31A-085 (6) 320 ELM ST BP-2019-0989
GIs 4: COMMONWEALTH OF MASSACHUSETTS
MalaBlock:31A-085 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catekorv'window replaced BUILDING PERMIT
Permit BP-2019-0989
Project JS-2019-001626
Est Cost $11515.00
flee—!U-0000 PERMISSION IS HEREBY GRANTED TO.
Const. Class: Contractor. License:
Use Group: TOM DOLAN 039281
Lot Size(sa. ft), 11107.80 Owner: MAIEWSKI PROPERTIES LLC
Zoning URB(100)/ Applicant: TOM DOLAN
AT. 320 ELM ST
ApplicantAddress: Phone: Insurance:
P O BOX 297 (413) 585-0612 WC
CHESTERFIELDMA01012 ISSUED ON.-3/1512019 0:00:00
TO PERFORM THE FOLLOWING WORKJNSTALL 7 REPLACEMENT WINDOWS
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 ft Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: S 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 3/15/20190:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File P BP-2019-0989
APPLICANT/CONTACT PERSON TOM DOLAN
ADDRESS/PHONE P O BOX 297 CHESTERFIELD (413)585-0612
PROPERTY LOCATION 320 ELM ST
MAP31APARCEL085 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
FNGD REQUIRED DATE
ZONING FORM FILLED UT
Fee Paid
Building Permit Filled out
Fee Paid
,TvaeofCo tructian: INSTALL 7 REPLACEMENT Wl
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 039281
3 sets ofPlans!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
lIw— Y _ _311 Y1 B
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.
r Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
�- — Versionl.7 Commercial BuildingPermit May 15,2000
Department use only
ity of Northampton Status of Permit:
MAH 1 1 2019 uilding Department Cum CutlDriry y Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
PFPT o-r,Un owe INsaecnous N mpton, MA 01060 Two Sets of Structural Plans
587-1240 Fax 413-587-1272 Plot/Site 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 DWELLINGnn
SECTION 1 -SITE INFORMATION Y—
1.1 Property Address: This section to be completed by office
Map Ojti A Lot 25, Unit
Zone U Overlay District I
Elm St District leJ N
CS District O
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Makeusk�, LeJ K'A
Name(Print) Current Meiling Address:
M 113-53`1- `0-7c5
Signature %tea Tdephunc
2.2 Authorized AuenC
7oar Z)O�RN 6tna.E Cunt u� lb Ao�34i /�d� r.r G�+vr�fery /•/✓Mw
Name(Prnl) Current Mailing Address:
W3-aq7-ai641
Signature r' ` Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)W be Official Use Only
wm leted by Permitapplicant
1. Building . (a)Building Permit Fee
S /
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Pemdt Fee
4. Mechanical(HVAC) n ��
5. Fire Protection FT
6. Total=(1 +2+3+4+5) sV Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Buildrg CommissionerllnspoMx of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-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❑ Change of Use❑ Other iZI
BrW Description Enter a brief description here.
Of Proposed Work:
'/Y\, ice krckc,ws c
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A [I
AA ❑ A-5 ❑ 1B
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential In I R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ 6-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Nixed Use 0 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(at) / )o
in 1S$9 is
2"d 15--,l
/W 2�e
3" COS 3,e
4s'
4a
Total Area(sf) 2)-3 3L/ Total Proposed New Construction(sf)
Total Height(ft) 3c)
Total Height It
7.Water Supply(M.G.L.c.40,fi 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public El Private ❑ Zone C Outside Flood Zone Municipal K On site disposal system[]
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10.STRUCTURAL PEER REVIEW(760 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, i<LCF��E-'E✓1 \ �F-,W`-> /-1 ,as Owner of the subject property
hereby authorize / ' m v✓�/v�'� to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of owner Date
I, IAC CA F cP y—, ��Q1CL�`.��I ,as Owner/Authonzed
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.
' �ktkQceA 1`Iat2 �S�
Print Name
Signature of OvherlAgent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Constructions augervissoor: NotApplicable
Nome of License Holder: 70-/11 /✓Q.(V Al �S ,.—x/ 2V
License Number
ted Rom 8977 'M it( si 6h®.4-04- WW A. 19t /,p - B-aol9
Atltlrass Expiration Date
-/' -� d1 yrs-a�-616el
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,125C(6))
[Signed
Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
enial of the issuance of the b 'Iding permit.
