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V larlie s' C mpe satinl hest `atue Affidavit: Holders✓ . .
ApNlicant hliOnnatia>< PleasePlit Legally
'Slane ( Business /Organization/Individual) : DA S u 11 I v a n & Sons, Inc.
Add ets 82 -84 North Street
City/altel/ x Northampton, MA 01060 1iii t 413 - 584 -0310
Arey arararlrbya? Check theappapiate Ix= Typeafpoject (regiaed):
1. X I am an employer with 40 4. CI I am a general contractor and I 6. New construction
employees (full and/or part time).* have hired the sub - contractors Remodeling
7. 2. 1 I I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. CI Building addition
[No workers' comp. insurance comp. insurance. t
required] 5.11 We are a corporation and its 10. ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their
11. C Plumbing repairs or additions
myself [No workers' comp. right of exemption perm MGL
insurance required] t c. 152, § 1(4), and we have no 12. N Roof repairs
employees. [no workers'
13.1 Other
comp. insurance required.]
*Any applicant lhatdedaboa #1 must aiso snaut uhesedionbelowsh]w:gua mss' avnpasatidi policy i ti
tliamownersmbosulmit this affidavit iiiallig they ate doing all murk and then tire °nisi& andraclatsnust subnit a/rewards/wit iYicatigsuch
#Cvladuis that die disbourustatlactunackitinal sheet shomig the name oldie sirmtradusads ewhedher or not thoseentities haw Employees. If
the sb -aa< shawemplo ees, theynabt provide their ws' any. , , rather.
I anal enpl ierthafisposidrgrrt ke s' omp I kIiisraK ek'myagrlojee . Bthwkt epalicyarI, jobske
Insurance Company Name: AIM Mutual Insurance
Policy # or Self -ins. Lic. #: M 21111 • 1 1 I Expiration Date: 7 /1 /2011
Job Site Address: 82 -84 North Street City/State /Zip: Northampton, MA 01060
Mach acupytftYrewirkets' oanpesabuipolicy dedaradonpagp (showa gibe policy "umber a idelchatiQi (date).
Failure to secure coverage as required under Section 25a of MGL 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
1chh rlycritify i ... a�orpaal�aFio�aju yuiattheirfmrr ipovirlada�eisal�r� a ocut ect
Signature: . Date: /0..27•/s
PrintName: Mark Sullivan Phone #: 413- 584 -0310
Official irecnly Donate ei:tl=sarealvheaordbydycrtomc 1k
Cityar Rimy PetnitAkense
IssragAr>rhorit3' (tadear):
1.Boadofxeath 2. Bracing Departmert a City/fawrCkik 4. Elect idJnjxdor 5. Pkinl:rghrspector
ra other
CayactpersoL Phore#:
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 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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, /lark S i' i/ rl , 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.
k .5 /~ 'Weer
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
/ (J'C6 1 0 � 66 5 G NYC i0
License Number
C M C S ie_t--r, e*? gel we. s11, " S/, y /a o i l
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 bu ing permit.
Signed Affidavit Attached Yes No 0
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 ❑
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
1) A 5L .'i /r vcun 9` .$c >n S" Not Applicable ❑
Company Name:
&id ‘C.h4te- 0:6 � r► 5
Responsible In Charge of Construction
Address
53 - C> 3"
Signature r r� ii Telephone
•
Versionl.7 Commercial Buildin& Permit May 15, 2000
Department use only
OCT 2 9 2010 City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
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
7. - :'i Mfr. -t Mfre-th Sfre et Map Lot Unit
Zone Overlay District
V0(411 1
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ` p A /
1) A S„ { Nh+1 '- 5,,,1 fJ J r : O j /Vo!`t, a.i S
Name (Print) Current Mailing Address:
/✓or fh p - tco.1 NI /1 oto,G
Signature Telephone 413 5 g/ 03%0
2.2 Authorized Agent:
l"l a rk Sx.,11. ✓arN 4 / n/t ti St
Name (Print) Current Mailing Address:
Signature /�" i Telephone ' 13 5 0 ,3 t 0
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building p O (a) Building Permit Fee
2 Electrical F,5 (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) S 8 3 £o Check Number /16
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0427
P -
APPLICANT /CONTACT PERSON D A SULLIVAN & SONS INC toofilled
Irit/d
ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413) 584 -0310
PROP ERTY LOCATION 84 NORTH ST
MAP 24D PARCEL 092 001 ZONE URC(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 /5/f S
Typeof Construction: ROOF
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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.