31B-264 CITY OF NORTHAMPTON
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: -�
The debris will be transported by:
The debris will be received at:
Signature o Pe it Applicant
Date
Building Permit Number:
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations ,
f Y -
600 Washin Street
T = Boston, MA 02111
"? www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): _
Address:
City /State /Zip: Phone #:
F lAre you an employer? Check the appropriate box: Type of project (required):
. ❑ I am a employ er with 4. ❑ I am a general contractor and I
P Y 6. ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
2.0 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 ci employees and have workers'
g for me in any capacity. tY� 9. F Building addition
[No workers' comp. insurance comp. insurance.$ - -
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers r I L have exercised their Plumbing repairs or additions
�. ❑ I am a homeowner doing all work ❑
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
_ 13. - ]Other
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 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 verificatio
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone #:
Of use onll'. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Versionl.7 Commercial Building Permit May 15, 2000
J
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) 7
Y
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 OWNER AUTHORIZATION - TOBE COMPLETED WHEN!
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ---------- as Owner of the subject property
hereby authorize �A _v. -_- - w _,_r. _. to
J
act on a f, in all matters r lativ to work authorized by this building permit application.
Signature of Owner Datem
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 Jdtei�nqs�and nalties of_er.......
Print Obme _
U
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION. SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder w_.. ...__
License Number
Address Expiration Date
Signature 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 0 No 0
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):
_._ .
Registratio N umber
._. T _ 3 `�1
A?ddr:�
mm ` Expiration bate
ur Telephone
9.2 istered Professional Engineer(s):
Name Area of Responsibility
........ .... . _ -_.._. _ __.� a, w ,- ____..... __.._.... _._.___.
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address R29istration Number w
Signature Telephone Expiration Date
Name Area of Respons
Address Registration Number
...... _... ... ..__._. ......... ....
Signature Telephone Expiration Date
Name Area of Responsibilit
Address Registration Number
i
Signature Telephone I Expiration Date
9.3 General Contractor
........._....... _.,._._,.. . ........_..___._ _ M Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
t
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning .
This column tbre filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L : L--- R.
Rear
Building Height
Bldg. Square Footage
Open Space Footage % _ `r
(Lot area minus bldg & paved i
# of Parking Spaces
Fill:
r
(volume & Location)
A. Has a Special Permit /Variance /, , Pinding ever'�een issued for /on the site?
NO 0 �DONT KN/ ` YES
IF,YES, date issued:�
IF YES: Was the permit recorded at the Registry of Duds?
NO 0 DO KNOW `YES\Cnservation
IF YES: enter Book' Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from Commission?
Needs to be obtained Obtained Date Issued
C. Do any signs exist on the property? YES 0 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 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 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition El Additions ❑ Accessory Building
Exterior Alteration E Existing Ground Sign [I New Signs � Roofing ❑ Change of Us ❑ O ther ❑
Brief Description 'Enter a brief dj s tion e
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TY E
USE GROUP (Check ap licable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ -2 ❑ A -3 ❑ 1A ❑
A--4 ❑ A -5 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ I F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ - 3A ❑
Institutional El I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 1 4 ❑
R Residential ❑ I R -1 ❑ R -2 R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 513
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDER GOING :RENOVATIONS, AD DITIONS 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)
z
1 1
st
5c
2nd „_.....» _.._, _ 2 nd ;
3rd 3ro
4 n 4m-
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 ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15, 2000
� r `* � +�a. fi r.• � �l D�I}artt'Cle t USE�,Qf11�1��7' � �a�
City of Northampton���
Building Departmentrrli f1Dtreway eri �� -
212 Main Street 5`eW2�icAatlbtlltj sa � , w'« r��'' ,` '
Room 100 WatetlRf�IA ��"-� fi 4� ka
Northampton, MA 01060�ts�tr��t
phone 413- 587 -1240 Fax 413 - 587- 1272 IQflte Pa
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE O OC UPANCY OF, OR DEM LIS ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY W LI
SECTION 1 - SITE INFORMATION
hr by ffice
1.1 Property Address
d
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
Signature c._ Telephone
2.2 Authorized Agent:
Name (Print) Current Maili Address
Signa re T elephone
SECTION - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building Jva� (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from - 6' _..,... _.__._..__ ..._...... _
3. Plumbing Build Permit 'Fee
4. Mechanical (HVAC)
5. Fire Protection
1 42 4
_ . �.. .
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building Commissionerllnspectorof Buildings Date
File # BP- 2012 -0417
APPLICANT /CONTACT PERSON SALLOOM ROGER & SIMON
ADDRESS/PHONE 83 POMEROY TERR NORTHAMPTON (413) 584 -6324 Q
PROPERTY LOCATION 4 CENTER CT
MAP 31B PARCEL 264 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T_ypeof Construction: INTERIOR DEMO
New Construction
Non Structural interior renovations
Addition to Existinp-
Accessory Structure
Building Plans Included•
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9XMATION 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
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.
4 CENTER CT BP-2012-0417
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 31B - 264 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -0417
Project # JS- 2012 - 000662
Est. Cost: $3000.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TRISTAM W METCALFE
Lot Size(sg. ft.): 4399.56 Owner: SALLOOM ROGER & SIMON
Zoning: CB(100)/ Applicant SALLOOM ROGER & SIMON
AT. 4 CENTER CT
Applicant Address: Phone: Insurance:
83 POMEROY TERR (413) 584 -6324 ()
NORTHAMPTONMA01060 ISSUED ON. 10/25/2011 0:00:00
TO PERFORM THE FOLLOWING WORK I NTERIOR DEMO
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 10/25/20110:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
ID,��