23A-080 (10) m
Zo IM
X a ; Version1.7 Commercial BUildiu= Permit May 15. 2000
Department use only
G) C ty of Northampton Status of Permit:
zzn ," u 1ding Department Curb Cut/Driveway Permit
m 0212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPl R, RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE IP114ORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) / Current Mailing Address.
4!3 ) 15'16 LA - 2c'tla
Signature Ar" CJ-/ Telephone
2.2 Authorized Agent:
%J ; 0; A r�1(,�rl3 ,�� _,>lz 5� SL�rh�„,�,►�>�, m�
Name(Print) Current Mailing Address:
V ' I
1-113) 310
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
4. rf"
2. Electrical (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 Commissioner/Inspector of Buildings Date
Version 1.7 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 El Change of Use❑ Other ]
Brief Description Enter a brief_d�escriription here. ni n
Of Proposed Work: R�Mz U� .7� f ,1(.f } Sc)CT �- )� k4r, r CST 1�U"/rj �b,
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 Q 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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)
1 1 st
2nd 2nd
3 d 3 T
4
4m ch
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 E] Private E] Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[]
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 ® 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 �� )r +� �`')Lj✓ Sc.,s ' >t r 1, L.L to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, W< l l_-`_:drc•. �1 I����:f 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 underthe pains and (penalties of perjury.
\ n
Print Name
Q
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
v
Name of License Holder: W . I 1 �_r,- /'v��� �7 ) I I qu U
License Number
zi:l ,�,.�1.� St• S�.,ZI� .r.,�F-.,.. m�1 . � r�?3 illt� �2ozo
Address Expiration Date
_,.J.ti:t n. ��� :SSI S -o`,3L,9
Signature Telephone
I -FSECTION 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 W 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: _, „� <,I-
The debris will be transported by: w,i ,, ,,,.,. i) . rJter
The debris will be received by:
Building permit number:
Name of Permit Applicant +�; j� i vl Ue
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Bu%lders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aoalicant Information Please Print Legibly
Name(Business/Organization/Individual): 0 , 1 1, -pq ���(,r t- L �.;,s ��.,,y r �J
Address: Z L., >> l. s t
City/State/Zip: nl n _ c i c 13 Phone #: 413)3q S--0'%U-1
Are you an 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.M I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8. 0 Remodeling
3.C]I am a homeowner doing all work myself LNo workers'comp.insurance required.]t 1• ❑Demolition
10 0 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.Q Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.L] p
Roof repairs
These sub-contractors have employees and have workers'comp.insurance.=
6.❑we are a corporation and its officers have exercised their right of exemption per MGL C. 14.[:]Other
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.
lam 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 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.
Ida hereby certify under the pains and penalties of perjure•that the information provided ahove is true and correct.
Signature: '1�k1� o,� �. Date:
Phone#: y (3) 3,4.1;
Official use only. Do not write in this area,to be completed by city or town offciaL
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#:
Name :
Number 4
Practice • • the numberfour.
a