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38B-104 (2) be4 orc,15 N\ \. 1 0 1.-)41 1 i rzy ((///,, cr\)•• N -� � �/�'_'^~"~ / -~' 1/4S 113 n 75 103 7 25 38B- ioo 6 1 11 7 38B- 75 cl= n 6. x 4.8 104 38 ~ ' 64 165 78.7 3 33.7 16.2 '''.1.*,..$`40■ 0.4' 38 B rm. 8B. 05 163 A IM 3 ft- . ./ 113.9 7 N- , 123 ni ° 130.1 CITY OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: /7 6t./. /26 f 7726 c The debris will be transported by: 4 47 ,tj 7 —7- 2u.0 <<N6-- The debris will be received at: Signature of Permit Applicant Date 3.30 .// Building Permit Number: The Commonwealth of Massachusetts • h := Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( 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. ❑ I am a general contractor and I mployees (full and/or part- time).* have hired the sub - contractors 6. New construction listed on the attached sheet. 7. ❑ Remodeling 2. gr am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. NrDemolition 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 10.0 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.E1 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 Investigations of the DIA for insurance coverage verification. I do hereby cer ' u er the pains and penalties of perjury that the information provided above is true and correct. Signature: — Date: • • 1/ Phone #: 1 I /3 71 1- 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 #: 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 I, _ -._ _... __ __.. as Owner of the subject property hereby authorize _ act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner _.__.._.~ ._._... M Date I, , 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 . t Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ( y . a.A,) ..�"l/r�LG/fC L..,.._......... . .... .... .. .....m.. _. ; 1..(4 77/, _ License Number �� (q _._ l�L /,,... __, __ m.,,itf.�'c..l,tJ.lt1'i b , Q,ILa. w..._..._...,,_,.M � 1,,,../ ...__ .. _ Address Expiration Date / . /7y_�' .. AA AL (Sir, Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT IDAVIT(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 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 ame Area .,..,. of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: PA A ..., .-..., CC. .,. Responsible In Charge of Construction • i • ess I Si , !re Telephone 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 J/ __ ,? 7 .____._- //.... Frontage 7 t _....., _? .) Setbacks Front :21_ Side _- R: Rear 8 Building Height 0 /91 ?" , Bldg. Square Footage % ` ` Open Space Footage (Lot area minus bldg & paved / it A , t4 „ s- parking) _... , . L # of Parking Spaces Fill: (volume & Location) 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 ® 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 ( 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 Q 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 dip 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 it ki;, , Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Bu' ding 3 Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing❑ Change of Use ❑ Othi r ❑ I .._._.._._.,.._..., _. __..,._.....,...,... ,.. H..._....,._.._,..,,°_.._,...., ..._...,,_M.._....,......_._... .,,_.._,..,......,..... w, m.,_ ,,..- ....._,_.,,..,__._._._ „_,. ,�4�:..:......w:.„;J.a "- .. Brief Description Enter a brief description here. Of Proposed Work: , 7 d'��lxv f gfrfiV Oct r t 0 4-'t 4 °`J.. ✓4,4- 77CL _ . _..._._._ .._ SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Ass tl A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ `� ❑ A -4 ❑ A -5 ❑ i 1B ❑ B Business ❑ ~ • ---�., 2A 0 E Educational ❑ --'2B---' ,2a -" r ❑ F Factory ❑ F -1 ❑' . , F -2 ❑ - "� 2C ❑ H High Hazard 0 - - , _ , 3A ❑ I Institutional ❑ I -1 ❑ 1 =2 ` ❑ 3B ❑ M Mercantile ❑ 13 4 ❑ R Residential ❑ R-1 ❑ R -2 ❑ ,� R -3 ❑ 5A ❑ S Storage ❑ s-1 ❑ Sj— � 5B ❑ U Utility El Spe ..__r____.,_,, _._,_._._. M Mixed Use ❑ Specify: S Special Use Specify: _ -� ..,__.m..� ___ _ ��. . a...__ 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): 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) % / i f 1st 1 . Tn_ ,.. , <M._ / a e . `,... 2 nd 2 3 rd 3 .. w 4m 4 th Total Area (sf) �g C) : i Total Proposed New Construction fsf) Total Height (ft) , { Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood_Zone Information: 7.3 Sewage isposal System: Public E,/ Private ❑ Zone Outside Flood Zone Municipal [� On site disposal system Lrr L `, i EV Version1.7 Commercial Building Permit May 15, 2000 HEUEI Y a' De}78ftt�lte USeOtlrf City of Northampton Sta uaf Pe lienteVil 3 2011 212 Department Cuufi�DriuewayPerxz ��� 212 Main Street Sewer /Se�U X�ratla�ili Room 100 Miat'etfiNglf Artrail i r � n, eulDiNG " PEGI4 Ne Northampton, MA 01060 two Sets a Struct ra Plan s NORTHAMPTON. rN one 413- 587 - 12240 Fax 413- 587 -1272 Plot/Site Plans° Other Speaf�r � _ . APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING QTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office _ ._ wa)49e sl. Map Lot Unit No dGTf 1l /orJ/ %419 Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address /34(0 c Signature Telephone 2.2 Authoriz:Agent: '31t014.1 �1, 1 "/" - Z-4- Co' 'U %G. _._.. ' / �' T ��f� � ✓c. �« % J ?/� _ G ' //, - Name (Print) Current Mailing Address �... _ .. ... .......... . .. Signature ! ‘ Telephone SECTION 3 TIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building d (a) Building Permit Fee aQ�d� 2. Electrical (b) Estimated Total Cost of 4 rieee Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) . ...._. ,_ ..__x.. _. _.,.. 5. Fire Protection ` .__ ... 6. Total = (1 + 2 + 3 + 4 +5) 41 .2 7 pt l ceP Check Number J� i/ �/a b This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0709 APPLICANT /CONTACT PERSON BRIAN WALLACE ADDRESS /PHONE 488 PORTER RD SPRINGFIELD (413) 374 -9502 PROPERTY LOCATION 13 MUNROE ST MAP 38B PARCEL 104 001 ZONE URB(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 ArcP Typeof Construction: REMOVE COLLAPSED GARAGE & REBUILD (24 X 24) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 96771 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 744.`j 3/0 0 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. 13 MUNROE ST BP-2011-0709 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B -104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: GARAGE BUILDING PERMIT Permit # BP- 2011 -0709 Project # JS-2011-001165 Est. Cost: $27000.00 Fee: $115.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BRIAN WALLACE 96771 Lot Size(sq. ft.): 1 1979.00 Owner: SEQUOIA PROPERTIES LLC Zoning: URB(100)/ Applicant: BRIAN WALLACE AT: 13 MUNROE ST Applicant Address: Phone: Insurance: 488 PORTER RD (413) 374 -9502 SPRINGFIELDMA01128 ISSUED ON:3/10/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE COLLAPSED GARAGE & REBUILD (24 X 24) 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 3/10/2011 0:00:00 $115.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner