18D-040 (4) •
• Massachusetts - Department of Public Safet■
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 74975
Restricted to: 00
STEVEN RIBEIRO
20 RICHARD CIRCLE
SEEKONK, MA 02771
Expiration: 7/6/2011
( misioner Tr#: 20228
•
.. .
t- The Commonwealth of Massachusetts
�'r Department of Industrial Accidents
y la t ' "
I r - , Office of Investigations • • -
i =.: 600 Washington Street
Boston, MA 02111
- =� www mass gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information j Please Print Legibly
Name ( Business / Organization /Individual): Heine kW/ igtsf/�t� i
?
' i71� .
Address: 4 11S s /,ee _c je,
City/State/Zip: A4// Pi 4490c277/ Phone #: .SDS C 77- O({0/
Are ou an employer? Check the appropriate box: Type of project (required):
1. [ am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
listed on the attached sheet. _ 7: lIRemodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working or me in any capacity. employees and have workers'
g Y P n' # 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions
3. ❑ I am a homeowker doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 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.
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 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: )44/ %form . ,_
Policy # or Self -ins. Lic. #: • Oct W /37 3 9 3 3 Expiration Date: / ? )– 09
Job Site Address: 3 7.S k// 7C .c .-- t -- City /State /Zip: NorTJ/ m7an
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 pains and . enalties of perjury that the information provided above is true and correct
Sil nature: AO ✓ , L_ !, ,r Date: • 7- " 30 ✓OD —
Phone . #: ' )O 6 7 7- 0 V/ .
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
b. Other
Contact Person: • Phone #:
The Commonwealth of Massachusetts
D epartment of Industrial Accidents
_ — Office of Investigations
N ' =` 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly_
Nanne ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. El I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
listed on the attached sheet. 7. ❑ Remodeling
2. El I am a sole proprietor or partner-
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.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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 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
hnvestigations_oftheD1Afor insurance coverage verification.___ -
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Dutc.
Phone #:
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 #:
rib.
r
y 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 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , «1r1.S1e _ _ SA i? 0 i W/ __ , as Owner of the subject property
y P,Q N NA to
hereby authorize � (it _��• ������ 1 .._
act on my behalf, in at matters relative to work authorized by this building permit application
S' atu z W ' 1 lU�� .
' b� Ye
i,
7 _- 11 -,�!!� .. .„ .,,.„ , 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 Name
Sign ure of Owne gent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ! � e' f
1� �e _ r ,. �1 F , ci s_. __ - -- . -
, License Number
17( ((4ill7 0 C(( ?<L t ..__. _....„ .._._.__,.._._. 7 ., __.. ...._ .
Address Expiration Date
Ep .. en ..
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
•
Apr
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
C/0lr(L ,9,✓e) mm �(JIG ._. Not Applicable ❑
Company Name:
57 .,.,,, 47(/36- 1/ ._........
Responsible In Charge of
Construction
Rt 0 C l?GC ( , .. , � Vie' 1 i4...._.. _ 0471 ! ....'
Address
3 4661
Signature Telephone
M �
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..__._ . _.. R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location) m ...., .. _ ..., _......
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW do 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 cp
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 110 NO 0
IF YES, describe size, type and location: t0m/6 5 (C'N 3)(2 AA)0 rifted
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 comiilerl pl8n
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
of -,
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 Enter a brief description here. k�t4(( an/A/7(`zs , !''t` F e ((c
Of Proposed Work: / ?f(,, /� tt/g/(s 12(4. in (47 6 g 1 ot - ,„
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
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 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify: . ,o. -- — .
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): . .......... __.....__ ,__..._r... 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)
1st 3 .z. 1st
2 nd
2
'
3rd 3rd
4 th
4th
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❑
10 4
Version1.7Commercial Building Permit May15,200
Dep artment use,onlY
, -
City of Northampton
Building Department turb:Cut/Dnve\ivay
212 Main Street Sewe;lSeOtie"Airatiabil(t
Room 100 Availability
Northampton, MA 01060 1 Plens
Two Seta of Structure
phone 413 Fax 413 Plot/Si P
Pther fy
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE L OR D O W C E C L U L P I A NG NCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
3 :IC /c/1//6 s'Y- Map /IP Lot L I - C) Unit
Zone Overlay District
0 OCC
c.1 1 ft(4 . Elm St. District
CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
J
/0/ i
t / ( ( ./19/7 e7.
