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37-018 (10) 722 FLORENCE RD,BIBLE BAPTIST CHURCH BP-2019-1295 G154: COMMONWEALTH OF MASSACHUSETTS Mao:Block:37-018 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Cateeory� ROOF BUILDING PERMIT ermit9 BP-2019-1295 Proiect4 JS-2019-002092 Est.Cost $4000.00 Fee;$100.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Groum ALEX KOMLEV 103055 Lot Size(su,@.): 432550.80 Owner: BIBLE BAPTIST CFtURCH THE zoninn, Applicant. ALEX KOMLEV AT. 722 FLORENCE RD - BIBLE BAPTIST CHURCH Applicant Address: Phone: Insurance: 710 FLORENCE RD FLORENCEMA01062 ISSUED ON:3/17/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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: T jr ,mpm FireplacdChimney: Rough: 9141 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 OccuD ncy Signature: FgeTvee: Date Paid: ,Amount: Building 5/17/20190:00:00 $100.00 212 Main Street,Phone(413)587.1240,Fax:(413)587.1272 Louis Hasbrouck Building Commissioner _ Versionl.7 Commercial Building Permit May 15,2000 i ) LCEIVED m°'�°°" -- C of Northampton Status pt Perms Iil; B ilding Department Curb CuvDrvawaypennrt 212 Main Street SewerlSep$c AVailebdity MAY 1 5 2019 Room 100 Watedi AVallsbillty No hampton, MA 01060 Two Sots of Structural File;;7- c ruID,N:r.I 13- 87-1240 Fax413-587-1272 Plot/Site Plans n�.nerlah rn moso Other Speciry 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 P- ►�� a-a 5 This section to be completed by otfiee 1.1 Property Address: 710 Florence ,Q O Map 3 7 Lot Q / Unit F)orenc! 1' 7'i D/©(L Zone Overlay District l'ia- ---- --- --' EIm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 6,6 e gF�{Sf car-.rs�t f7v,,nec '�Q�.r,a, t c�« Name(Print) Current Mailing Address: > (1//3) 38G_ X17 -3 Signature ��� Telephone 22 Authorized Ap nt: Name(Punt) Cune Mailing�Address `1i 3) 3Se-'- 117311 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permitapplicant 1. Building � ��/J (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing - -- -- Building Permit Fee r�T) 4. Mechanical(HVAC) 5. Fire Protection Y 6. Total=(1 +2+3+4+5) Check Number P- This Section For Official Use Onl Building PermitjNumbe Date Issued Signature: 5- 1�- 201q Building nhimf Buildings Date r Version 1.7 Commercial Building Permit May 15,2000 SECTION M 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 El Rooflni Change of Use[I Other Brief Description Enter a brief description here. Of Proposed Work: �'e�/tic� 7(' P 5{�,✓l CS GN tV� �2L7 ���. G J�r.�/C SECTION 5.USE GROUP AND CONSTRUCTION TYPE ✓✓✓ USE GROUP(Check as applicable) CONSTRUCTION TYPE A AssemblyE] A-1 ❑ - A-2 ElA-3 El 1A ❑ A-4 ❑ A-5 ❑ IS ❑ 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 ❑ 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(sf) I. 2nd 2" 3 e 3m Total Area lid) Total Proposed New Construction (sf). Total Height(ft) Total Height it 7.Water Supply(M.G.L.e.40,§54) 7.7 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone Outside Flood Zane❑ Municipal ❑ On site disposal system❑ e Version L7 Commercial Building Permit May 15,2000 8. NORTRAMFFON TONING Existing Proposed Required by Zoning lLis column m be filled in by Building Depamnent Lot Size __ .._._ ......._-.__. Frontage — -- Setbacks Front Side L. R L: R: _.._.._. Rear _......... Building Height Bldg. Square Footage ' " °/o Open Space Footage (I.ot arca minus bldg&pavedpori R of Parking Spaces Fill: -.__ .... vulame&Location) -- "--' A. Has a Sp ial Permit/Variance/Finding ever been issued for/on the site? NO (F DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0.... ,.. IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 0 NO 0 IF YES, describe size, type and location: E. Wil the construction activity disturb(clearing, goading,exc ion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES C NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versiori Commercial Building Permit May IS,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 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 Z/t co"5jr'C)•9N Not Applicable ❑ Company /Name, )) )) ey vt Responsible In Charge of Construction 7/.9 'e ID Address W3 331,X73 azure Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 LMR 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 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 Lice nsed Construct on Supervisor: Not Applicable ❑ Name of License Holtler: 9MA lii 19 30 55 License Number 7Z�2 F/91-e-ce _ Z'D 1213011-20 Add Expiration Date €� P 9735 Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§ZSC(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 buil 'ng permit. Signed Affidavit Attached Yes No O 4 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 byMGL c 111, S 150A. Address of the work: 7�-0 F�� I°.�ce f-D The debris will be transported by. /V 50,1 I/ The debris will be received by: d-d And 59p/ Building permit number: Name of Permit Applicant Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-20-20177 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I' l / Please Print Le ihl Name (Business/Organizatiomindividuap: /L hLO/I S Yr_LTO4 Address: TO / hreHC 2 n /D F/01-Ice /1/P City/State/Zip: 0* Z Phone #: 1// 3 G 7 7 3� Are you m employer Check the appropriate box: Type of project(required): 1.❑l am a employer with emplowes(full and or part-tbve)." 7. ❑New constmction 1a sde proprimor or partnership and have no employees working for me in g. ❑Remodeling any capacity.(No workers ramp.iasutance required.] 9. 3.�I am a homeowner doing all work myself.[No workers'emer,insurance requrall 1 10 Demolition 4.❑1 am a homeowner amat ng contractors to conduct au work on myproperty will ld will be hiring Building addition re sole en e mall conmm acrseimdm either here wna'cominsurance or are sale ll.❑Electrical repairs or additions praprichors with no employees. 12.❑Plumbing repairs or additions 5.rl I am a general contactor ane l have hired the sub contractors listed on no attached sheet 13.E]Roof repairs These sub-contractors have employees=it have worken'camp.insurance. &M We are a corporation and its Officers have exemieed tbeir right of exemption MGL c. 14.❑Othe[ rpom g prion per 153,�I0J,and we have voemployees-[No workerscomp-imuranoerequimd] <my applicant that checks box#1 mast also fill out the section below showing thou workers compensation policy information. 'I Imnawress who submit this affidavit indicating they are doing ail work and Nen hire outside contractors most submit a new affidavit indicating such, tCommmnn that check this box must attached an additional sheet showing the time niche sub-convactors and state whether or not those entities have employees. time sub-conthema have employees,they must provide their worken'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: Policy#or Self-ins.Lic.#: Expiration Date: Job 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 MOL c 152,g25A 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify it th 'is and penol9es of pepu that the information provided above is true and correct. i S' t ��"i/ �- Dale' Ph #: liz/'5 86 x/73 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitfLicenae# Issuing Authority(circle one): J.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t 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 ofthe foregoing engaged in ajoitn enterprise,and including the legal representatives of a deceased employer,or the receives 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 bean employer." MGL chapter 152, $25C(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 ofthis 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 sub-contractor(s)camels),address(es)and phone numbers)along with their certificates)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. If an 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 resumed 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 most submit multiple pennir'license applications in arty given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Deparunent of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.naass.gov,rdia From: /yn�///�(�jy�'S '/,1 1 // /` lam _ �rc-.0 C2 -711 1-7o-e-,66- To: -79rcnC a To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at because the work is of a minor nature,will not affect structural elements, health,accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully,