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;:=;---- DEPARTMENT OF BUILDING INSPECTIONS
i -
212 Main Street ' Municipal Building
Northampton, Mass. 01060
W O RKER'S COMPENSATION INSURANCE AFFIDAVIT
I, •
(It s. -�`pe: t )
with a principal place of bus ness/residence a::
(pccne#)
(st/ctrist :trap)
do hereby ce Wy, under the pa;:os and penal of perjury, tha :
•
( ) I am an. Wplayer providing the following worker's compensation coverage for my
employees wor'Aing on this job:
(Lrstiy.. w C tami y) (P - .-.;..i.. ,- .7 Number) (Ex rir data Dare)
ii ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contra tors listed below who have the following worker's cocT.; sation policies:
(Name of Coaeaccr) (In uranc Corr ydzy/Poiicy Number) (E' irdon Date)
(Name of Contracor) (Insurance Co a, Number) (Expiration Date)
(Name of Conncor) (Lnswance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comoany/Policy Number) (Expiration Date)
(much additioml shoes if ociry to include information pataiainsg to all 000riaesocs) .
( ) I am a sole proprietor and have no one working for me.
() I am a home owner performing all the work myself
NOTE: please be aware that while homeowners who anploy pawn to do asaimm e, � ntr oa orrepairwork oa a dwefr sg of
not more than three waits in which tba bomeowaectmides or on the grounds apputtanscatbeeto we not geaasily coceidatd to be
employers under the wodtn s ceaspassatica Art (GLLS2431(5)), appiatice by a homeowner far* Gamma or permit may evidence the
legal ctaais of as employer uad.rdue Waimea Compossation Act.
I understand that :copy of this wtomeat assay be forw.rd.d to the Deprrmhcae oftabottial Aeddom& Offio. of Iaauraoos for the
overage nxianni as and that star to secure coverage under =cam= of UOL 152 an lad to the imposition of nimical penalties +
oomissmrg of a fine afup to SI�00.00 a mmptaoa men of up to one year and ant pests/tin in the form of s Stop Wait Order and a
Ism of 3100.00 a.day agatiiast me.
• For depetmada1 use catty
Permit Number
— - spa Lot #
..; • -• :. Sigstal re ofLier,.asedPermittee nat
Version1.7 Commercial Building Permit May 15,'_000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) .s J
Independent Structural Engineering Structural Peer Review Required Yes ❑ No Xr
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 'Diet- C/} -?'UM Ari 14A-M f ctiv- NU c. , - D /VA' ' as Owner of the subject property
• hereby, horize V Jf �, ) 1i 16A l (�es, (� ('' (.21 '�4V to act on
Signatur of Owner Cate
my behalf in all m ters r ativ tc wcr'K authorized by this building perm ap•licat
/
I, w / l (-/ D't '' iN W 0 / n ' ' ! as Owner/Authorized Agent
hereby declare that the statements and in ormation 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
■44
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Constructi Supervisor: , p Not Applicable Cl
Name of License Holder : .l.J.A 6 ' ^ V'/'�`f-� / (
d / so
License Number
" .B tte S i j f'o -1- e `1'o w /Ilk /
,.........atizTia
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 building permit.
Signed Affidavit Attached Yes No ❑
Version1.7 Commercial Building Permit May 15, 2000
SECTION: 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - F013 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
92 Registered Professional Engineer(s):
1
Name Area of Responsibility
Address Registration • •mber
Signature Telephone •iration 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
S': ature Telephone Expiration Date
9.3 General Contractor
(43e f INC-. Not Applicable ❑
Company Name:
i Olf M A R * � o 1 536,
Responsible In Charge of Construction
P? 4A-1e' " 1 f /
E 7e : '' (a
• Address ;?)(2- DA/
• Signature Telephone
•
Version1.7 Commercial Building Permit May 15, 2000
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: �/i� 7.3 Sewage Disposal System: N/r
Public ❑ Private ❑ N p( Zone: Outside Flood Zone ❑ _ Municical ❑ On site disposal system ❑
8. NORTHAMPTON ZON G
New wo o 7- Existing Proposed Required by Zoning
7T w This column to be filled in by
P 6 ./50N U/1 N e?c67 Building Department
OF el) •
Lot Size
i �? N
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 X DON'T 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: I ' 0 A N N E'
A - 1 R- i b /p- 6f (r .
D. r here any proposed changes to or additions of signs intended for the property ?YES _
•
No
IF YES, describe size, type and location:
r
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 AlterationsX Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ■
❑ Accessory Building [ ] Repairs [ ]
2>FF 'D c SCRri° - rrr>: It St New 1/4reProe- f 41--iiti eri wAlAj I c�e7
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE AIN iaeASv Off ,f i Ace,0 1,J1 N(..-
e
USE GROUP (Check as applicable) I CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
A -4 ❑ A -5 ❑ 1B I ❑
B Business ❑ i 2A ❑
E Educational X i 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ I 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I.1 • ❑ 1 -2 ❑ 1.3 ❑ I 38 ❑
M Mercantile ❑ ! 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ ! 5A ❑
S Storage ❑ 5-1 ❑ S -2 ❑ 53
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: 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 t -. QFFIIC _-
NIA- t‘i
Floor Area per Floor (sf) 1st - , ., ,,.