4 M) ''11€) 5:41.7'.°/:(' (114/d
Name (Print) Current Mailing Address:
r 0,7
Signature , . Telephone 4' f_ 0- #6 94416
2.2 Auth° () gent
c
Name (Print) Current Mailing Address:
- d
Signature . , Telephone 4/ - 5ZA6 94'76
SECTION 3 - ESTIM • TED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use OnIy
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
if 000 Construction from (6)
3. Plumbing — -6 - Building Permit Fee
"(GU Ot Ci` 601 L D.
4. Mechanical (HVAC)
5. Fire Protection
6. Tota?)= (11+2+3/4+5) - Check Number 13() c* ate
/14 Thin Section For Official Use Only
Building Permit Ndti Date
Issued
Signature
Building Commissioner/Inspector of Buildings Date
•
File # BP- 2010 -0352
APPLICANT /CONTACT PERSON STEVEN RIBEIRO
ADDRESS /PHONE 465 SYKES RD FALL RIVER (508) 677 -0401
PROPERTY LOCATION 375 KING ST
MAP 18D PARCEL 040 001 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 i �/ � � 6
Fee Paid `
�
Typeof Construction: REPLACE COUNTERS,FLQI R TILES,REFINISH WALLS & RELOCATE BACK BAR -
DUNKIN DONUTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074975
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
p proved 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 Officia 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.
a
4.
. BP- 2010 -0352
GIS #: COMMONWEALTH OF MASSACHUSETTS
ROO CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate _gory: BUILDING PERMIT
Permit # BP- 2010 -0352
Project # JS- 2010 - 000473
Est. Cost: $44000.00
Fee: $264.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN RIBEIRO 074975
Lot Size(sq. ft.): 42209.64 Owner: Pride Convenience Inc
Zoning: HB(100) //WP Applicant: STEVEN RIBEIRO
AT: 375 KING ST
Applicant Address: Phone: Insurance:
465 SYKES RD (508) 677 -0401 WC
FALL RIVERMA02720 ISSUED ON:10/6/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE COUNTERS,FLOOR TILES,REFINISH
WALLS & RELOCATE BACK BAR - DUNKIN DONUTS
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 $264.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
' U.S. Postal Service,-.
CERTIFIED MAILTM ECEIPT
O (Domestic Mail Only; No lemur: , ,,overage Provided)
u For delivery information visit o .usps,come
ru P ostage $ 4 0 4 .
Ar
Lri Certified Fe C
o p� U, '\' O
Return Receipt Fe U' •
Q (Endorsement Requirr ov •
Restricted Relive L6 t
O (Endorsement Rr c, i 1 . E st'
ru Total Poi' ,s�
N,' < Quo 0 4 a a . AP
Sent Tr 0, C e %,,,. a 0� `
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er
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0 6 ° . 0 0 4 0 � r \ \%‘ , / ‘'.\\'‘' t -. I 'X / 0 4 py 4 1/ 4 ,1 I
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Secondary to a review of the plans and fire protection narrative that was submitted to me for
review, I concur with the issuance of a building permit for this property subject to the following
conditions:
• A Knox Box is required on the exterior of the structure near the main entrance; the red
120 - candela strobe light that actuates upon an alarm condition is required above the Knox
Box.
• The suppression system needs to be monitored by a direct connection to the
Northampton Public Safety Dispatch as a condition of permit.
• A pull station behind service counter to activate an alarm to the fire department that is
clearly labeled.
• Fire alarm control panel needs to be marked with a red engraved sign with one -inch white
lettering on red background "Fire Alarm Control Panel ".
• Signage clearly labeling pull station for suppression system
118.4 Violation penalties: Whoever violates any provision of 780 CMR, except any specialized code
referenced herein, shall be punishable by a fine of not more than $1,000 or by imprisonment for not
more than one year, or both for each such violation. Each day during which a violation exists shall
constitute a separate offense. The building official shall not begin criminal prosecution for such
violations until the lapse of 30 days after the issuance of the written notice of violation.
Mr. Bolduc your failure to receive written permission from the head of the Northampton Fire
Department to disconnect monitoring of fire alarm system which was a condition for the operation of a
self serve gasoline station at Pride gas station at 375 King St. in our city is a violation of 780CMR and
subject to above fines. This letter shall serve as notice that you are in violation and will be subject to the
fines allowable by statute.
Please contact this office upon receipt of this letter with your plans to reconnect monitoring of fire alarm
system at Pride Gas station.
