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DEPARTMENT OF BUILDIT(G INSPECTIONS , V.j.
212 Main Street Municipal Building
•
Northampton, Mass. 01060 r' '‘
WORKER'S COMPENSATION INSURANCE AI+'1 UJAVTT
Pioneer Contractors
(licensee/permittee)
with a principal place of business/residence at:
•
P.0. _Box 114 Nnrthampt MA n 1.0 .__
1- (phonerr) 586 5491
(street/cit y /starch p)
do hereby certify, under the pains and penalties of perjury, that:
(fri I am an employer providing the following worker's conipensanon coverage for my
employees worming on this job:
Wcc 50059570120CCi Q
Associated Employers Ins - —_ —_ _ /30/1
(Insurance• Cornpeny) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circie one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (FxTuution Date)
(Name of Contractor) (Insurance Company/Policy Number) (Ex Date)
•
(Name of Contactor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E.yairation Date)
(attach additional wheel ifnezauy to include information pertaining to ell ooatractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myse.if.
NOTE: please be aware that while homeowners who employ parsons to do ai i o - oonstructioo or repair work on a dwdlin of
not mere than three units in which the homeowner resides or oc the grounds appurtenant thereto arc not gtally 000aiderod to be
employers under tbo worker's compensation Act (GL152,-es 1(5)), application by a homeoavcr for a license cr permit may amp 'r the
legal'stanas of an employer under the Worker's Compensation Act -
I understand that a copy of this cmlemem may be forwarded to the Dcpermxvi of Industrial Accidents' Office of Ias<tr.nca for the
coverage verification and that failure to acaue covcrago trader section. 25A of MOL 152 can lead to the imposition of criminal pcoalEcs
°omit ing of a fine of up to S 1,500.00 and/ca imprisonmxn, of up to one year and civil pcnaltics in tae form of a Stop Work Otte and a
foe of 5100.00 a day against try
t For dcpntmtcal roc only
/ , Permit Number
%a, IN f qb/f M Lot #
r`N Sids lure of Liccnsce/Pcrmi • • e
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
SECTION 11 OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Northampton Properties
I, "., as Owner of the subject property
Pioneer Contractors
hereby authorize to
act on my behalf, all matters relative to work authorized by this building permit application.
04/19/2010
Signature of Owner Date
Pioneer Contractors as 9wnetiAuthorized
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.
Pioneer Contractors -David Claxton
Print Name 4 /
G`r�
04/19/2010
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . David A. Claxton 17890
License Number
P.O. Box 1145 Northmmpton, MA. 01061 01/19/2012
Address �/ Expiration Date
G;�� I ∎i f/ (413) 586 - 5491 ._
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 No
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
Pioneer Contractors Not Applicable ❑
Company Name:
DAvid Claxton
Responsible In Charge of Construction
P.O. Box 1145 Northampton, MA. 01061
Address
42 (2 '(413) 586 -5491
T I h n
Signature a ep o e
Version1.7 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: L: R:
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 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 DON'T 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
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
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.
Version1.7 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 El Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 19 Change of Use ❑ Other ❑
Brief Description Enter a brief description here. Install new one ply rubber membrane roof over single layer
Of Proposed Work: existing roof.
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly C3 A -1 CI A-2 ❑ A -3 1:1 1A I ❑
A -4 ❑ A -5 ❑ 1 B ❑
B Business p 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B p
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B L ❑
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: Business ". Proposed Use Group: ; S ame
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
1
2nd 2nd
3rd 3 rd
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 p Private ❑ Zone Outside Flood Zone p Municipal p On site disposal system ❑
Version).7 Commercial Building Permit May 15, 2000
Department use only
Cjty of Northampton Status of Permit:
: Biuilding Department Curt) Cut/DrivewayPermit, -
�� 212 Main Street Sewer /Septic Availability
APO 2 1 2010 Room 100 Water/WellAvailability,
N orthampton, MA 01060 Two Sets of Structural Plans
phone 413 -.587 -1240 Fax 413- 587 -1272 Plot/Site Plans
C G Other Specify`'
ARRL.ICA -TION TO C0f4STRUCTTFZET 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
136 West St. Map ` Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Northampton Properties /Eric Suher P.O. Box 790, Holyoke, MA 01041
Name (Print) Current Mailing Address:
(413) 534-5634
Signature - -� Telephone
2.2 Authorized Agent:
Pioneer Contractors P.O. Box 1145 Northampton, MA 01061
Name (Print) Current Mailing Address:
(413) 586 -5491
Signature (/� Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
$58,000.00
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) `•11M..!99 Check Number /'d �O
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
1
0 S 'ST - BP- 2010 -0939
GIS #: COMMONWEALTH OF MASSACHUSETTS
418049* ) 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 -0939
Project # JS- 2010- 001398
Est. Cost: $58000.00
Fee: $348.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 56540.88 Owner: NORTHAMPTON PROPERTIES INC
Zoning: SI(100)/ Applicant: PIONEER CONTRACTORS
AT: 136 WEST ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586 -5491 Workers
Compensation
NORTHAMPTONMA01061 ISSUED ON:4/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL NEW 1 PLY RUBBER MEMBRANE
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 4/28/2010 0:00:00 $348.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo