18D-001 (2) File # BP- 2011 -0169 ,
APPLICANT /CONTACT PERSON JSP /LAND DEVELOPMENT SERVICES INC
ADDRESS/PHONE 181 NOTRE DAME ST WESTFIELD (413) 564 -0404 Q
PROPERTY LOCATION 188 NORTH KING ST
MAP 18D PARCEL 001 001 ZONE HB(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid Yf55 ~ '
Typeof Construction: NEW FACADE FA CA L E ON ,- :. .' _
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 54348
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
tO.. __.;
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.
Department ' Versionl.7 Commercial Building Permit May 15, 2000
use only
- City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
1 7 5 LC. \� \Room 100 Water/Well Availability_.
` \,\G Itortha pton, MA 01060 Two Sets of Structural Plans
phone 413- - 240 Fax 413 - 587 -1272 Plot/Site Plans
Other Spool
fy
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BU ILDING
�` OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
- -1 fk t-ube, * 1164 Map Lot Unit
188 1•102-rh ii NIG S'K6L f Zone Overlay District
r,/,c,M�GN; �A o� al�o vc .
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�L Rcib4 co 1ntC . � W- I3ao S'f , 1,,1AsFt.�cl��, 4/244"63----
Name (Print) C urrent Mailing Address:
/0 0 - y7/
Signature Telephone
2.2 Authorized Agent: Oe_vc,i tii,e/i.zirt
S?_;-P LAND
Name (Print) Current Mailing Address:
Signature 1/4/ C a Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
7.3
'S'D � �`� (a ) B Permit Fee
1 _ _
2. Electrical ( b) Est imated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
\ 6. Total =(1 +2 +3 +4 +5) \ 7S - r-c i °� Check Number
l god- �jr
This Section For Official Use On
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector 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 'R' Existing Ground Sign ® New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
'..)
Brief Description Enter a brief description here. N e.,1, Z<'VeriGr WI - 50,C\ - 1 - PA ^'F''1 Aiso S
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 -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 P 1 -3 • 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ Si - ❑ S -2 ❑ ❑
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 C - 4): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND • -
BUILDING AREA EXISTING " •POSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 1 St
2nd 2
3rd 3rd
4 th
4 th
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
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 L: • . _ L: , R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & ation)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW YES C
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO C 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 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,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 ciD
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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 El
Name (Registrant):
Registration Number
Addre
Expiration Date
Signature Telephone
9.2 Registered Pro • ssional Engineer(s):
Name Area of ' esponsibility
Address - egistration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Te -*hone Expiration Date
Name Area of Responsibility
Address - -gistration Number
Signature Telephone Expiration Sate
Name Area of Responsibilit
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
i I'S P t, 1 ---r Not Applicable ❑
Company Name:
je-Ci Paci\LN(1, /Mike. A nu4. 1:5
Responsible In Charge of Construction
I2 I.Ic F ri Pill' mi= t� ��f -eJd l �q Address
y 56 6vay
Signature Telephone
Version1.7 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
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, \ 1� 4+ 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 t pains nndenalties o perjury.
C I n1 ck
Print Name
liii C. jk,_ 6,1k.--,
Si nature of Owner /A ent opqiy,-,
9 9
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction
,( Superviso 1 r: Anne-A-6 Not Applicable ❑
( Name of License Holder • 1'" k e - CS 5 4/ s
License Number
2(( Ct ,' oRc -k A (. p1 t . m A of G� 6 2P11...
Address Expiration Date
//r�.. � A 1 113 - — aO
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 el No 0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
=;11,1!=-..7. = Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information �^ Please Print Legibly
Name (Business /Organization/Individual): J P Develcrert
Address: 101 k YQ L Dpmg s.
City /State /Zip: 1,& TT) C61 14/4 Phone #: I/3 ,L/ Del G4/
Are y an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ 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. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t employees. [No workers'
13. ther
comp. insurance required.] (Y /�/��/ r' ✓R7�4y/
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I 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 their workers' comp. policy information.
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 verification.
I do hereby certify under the p in and pe 'es of erjury that the information provided above is tr e and correct
Signature: 01 4( Date:
Phone #: 7 /"' 1 /0 /
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 #:
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Details: Paint Only
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FO Approval Signature:
Date:
♦ Store k Date:
`, 7325 Oak Ridge Hwy., Suite 200 • • 1164 07/06/10
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Knoxville, TN 37931 i ffy 1 u be Address Drawn by Sheet No
VISUAL PRODUCTS Phone 865 - 693 -2272 188 North King Street, Northampton, MA 01060 Allington 2