Sincerely,
Anthony Patillo
Building Commissioner
City of Northampton
CC: B. Duggan NFD, City Solicitor E. Reall
City of Northampton 4
1s
Massachusetts N
.4i
D EPARTMENT OF BUILDING INSPECTIONS d b
212 Main Street • Municipal Building s `
Northampton, MA 01060
Building 413 -587 -1240
Commissioner
February 8, 2010
Robert Bolduc
Pride Gas Station
King Street
Northampton, MA 01060
Failure to maintain Alarm Monitoring Service
Dear Mr. Bolduc,
Northampton Fire Department has informed this office that you have terminated the alarm monitoring
service for the fire alarm system at Pride Gas Station located at King Street in our city.
You are in violation of 780CMR sections 901.3, 901.4, MGL 148 sect 27A and conditions of
Northampton Fire Department permit conditions .
780CMR 901.3 States; "901.3 Nonrequired systems: Any fire protection system or portion thereof not
required by 780 CMR shall be permitted to be finished for partial or complete protection provided that
such installed system meets applicable requirements of 780 CMR. A building permit shall be required
for systems installed pursuant to 780 CMR 901.3.
780 CMR 901.3 states;" 901.4 Maintenance: All water based fire protection systems shall be
maintained in accordance with NFPA 25 as listed in Chapter 35. All other fire protection systems shall
be maintained in accordance with the requirements of the applicable reference standards and
standards listed in Chapter 35. The owner of every building or structure shall be responsible for the care
and maintenance of all fire protection systems, including equipment and devices, to ensure the safety
and welfare of the occupants. No person shall shut off, disconnect, obstruct, remove or destroy, or
cause or permit to be shut off, disconnected, obstructed, removed or destroyed, any part of any
sprinkler system., water main, hydrant or other device used for fire protection or carbon monoxide
detection and alarm in any building owned, leased or occupied by such person or under his
control or supervision, without first procuring a written permit so to do from the head of the fire
department of the city or town wherein such building is situated in accordance with M.G.L. c. 148
s. 27A."
When installations of fire protection systems are interrupted for repairs or other necessary reasons, the
owner, tenant or lessee shall immediately advise the local fire department and shall diligently prosecute
the restoration of the protection.
The building permit was issued with the following conditions from the Northampton Fire Department
dated May 6, 2003 which you agreed to prior to issuance of building permit, memo reads;
Re: Pride Convenience, 375 King St.
From: Duane Nichols Assistant Fire Chief, Northampton Fire Department
Date: May 6, 2003
CC: Brian Duggan
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 12
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 0
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
•
Version 1.7 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 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 DONT KNOW 0 YES
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 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES NO i
IF YES, describe size, type and location: ?,Street, gas canopy and Building
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 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 ❑ Repairs GI Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Replace accoutical ceiling system and HVAC equipment
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) _ CONSTRUCTION TYPE
A Assembly [171 A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory 0 F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ _ 3B ❑
M Mercantile 12 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B
1 ❑
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: Mercantile Proposed Use Group: same
Existing Hazard Index 780 CMR 34): ,., .. .. Proposed Hazard Index 780 CMR 34): _
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED kliVrCONSTRUCTION OFFICE USE ONLY
RG+ev savrO.J
Floor Area per Floor (sf)
1s` 4 400, 1 3156;
2nd 2 nd
3rd 3rd
4 th
4th
Total Area (sf) 4 Total Proposed New Construction (sf) 3,156
Total Height (ft) 16
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public p Private ❑ Zone Outside Flood Zone p Municipal 12 On site disposal system ❑
Version 1.7 Commercial Buildm Permit May 15, 2000
' City of Northampton
Building Department C i€1
._
}� 10 ' . 12 Main Street
1 Oom 100 ���� 11
Northan ton, MA 01060
phone 43 -540 Fax 413 - 587 -1272 P4*
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
1.1 Property Address: Tills section to be completed by office
_.
375 King Street Map Lot Unit
Zone Overlay District
Etm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Pride Convenience Inc. ;246 Cottage St. Springfield, Ma. 01104
Name (Print) Current Mailing Address:
(413) 737-6992
c. Signature / Telephone
2.2 Authorized Agent:
David A. Sabourin ,246 Cottage St. Springfield, Ma. 01104
Name (Print) Current Mailing Address:
(413) 737 -6992
Signature - ,�_ Telephone Jar
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b Estimated Total Cost of
$$00.00
_. Construction from (6)
3. Plumbin $400 00 Budding Permit Fee
4. Mechanical (HVAC)
5. Fire Protection $8,000.00
6. Total = (1 + 2 + 3 + 4 + 5) lot 1C % 000 Check Number , /00 14 0 '
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date