Affidavit Attached Yes 0 No O
Version1.7 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
EViratian Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registaeon Number
Signature Telephone ErgiaWn Data
Name Area of Responsibllily
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registmb n Number
Signature Telephone Expiration Data
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Dale
9.3 General Contractor
/DIY/ ZD ps04 j',9W1 &e-J I` Nat Applicable ❑
Company Name:
Responsible in Charge a Construcgon
Po ,Dox. m7 -14&'jtlic hce �Yla llr0/�
Ad7Z j/�/�/
Signature Telephone
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
W4.,kers'Compensation Insurance Affidavit:Builders/Contmetom'Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Infrmatin Please Print Leeibl
Name(Buinmess/Organiwti-mlinl iduap: 'E?M Z)D/An7 1"'Polio{ &&jRArfeM_
Address: &e,1 'a97 04t�2relt Ag/d &W 0101z-
City/state/zip:
/b/ZCity/State/Zip: Phone M _-1_'7.- S/eI/
Are you as employert Chmk the appropriate box: Type of project(required):
II _employees(fullunNorpan-time)• 7. ❑New construction
3❑l am a sole Mimmir or pnmiership and have on employees oohing for me in g, ❑Remodeling
any rapecey[No xmk.'com,ma w restumed 1
3❑Iams heramenur doing ell work myself Mo woflrs'comp.i.re,umelf]t 9. ❑Dildin ion
4.❑ m I aa bommwrrer and will ho cod
hinng contractors to rouct all said,on my property Iwill 10[]Building addition
ensure Nat all comracmdseither have workm'wmpenmtion irrsmance mare sole 11.❑Electrical repairs or additions
proprietors with as employees.
12.❑Plumbing repairs or additions
s❑I an a general emmector and 1 hove hired the subcontractors latest on du anached shed. 13.�Roof repairs;
These subcmmcmrs have employees and have omilm.'comp.insurance t
6.❑We are a ompmmion and its oM..have exomeed their right of exemption per MGL c. 14.[—]Other
152,§I(4),andeie Idsve no employees(No wmkers'camp insurerdce requhcd.]
•Any applicant the clacks box a1 muat also fill out the sermon below showing their workns'rme,mornon policy informaion,
'Homeowners who submit this affidavit indicating they are doing all work ala then hire outside emotracmrs must submit a row andaut iodinating such.
:Contmetms the check this box must amcldN an additional sheet showing the more offle suh-cone ass and sure whether or not Nose entities have
emploYms. If Ne subcontractors have employes they mart provide their workers comp policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy andjob site
informaaom //
Insurance Company Name: �Jkem& / yr✓ L r J
i p
Policy#or Self-ins.Lic.#: Vl! S- 3/S 3&2/99- 037 Expiration Date:
Job Site Address: dGM -67 City/Srawzip:_J Y o 44' &106V
ro !4
Attach a copy of the workers'compensation policy declaration page(showing the policy number and . piration date).
Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerdfy under the pains and pen/dlfpedury that are information provided above is true and correct
Signatum 77 D [ '
phone#: ;(/-4— -7 f2 579W
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Per aittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Fown 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: 320 Ar-
The
rThe debris will be transported by: ib, ,DoA,t,,.,
The debris will be received by:
Building permit number.
Name of Permit Applicant ���)a.4f7t/
L� 41f — Lf -
Date S,i`gnnature of Permit Applicant
Version1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be fillod m by
Buddingneomvnem
Lot Size
Frontage 7
Setbacks From '-10
Side L: a0 R: o-10 L: R:
Rea ;t,
Building Height 30 1 q/
Bldg.Square Footage
Open Space Footage
(Lot°res minus bldg&pavM
#of Parkin Spaces 6 6
Fi11: 1
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT 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#
B. Does the site contain a brook, body of water or wetlands? NO 171 DONT 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 O , Date Issued:
C. Do any signs exist on the property? YES O NOVY
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. Wit the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is R part or a common plan
that will disturb over l arae? YES O NO
IF YES,then a Northampton Stora Water Management Permit tram the DPW is required.