24C-174 APPLICATION ON HOLD RECEIVED ---) 41,
DEC - 2 2020 I
` The Commonwealth of Massachusetts
'TF gun oiN�,INSPECTION$ Office of Public Safety and Inspections
• "�. THAkir-r 1N.AAA 0106o
FAQ; tt Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Nimber '-RI"416 V ate Applied: Building Official:
SECTION 1:LOCATION
O'ill wins+ API d(d6d
No.and Street City/Town Zip Code Name of Building(if applicable)
a4fC,- 1 -pi
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building 0 Repair a Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes t No 0
Is an Independent Structural Engineering Peer Rev' w requir ? Yes 0 No l
Brief Description of Proposed Work:Q'el`of /1 rcetev, Dec
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub ❑ A-3 0 A-0 A-5 0 B: Business 0 E: Educational ❑
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 ❑ H-4❑ H-5 0
I: Institutional I-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ LIB ❑ ILIA ❑ LIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disp sal Site❑
Public IQ Check if outside Flood Zone p Indicate municipal l� S
Private 0 or indentify Zone: or on site system 0 required or trench or specify:
permit is enclosed 0 ihriti
Railroad right-of-way: Hazards to Air Navigation: i4A Historic Commission Review Process:
Not Applicable 111Z. Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No'N Yes 0 No in
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): T s .
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assemb pace:
fit' Iva 41 6'
L -,, t t d. 12121
City of Northampton
•=� � Massachusetts ;
t
i .. DEPARTMENT OF BUILDING INSPECTIONS
`` 212 Main Street • Municipal Building
• Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized
agent.
2. One set of plans and specifications of proposed work(Digital & Hard copy). •
3. Site Plan with location of proposed structure(s) and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11. Trench Permit(if applicable).
12.Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible,charge.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes: ^ ' `��
1,uV Qce,,J,�/ 1�'(1 `vow 114il IV WQ tti iiii4013
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
CACI 9041 %,/ItkilS 4 G
Company N e
Lu e. � GC- 1 63gyS' — U
Name of Person Resspchesible for Construction License No. and Type if Applicable
‘ 11 tAkk V II\ Q4a IA WOO M o►S
Street Address City/Town 1 State Zip
Telephone No.(business) Telephone No.(cell) e-mail addres
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Ls a signed Affidavit submitted with this application? Yes pi No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $
-4-'t tC,10 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$ .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ 111:1 (contact municipality)
5.Mechanical (Other) $ Enclose check payable to /,
6.Total Cost $ �-, d T (contact municipality)and write check number here .- D L '/05
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,!hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurat o the best of my knowledge and understanding.
✓v ct bOdt/ 4, 91? ITV- 1� d
Please print an"""d��'s4- na Ai Tel'ephoope_No. �f Date
•‘ 1---4 W TAllik 11 01 5 ri OW I 0,41A ‘Iil
Street Address City/Town State Zip Email Address i
Municipal Inspector to fill out this section upon application approval: 7Z i Z"Z"2026
Name Date
w
CITY OF NORTHAMPTON
SE 1'BACK PLAN
MAP:_ LOT:
LOT SIZE:
REAR LOT DIMENSION
KEARYARD
SIDE YARD SIDE YARD
FRONT:EIBAC6
FRONTAGE
mDICATE LOCATION AND DI ME NSJ ONS OF 11 OLE E.GARAGE,ADDITIONS OR ACCESSORY BUILDING. lIE
SURE TO INCLUDE FRONTAGE AND LOT SIZE(SQUARE FEET OR ACRIZS)
4.
0
t:4 The City of Northamp ton
g' `` Building Department
:_ ,'� 212 Main Street
aRgp JO{16���`1 Northampton, Massachusetts 01060
Phone (4I3) 587-1240
Fax (413) 587-1272
•
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVAT ION PROJECTS)
In accordance with the provisions of MGL c40, s54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility as defined by MGL c 111, s150A.
The debris will be disposed of in: Qt\ dct- %44.1"or
Location of Facility AtAGty OA
The debris will be transported by:
Name of HaulerA-AWWI1 O .I 4
Signature of Applicant: A., Date: `a1t)L'-. 6
The Commonwealth of Massachusetts
Department of Industrial Accidents
F =�
—�!+I= > 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.ntass.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/Individuall):Q' t is L i (. — L. Ke D c i
Address: �S'• lyOtt 4,4 foJ "�+�
City/State/Zip:\ tat AA4 01 Phone#: 91T a- goi
Are you an employer?Check the appropriate box: Type of project(required):
LE]I am a employer with employees(full and/or part-time).* 7. New construction
2.J I am a sole proprietor or partnership and have no employees working far me in 8. Remodeling
ny capacity.[No workers'camp.insurance required.]
3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]r
9. Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10�]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 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.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14•❑Other
152,§l(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:
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.
I do hereby certi",under the pains and penalties of perjury that the information provided above is true and correct.
Signature: L�/Date: c k
Phone#: L\\3 — q 418
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#:
0
Initial Construction Control Document
11
To be submitted with the building permit application by a
Registered Design Professional
• for work per the ninth edition of the
S° °y Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date:
Property Address:
Project: Check(x) one or both as applicable: New construction Existing Construction
Project description:
I MA Registration Number: Expiration date: ,am a registered design professional,and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerningl:
Architectural Structural Mechanical
Fire Protection Electrical Other
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee) shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the
progress and quality of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
•
Enter in the space to the right a"wet" or
electronic signature and seal:
Phone number: Email:
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an'x' project design plans,computations and specifications that you prepared or directly supervised.If'other' is
chosen,provide a description.
Version 01 01 2018
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 ArciitecturaI
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 1 EIectrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications •
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
1S Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
'Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Name(Registrant) Tel-ephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
-
Name(Registrant) Tel-ephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Tel-ephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
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