25C-251 (14) R �tw r p
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,M ti (riIT of Northampton ►
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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street Municipal Building •
Northampton, Mass. 01060 r•
WOR1OER'S COMPENSATION INSURANCE AFFIDAVIT
(liccnsc ipermittcc)
\vith a principal place of business/residence at:
(phone:')
(s>?=4/city /staiefa p )
do hereby certify, under the pains and penalties of that
•
(/ I am an employer providing the following Ivorkcr's compensation coverage for Iny
employees worldng on this job:
— J'.f OC;r7 - 7" C A. Xevzi •
ilviva .,e ca. WICC g?��1 Vie , 60i cri✓ - �
(Innu
Company) (Policy Numb- r) (T :ptruorr Date.)
( ) barm a sole proprietor, general contractor or homeowner (ccle one) and have hired
the non listed below who have the following worker's compensadon po icier:
(Name of Contracto-) (Insuranc Company/Policy Num_c) (- ._:pirdL•on Date)
(Name of Contractor) (Inssrancc CompaayfPoUev Nurnc ^r) (Lx�ir tion Date)
•
(Name of Contractor) (thsuanec am—pally/Polk). hiumbcr) (aspiration Date)
•
(Name of Contractor) (Lasuraao Company/Policy Number) (Expiration Datn) .
(ea .had . ccJ cso . if ooc to istcurk infora oo po - ta.iniag to .11 coccrar_.o:-s )
( ) I a-m a sole proprietor and have no one world.ng for me.
( ) I am..a home owner performing all the work myself.
NOTE: pl0sc be ev- rat t bomcawocrs vv'oo employ pc to do rgaa work oa . d.•e1L•:g of
not most lhoo t tars in a the botnoowocr rrydp cc oa the grounds zppurtccc the-ea) c.-t pot Clly war:6 cd to be
ccaploycs ua ' the v • ; 1 -cox &o (GLl52cs 1(S)). applicsaoa by a boassownot for - 6c era pertan :y n the
Iegil n.,n,,
ore: oo ,loyar under dao Workora CompemLLioa Act
I understood th-e a Dopy of thi. mrcmem clay be focwnrd.ed to the Dope-mo :a Acodaorf Ofl oo of Oar "ono for th.
e velxc v tj3cnioo sod th1 L-iltzc to secure Onvczase tractor sco ioa 25A of MOL 152 na lead to the imposition of cimictl portal/3m
ooasiming of t Ems of up to S I .500.00 and/or iccp-j3 of up to one yt3r end avil pavluo to the form or.' SIC'? Wort Or ead ■
lion of S100.00 a day cE7tiasi tae •
For dqu -�`' u.c only
' Permit Number
Map~ Lot n
itn�urc of Licz:nscr/Pc Late .
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10 STRUCTURAL PEER REVIEW (780 GMLllP 11)
Independent Structural Engineering Structural Peer Review Required Yes ❑ No
SECTION 11 OWNER. AUTHORIZATION TO BEfiCO-MPLETED ;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, UCCA (ti . �hla. \ef s s, ( , 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.
R . C-2 c 5
Prin ame
r
Signature of Owner /Agent Date
"SECTION 12 CONST,Ri�CTIOt�- SERVICES
10.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
SECTION 13 WORKERS` O'IMPENSJT ON NSitRANCEAFFIDAVIT M ice. 152, '.,251 »
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 ❑ No ❑
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Version 1.7 Commercial Building Permit May 15, 2000
.SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS AND.STRUCTURES SllBJECT TO F '
CONST tiCT ONCQNTROLIPURS PANT TO 78,0 GMR 316 CONTAlN1NG MORE THAN 5,flO0aC F OF ENC12OS,EO7SRACE)
9.1 Registered Architect:
Not Applicable El
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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 ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15, 2000
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 ❑
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: L: R:
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
Versionl.7 Commercial B uilding Permit May 15 2000
t� � � CG t ty of North �a�
G ` — Bu De partment �- .,_ ..,
+`:= Mai Street ,,,,
` v.\1\9, , oom 100 c 6��
4 Northa ton MA 01060
r =
r .� - F
_�-� pfir� ,„ - 5 240 Fax 413 - 587 -1272 , F � � k
APPI{ICAFION T O CO REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
.�. . - € tt� w / d e" p� e . - flice t'49:-,.. 3,,,
1.1 Property Address: �� i . a te �, `
e � �v •� M1 V 2 V� AJ V ap'� ... 6� . Te / ^' ' "". ' - v . ,3 AA F n
70\,,.K • -.... - „�°' h* y h� > g ,, z CJ� -1, I .MI's A " '6 � _
�ot2�1�. rn o t eG b " - - p °� " ., •
SEC.LIO PROPERTY OW E RSHI P /AUTHORIZED A
2.1 Owner of Record:
O 2c, ER"N' . li Jr / �9>71�J�F� 1/6''e Gtc ITrsrl S�� rT G. D 4k3US lU ( TG(J
Name (Print) Cur Ma Address:
,A,Lt -P-�P 1 Sg - a3 T)
Signature Telephone
2.2 Authorized Aaent:
Name (Print) Current Mailing Address:
Telephone
Signature
.SEC ESTIMATED COI ST CO 3
Item Estimcompated t Cost (Do to be r Of I lase Only
le ed by perm applicant
o O 5 �� u a :Building Perr Fee
1. Building 7 '
�a
> .bv — ST i.ls 7 S d u
2. Electrical S , t i s , - matte Tot Cost or
–
= Cons cbon *Di"
3. Plumbing 1d - g — i61 ee
4 1
4. Mechanical (HVAC) 2
5. Fire Protection
6. Total= (1 +2 +3 +4 +5)
19 042 'Check Nun er %i� -'
µ l s= 5e c6a> a rr0.1<f a1 siOe ffly
Btnlding P er ` '' glum er• t: x a e ued
Signature:
BuildingT- ommissione IPispeetord-Bulduags Date
r A
File # BP- 2004 -0872
APPLICANT /CONTACT PERSON HAMPSHIRE FRANKLIN & HAMPDEN
ADDRESS/PHONE P.O. BOX 305 NORTHAMPTON (413) 584 -2237 (112)
PROPERTY LOCATION FAIR ST - FAIRGROUNDS
MAP 25C PARCEL 251 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 9 /dr��
Fee Paid `,j
Tvpeof Construction: REPLACE ROTTED SILLS, STALL FRONTS, WINDOWS, DOORS & SIDING ON
CATTLE BARNS
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 PRJSENTED:
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
�ermit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Stree ommission
�,s 00 y
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.