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44-035 x '. )VEFIELD ST BP- 2010 -0460 : COMMONWEALTH OF MASSACHUSETTS Map:Bloc 44 - 035 CITY OF NORTHAM 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- 2010 -0460 Project # JS- 2010 - 000632 Est. Cost: $6000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD LABOMBARD 055340 Lot Size(sq. 111 36416.16 Owner: RAYMOND JACQUES L & DONNA B C/O RAYMOND REALTY TRUST Zoning_GI Applicant: RICHARD LABOMBARD AT: 1 LOVEFIELD ST Applicant Address: Phone: - Insurance: 119 Park St (413) 527 -7427 EASTHAMPTON MA01 027 ISSUED ON :1111212009 0:00:00 TO PERFORM THE FOLLOWING WORK.- REPLACE 10 X 6 DECK, STAIRS & SLIDER FOR 2ND FLR EGRESS 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: . 'nugh: 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 VIOLAT -LON OF ANY OF ITS RULES AND REGULATIONS. °' y Certificate of Occupancy Signature: FeeT_ype: Date Paid: Amount: Building 11/12/20090:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0460 APPLICANT; /CONTACT PERSON RICHARD LABOMBARD ADDRESS; PHONE 119 Park St EASTHAMPTON (413) 527 -7427 PROPERTY LOCATION 1 LOVEFIELD ST MAP 44 PARCEL 035 001 ZONE GI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeo Construction: REPLACE 10 X 6 DECK STAIRS & SLIDER FOR 2ND FLR EGRESS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Build Plans Included: Owner! Statement or License 055340 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved 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 Demolit Delay i 26c 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. �1MMA ANT MESSAE's FOR A.M. DATE TIME 40 P.M. M OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU if WILL CALL AGAIN - - �WANTS TO SEE YOU l RUSH � RETURNED YOUR CALL ! l SPECIAL 1kTTENTION MESSAGE t SIGN FORM 30025 MADE IN U.S.A. Version 1.7 Commercial Building Permit May 15, 2000 '= Department use a�ly , s City of Northampton Status af'I?ermtt r N° Building Department Curb Cut/Dr�siewayPermtt 212 Main Street Sdw"' i r'. epic varia6 y Room 100 'WaterN I Avatlabil' _Northampton, MA 01060 Two bets of atructuraC Pfarts; j $hone 413 -587 -1240 Fax 413 - 587 -1272 i?lot�sate Mans y APPLICATION.TOCC)NSTRU , EPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office 1Map Lot Unit 7 4f 1 V A,'� ,t/I Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record Name (Print) �" � .� r^ �Aev$� /�-) Current Mailing Address Signaturo Telephone 2.2 A hor' A ent: Name (Print) Current Mailing Address, Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building /_ D d d a (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 Sectlon ForOfficial Use Orel 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 El Repairs El Additions El Accessory Building El Exterior Alteration L Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description h ee� re. /� /P Of Proposed Work: r,�./V0Ic SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly El A -1 El A-2 ❑ A -3 El 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 ❑ 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 OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor (so _ 1 st 1 st _. ,.._ ... ... .. ... , ., 2 nd 2"q : _ ...... .. . ....... __..._....__ 3 ro 3rd_,__._ _.. _........, _ .... .......... _. 4 m 4 m Total Area (so 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 F1 Municipal ❑ On site disposal system Versionl.7 Commercial Building Permit May 15, 2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size _. _ . .... . ..._.. ... Frontage Setbacks Front _..,,.. __....: r Side L .._.__. _.. R: _,_ L ..M_...' R> Rear Building Height Bldg. Square Footage % Open Space Footage __. % (Lot area minus bldg &paved p arking) # of Parking Spaces Fill: (volume & Location) _ ._ _., .. ., „.. . . ....... __., A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was t permit recorded at the Registry of Deeds? NO 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 DONT KNOW C) YES 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 0 NO 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 cornMon plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 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: J 1 �� �".____..___._. Res In � r Constructi P Addre 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 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, !(AU? ��� /4 4 �� A O / ..,/ ��/tcs�:af.4� -- ?!?#4 � ti�S� `a's Owner of the subject property hereby authoriz �. _ _ ._. - Ito my behalf, in all matte elative to work authorized by this building permit application. V ignafllffe Ol 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 N Signature of Owner/AgOd Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Lice nsed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Add; e Expiration Date Signature Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L. c. 152, § 25C(S)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial -of theassuance of the - building- permit _ - ---- _ - - - -- -- -_-------------.____---- Signed Affidavit Attached Yes No 0 The Commonwealth of Massachusetts Department of Industrial Accidents ; _ � - Office of Investigations Wit- 600 Washin Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers Applicant Information , Please Print Leaibiv Name ( Business /Organization/Individual): �« Z *, , ;J ,_ d" ,11. 4 _ Address: zeoL C4wl City /State /Zip: Phone #: 5 d l l? �Z7 Are you an employer? Check the appropriate bog: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub - contractors 6. E] New construction 2. F I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.T 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. o workers com . right of exemption � ' per MGL P 12. ❑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. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. aContractors 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 Investi-ations_of the DLA _for insurance coverage _verification. I do hereby eerti r the sins and penalties of p jury that the information provided abov is true and correct. Signature: Datc. , Q 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 #: Ow saw. I t V i i i i d o i I f i i - �� r ICZ e Ilk 49 M �- cam. clr) L c) 7Z a � Ln :� x 1 � u U co co tU to Vol t" M O co a . 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