32A-126 (14) 11111111111 B P-2008-0596
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0596
Project# JS-2008-000925
Est.Cost: $7300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SOVEREIGN BUILDERS INC060176
Lot Size(sq.ft.): 14592.60 Owner: BANK OF WESTERN MASS
Zoning:CB Applicant: SOVEREIGN BUILDERS INC
AT: 43 KING ST
Applicant Address: Phone: Insurance:
135 SOUTHAMPTON RD Workers Compensation
WESTHAMPTONMA01027 ISSUED ON:1/4/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE PLANTER AREAS
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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/4/2008 0:00:00 $50.0013671
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
•
File#BP-2008-0596
APPLICANT/CONTACT PERSON SOVEREIGN BUILDERS INC
ADDRESS/PHONE 135 SOUTHAMPTON RD WESTHAMPTON
PROPERTY LOCATION 43 KING ST
MAP 32A PARCEL 126 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 2/ .
Fee Paid w 671
Typeof Construction: RENOVATE PLANTER AREAS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 060176
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
c /W. O8
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.
*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 Building.Permit May 15. 2000
�1" ``� Department use only
\v� \2 City of Northampton Status of Permit:
\' ,f Building Department Curb Cut/Driveway Permit
‘&161 212 Main Street Sewer/Septic Availability
2 rp Room 100 Water/Well Availability
Q�C Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
1.1 Property Address: This section to be completed by office
1/ I rl �� 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:
4113. g)- . - 7g70
Signature Telephone
2.2 Authorized Agent:
ToctclCelturci (Sorn guTitigs 13 _S f4 ( Is om"
Name(Print) Current Mailing Address: O/o, -7
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS 73 0a,o d
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
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number /3/7/ ,�
This Section For Official Use Only w
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector 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 0 Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief description here.rcv
Of Proposed Work: PnaJa f-f FI , pi..fri ,,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 0 1A ❑
A-4 0 A-5 ❑ .1 B 0
B Business ❑ 2A 0
E Educational ❑ 2B 0
F Factory ❑ F-1 0 F-2 ❑ 2C 0
H High Hazard 0 3A 0
I Institutional ❑ I-1 0 1-2 0 1-3 ❑ 3B 0
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage Cl S 1 ❑ S-2 ❑ 5B I 0
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)
15t
1s __w _ �.T _
.„ _, _._ „_ ._.. 2nd
2nd i
3`d ,
3rd _- ,_.....
4 i n „ :
4tn
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 0 Private ❑ Zone Outside Flood Zone❑ Municipal 0 On site disposal system
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: ___, _ R: . .. ... L:i R:
Rear
Building Height
Bldg. Square Footage % '"
Open Space Footage
(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 Q DONT KNOW (;a) YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES
IF YES: enter Book Page` and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO l's DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
. ......_ .... . ....._
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES NO Q
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 Q
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 Q NO •
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
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
6- \q 1
�ere I Jn _ .l- 1 e rS _ _._ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
S'01 A010} _. ._ .. . In sl 11G 7w, 4i
Address
(13 5 7& (
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 O
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 perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
-ToName of License Holder: `'. C u,( "f_._ _ =^._. __ �1 Go vi
Licens Number
Address
xpiration Date
6;. Nr,3 Sa 7 oL
gnature 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 ® No 0
The Commonwealth of Massachusetts '
Department of Industrial Accidents
"-�---, —„ Office of Investigations
-'-5J 600 Washington Street
Boston,M4 02111
www.mass.gov/dia
-Workers' Compensation Insurance affidavit: Builders/Contractors/EIectricians/Plumbers
ADolicant Information Please Print Legibly
Name (Business/Organization/Individual): cO 4 OIc l 5 le) 13 u N i e
Address: 1 C So v +1 a M t, ii j
City/State/Zip: Lif SI- ko ✓1i 1)1rni 194 010a) Phone#: Lit -3 c.)--1Foot
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).*
2.❑ I am a sole proprietor or partner-
have hired the sub-contractors 6. El New construction
listed on the attached sheet 7. ❑Remodeling
slop and have no employees
working for me in any capacity. These sub-contractors have S. ❑Demolition
employees and have workers'
comp.insurance.: 9. ❑Building addition
[No workers'corm.insurance
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp.
ins right of exemption per MGL 12.0Roof repairs
trance required.]t c. 152, §1(4),and we have no �n
' employees. [No workers' I''�" � '� �OQ�t�S
•
comp.insurance requited.) I
*Any applicant that checks box#1 must also fill out the soon below showing.their workers'corncorniri=sation 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'workets'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. f /
Insurance Company Name: t-p e Y 1(col j Girvi/•i,ll dY)Lj A ( C(,c)t I�' C ,
Policy#or Self-ins.Lic.#: W C, `74 1.71 3 Expiration Date:- I G;'*(JS
Job Site Adriress: 1.3 6 Sot,*l'1ri AiLytLn (,(i City/State/Zip:.bUp5 ljyfelk1, M4- Uf.0 27
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 criminsl penalties of a
fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby certify un le pain penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#: - -
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#:
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