22B-040 (21) Versionl.7 Commercial Building Permit May 15, 2000
HE1 f Department use only
'l VED
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
APR 1 4 2020 212 Main Street Sewer/Septic Availability
( i ROOM 100 Water/Well Availability
_..(Jlorthampton, MA 01060 Two Sets of Structural Plans
DEPT.OF GUILDlNGu{�;�:,�,.;��
yNORT. AMP,(*$tj }•,4}rp4"133-587-1240 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 DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
51-' 5,.� t e D Map �a > Lot 0 q(1 Unit
I rL o �cr Ct l /"i.0 U Zone Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
F/1o✓� R,I yol(t..,.t4AN.4 6&MCAll Ti.I tl
Name(Print) Current Mailing Address:
FL0ienCc f ��U6
Signature Telephone
2.2 Authorized Agent:
e S /11.4 t ZZ i ?/a 0
Name(Print) Current Mailing Address:
l%v/cn(c/
Signature Telephone
SECTION 3 -E6114ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee L 3
4. Mechanical (HVAC) "f
5. Fire Protection
6. Total = 0 +2 + 3+4 + 5) Check Number
his Section For Official Use Only
Building Permit Numberton.� Cal� / Date
�/ Issued
Signature:
Building Commissioner/Inspector of Buildings Date
0
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 ❑
Brief Description Enter a brief description here.
Of Proposed Work: -sem r 1 6 O
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
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 ❑ 513 ❑
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)
1 Sc
1 St
2nd i 2nd
3rd
3rd L
4th
4�h
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 ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONi&iT]
Existing Proposed Required by Zoning
This column to be filled in by
7 Building Department
Lot Size �---• �-
Frontage
Setbacks Front
Side L:= R:= L:= R:=
Rear _7
Building Height
Bldg. Square Footage F, % l�
Open Space Footage % u
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW 0 YES 0
IF YES: enter Book17777 '1
Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 O NO 0
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. Will the construction activity disturb (clearing,grading, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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):
71 71
�.
Name Area of Responsibility
Address Registration Number
71
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date i
i
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
I"1 Ef_ 141A I LL qL-t Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
585_ �sg�
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR AP ES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize v��r�� /44,0) to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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. SA 1cS AIA ILC-oux � CSL g�19 4
License Number
env Se_ 5�,_ _Irz e MA
� r
Address Expiration ate
Signature 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 O No 0
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: ZZ 1 q'"e 5� "5'—A° W
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
d I Congress Street, Suite 100
Boston,MA 02114-2017
s•W� www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ;ZYA
Address:
City/State/Zip: 4 fe Phone#: S 1 ,SS�
Are yo n employer?Check the appropriate box: Type of project(required):
1. I am a employer with?_employees(full and/or part-time).* 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs Or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.;
14.❑Other
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 name 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ^ l" c Nay l
O rpn�Q�
Policy#or Self-ins. Lic.#: U)C '�C171 Q Expiration Date: 2�
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 MGL c. 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 cerd u r t i an penalties of perjury that the information provided above is tr ie and correct.
Signature: /, Date: y
Phone#: ` )� �� 1 ss�
Official 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.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
A�� J Freight
1 St 11F/ Elevator
FloorISD �
1
�6d ate•
i
165 159
i
130
150
155
140
120 WDM
141 145
116 136
112 ., . .. ��
115
Ua
108 E
7 DQ
106 r West Entrance
104 102 100
PINE STREET
1 sT FLOOR STUDIOS
100 BrushWorks
120 Patrick's Art House/Patrick Foley
102 Writer's Ink/S.G.Tyler 130
104 America Garcia/Alex Evora 141 Feeding Tube Records
106 Margaret Arraj/Mill River Rugs 143 R-Kade Games/Richard Kalin
107 145 Rising Tide
108 Jo-Anna Ross + 150 i�,•
112 Contact Quarterly 155
115 Kate Jenkins/Jahnava's Oriental dgF, M Salmon Studios
116 Herzenberg Designs a *160 Pioneer Heating and Cooling
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