23D-052 63 RIVERSIDE DR BP- 2011 -0326
GIs #: COMMONWEALTH OF MASSACHUSETTS
' v1� p Df c k::23D— 052 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- 2011 -0326
Protect # JS- 2011- 000534
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM MAZUCH 010936
Lot Size(sq. ft.): 10410.84 Owner: AMERICAN LEGION POST #28 HOME INC
Zoning: URB(100)/ Applicant: WILLIAM MAZUCH
AT: 63 RIVERSIDE DR
Applicant Address: Phone: Insurance:
69 OLD STAGE RD (413) 247 - 32420
WEST HATFIELDMA01088 ISSUED ON :101812010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 Sisnature:
FeeType: Date Paid: Amount:
Building 10/8/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Versionl.7 Commercial Building Permit May 15, 2000
Deparlmenfi use only
City of Northampton statics of Per u
Bu�lding Department Curi_,,Cut/Drtyeway Perritit
. N �.
2112 Main Street SewerlSepttAyarlabrlity
Room 100 eII f( aila"bitit
OCT
- 8 2010 No rth� rnpton, MA 01060 Twa,Sets of StructuraE Plans
phone 413-587-h240 Fax 413- 587 -1272 PiotlSrte 'laris
APPLICATION TO CONS 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
'l .
Map Lot Unit
Zone Overlay District
... ... -r_ - ... _ .. ,. Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
A J�1.�
Name (Print) Current Mailing Address
' r
Signature = e( - Telephone J —
2.2 Authorized Agent:
Name (Print) Current Mailing Address
Al
S ign a ture Telephone / ,
SECTION 3 - ESTIMATED CONSTPOCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit 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
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building CommissionerlInspector 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 ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enterh brief description here.
Of Proposed Work: -
�" f
SECTION 5 - USE GROUP AND CONSTRU ION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business E9 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
�_ .. — w.. -
M Mixed Use ❑ Specify:
S Special Use El Specify:
COMPLETE THIS SECTION IF EXISTING`' BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _ _.....,._. ___ Proposed Use Group _ _._._ ____ .... ........ . w_..._._ _ -_, ._.....
Existing Hazard Index 780 CMR 34) _ _ ___ .. _ - -. Proposed Hazard Index 780 CMR
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
i
__ 1 st
St
2 nd
2
3 rd
rd
3
_._...__._... _... 4m
4
Total Area (sf) Total Proposed New Construction �sf)
Total Height (ft) w,._..._,._..__. _.._.
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 E] Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONIKG7
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage _ .... ._ ................. _. ,
Setbacks Front
Side L. _...,_ _, R: ',_.,_,.. _ U L... ....... i R
Rear
Building Height
Bldg. Square Footage _. %
Open Space Footage __ %
(Lot area minus bldg & paved „....._ ,.oti.
p arking)
# of Parking Spaces
Fill:
(volume & Location) _ ._..__:.. „_. ..., _ ... ... _ ..:.._,. ,. _.,,...-. "_
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT 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 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES I 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.
Version l.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):
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
Not Applicable ❑
Company Name:
Respo'gsible In Charge of Construction
-��
..... .._ ._.
Address �.
Signature Telephone
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED_ WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
9
hereby authorize
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 penury p ,_
;,7W
Prin Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder . . .....
License Number
Addre Expiration Date
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(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 0 No 0
Y
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
m Boston, MA 02111
..- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Leaibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
F? _1 . re you an employer? Check the appropriate box: Type of project (required):
❑ I am a employer with 4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part- time).* have hired the sub - contractors ❑
2.V I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10. E] 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. right of exemption per MGL 12.7 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage v e rifi cati o n.
I do hereby ce tify under the pains and penalties of perjury that the information provided above is true and correct.
Sienatur Date: M —
Phone #:
Of 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 #: