,e.(Ic 5'� crLo,•., ts,.i lcE �"1 !-> z. cxek sizE l'1 n1Y __ 3. 'Fe,om a1gq, d� Oot(�rNS J-•. S,ctS w+rI k r (Example on back) b r.�s URn o2G(c