1st 2 _, ' 7"1 4 &.;
` s
--; .` e., -,
3 rd = =
2nd - x x
M ;. r e
3rd 4th ** =
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft) _ ;
• Total Height ft .,. '
t ----.
Versionl.7 Commercial Building Permit May 15, 2000
t p r :k h a . •=._;4,,:z,"" eft d se"on1 . :k.--_
177' �` • Northampton S e r= �',,,� ' • I , S Burl. Department Cigna' CUt/D ,..• e - iiierrni : '�
cr i 2002 1L ain Street Saver/ p v ai a ' .
' o •m 100 WaerlW_ell � ny ;�: _+
.T_ __..._..Alfa mp on, MA 01060 - S tsa } t ,• ' i -, r�.' ,i
P(r ilt14 -1. Fax 413 587.1272 P le''!a r 3 xt* }� >� 4' *f ,, -
Oth S pec . -Ix . t. , : i
r.
d Y - , , 4 A?.,A „ ; .
APPLICATION TO CONSTRUCT, REPAIR. OR RENOVATE, CHANGE THE USE OR OCCUPANCY OF, O DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELL! ({; . _._
�, ..t. 1 1`
i
i,
I s
SECTION 1- SITE INFORMATION ., ' FEB i 4 2002 !'
i This se ion t be completed by offic
1.1 Property Address: 1 -}4MfO eb(,C pff il--
1 / PAIN Sr. Map - Lit !4`17 , i r l f`l.}i�,
N 0 gilt A—nel Prt N 1 Mt\-- Zone Overlay District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: f -1-1PS ) e p CA DN/m (cL(,/'tgO TI ve
-(1 A sO- wnMAiJ, 1>1 �i
' '1 ) fti9wc/ T. N ' ld
Name (Prin) Current Mailing Address:
Signature Telephone
2.2futhorized Agent: (.'6 MAR -d'/
I
I N , g , 4 ' r eV Itib E ' R - S , IN c- t i " 6f Or. N o t- A-, 'IT'S
Name (Print Current Mailing Address:
aA...e.A...1/4..„-r--<_ c I, - t 247
1
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building f t )-)1 "- (a) Building Permit Fee
2. Electrical / // o 9' _ (b) Estimated Total Cost of
b t Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) # 3 i / .
5. Fire Protection T F —
6. Total = (1 + 2 + 3 + 4 + 5) 4 9 )--g`. : Check Number - - I :. . A ,\j .:
3 �� 7:7'..i - - Th is Section For Officia Us e'Onl .. T
4
t
,,. iJ� },. 3. " " rK a r_
to wr i 1 .;.' r My. ... .lr r -�. - 4 t';hakWt01 , t ':-!CS4n a } - s' : - v s, .X
B uilning P rmit Numr -..ee r• 7 .. 'x -. Dat I +II z e
' u r '4�'4� � Cx yl.c�i .: - < � e"�3 - ��'P�''" 4 �? M..sr.. �''"; ' - -c 1g: � .. '� ._'F
'k � -:
-i atr! 4 "'' irow. ; t t � �,r t i 4 „h x V �a•k j ^ c , "' r _ i` s 7-, ,i,.1,1;-;.:F , .:-...4.:,!-:t:1,-..,-; 1
Signures .. * ' * .�» y .
ak `.Building Commissioner /Inspector of Bu ": Date - r i.-::p. , '
File # BP- 2002 -0717• ,
APPLICANT /CONTACT PERSON Wright Builders
ADDRESS/PHONE 48 Bates St (413) 586 -8287
PROPERTY LOCATION 97 HAWLEY ST
MAP 32C PARCEL 221 001 ZONE SI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid j /d 9 '--
Typeof Construction: INTERIOR PARTITIONS FOR PERSONNEL & ACCOUNTING OFFICES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 045075
3 sets of Plans / Plot Plan
THE FO OWING 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 Commissi n
-•‘ Z—Z-- Z c7 C
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.
97 HAWLEY ST BP-2002 -0717
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 221 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Non structural interior renovations BUILDING PERMIT
Permit# BP- 2002 -0717
Project # JS-2002-1177
Est. Cost: $7228.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Wright Builders 045075
Lot Size(sq. ft.): 49658.40 Owner: HAMPSHIRE EDUCATIONAL
Zoning: SI Applicant: Wright Builders
AT: 97 HAWLEY ST
Applicant Address: Phone: Insurance:
48 Bates St (413) 586 - 8287 Workers Compensation
NO RT H A M PTO N M AO 1060 ISSUED ON:2/20/02 0:00:00
TO PERFORM THE FOLLOWING WORK: INTERIOR PARTITIONS FOR PERSONNEL &
ACCOUNTING OFFICES
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: ,,e 4/ House # Foundation:
Driveway Final:
Final: Final: 3)&42.— 14 /`
,vol [ • (/, Rough Frame: d / j L Q / Z
t N
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:QK 3-; 4 --1 .n
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Xlie----signature:
Fee Type: Receipt No: Date Paid: Check N . Amount:
Building 2/20/02 0:00:00 12312 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo