17C-214 (32) •
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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 Q No C r.--
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ` a .fir - .. .,,. - 16 / 1 5 + 4 6 » e J? 6,,A1'4 , as Owner of the subject property
hereby authorize ra i / * / to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, e . _ .- , _ , _ __ .... _ ..- _ ., _ __..__ _ _ _ ... .. .. ..... . .' , 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 pen !ties of per ry. n nn _
Print Name
t
Signature o Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervisor: Not Applicable ❑
L
Name of License Holder : w. � -- 1 - 1 1 _ft , . 4. ell .
License Number
Address Expiration Date
Signature ut re 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 C3 No 0
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Version1.7 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
,/ � __.. �- i ._.....,..,..__w ._. ___..,, _. _.......__ ..,..... „.,,__ ____ w Not Applicable ❑
Company Name:
Responsible Charge
onsi le n
of Construction
/'I / .. 4)0r y!.X. !l %-d_._, ?___12/,r'.�. c .
V J Telephone
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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
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 ver been issued for /on the site?
NO Q DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 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 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 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 Q 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 corntllOrl pl8r
that will disturb over 1 acre? YES ( NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 0 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration Existing Ground Sign ❑ New Signs ❑ RoofingP�hange of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work: ......_.,� . � ,
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 0 S -2 ❑ 5B I ❑
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: ..,..._...._ ... ._....._... ...__... __r 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)
1 s
1st a _ .
2d _...
..._ ., rd
3rd 3
4th _. _
.... _.. . .._......... _.,....,._._ ., 4 m
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 Zone0 Municipal ❑ On site disposal system
Version l.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton atus �eoria
Building Department C CuflD P revvay Pert
212 Main Street Sewer /SepticAvaxlabiiity
Room 100
Northampton, MA 01060 Water/We f va ilabtl>t y
Two bets of il Structural.Pl
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
, „ /� ` .. -e Ile` --7-1, Map Lot Unit
�1ptrr GI /rr /r
Zone Overlay District
......_ ....._ _ ... .,,._ ... _... ___zw.„_. Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address: /
Signature ! �j � — Telephone 1/3 �'d ��/ z �y
2.2 Authorized Agent:
Name (Print) Current Mailing Address.
J
SIC _?.... /././.._i /0-, � /. .._,.. 1 _....,
Signature 9 / Telephone 9 3 ? 2 r `
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building C '$ � 1-5' � (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) / J y1, e _ c ) Check Number
This Section. For Official Use Only
Building Permit Number Date
Issued
Signature'
Date
Building Commissioner /Inspector of Buildings
..
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}
n ST t BP- 2010 -0378
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- 2010 -0378
Project # JS- 2010- 000502
Est. Cost: $4400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENT HICKS 066104
Lot Size(sq. ft.): 44474.76 Owner: FLORENCE FAMILY ENTERPRISES LLC
Zoning: GB(100)/ Applicant: KENT HICKS
AT: 99 MAIN ST
Applicant Address: Phone: Insurance:
P 0 BOX 119 (413) 238 -0122 0
WORTHINGTONMAO1098 ISSUED ON:10/6/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR ROOF
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 10/6/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
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Official Receipt for Rec: in:
Hampshire r.inty Registry of Deeds
33 King S.
Northampton, Massachusetts 01060
Issued To:
JERICHO HENDRICKS
45 CURTIS RD
WILLIAMSBURG MA 01096
Recording Fees
* *
Document Recording
Description Number Book/Page Amount \ r
DECIS 00014586 9534 44 $75.00
89-93 MAIN STREET LLC
$75.00
Collected Amounts JUL 2 - 2008
Payment r- •
Type Amount
Check 1004 $75,00
$75.00
Total Received : $75.00
Less Total Recordings: $75.00
Change Due •
8.00
Thank You
MARIANNE DONOHUE - Register of Deeds
By: Marilyn H
Receipt# Date Time
0192724 07/02/2008 09:52a
+�'
` rile # MP- 2008 -0065
APPLICANT /CONTACT PERSON HENDRICKS JERICHO
ADDRESS /PHONE 45 CURTIS RD (413) 296 -4354 O p
PROPERTY LOCATION 89 MAIN ST -'
MAP 17C PARCEL 213 OO tONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FO' 'ILLED OUT — ,
ee Paid — or '/
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA - TAKE OUT RESTAURANT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 Pei nit 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
c'
7/0/b
Signature of Building O' 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 the Office of
Planning & Development for more information.