24B-083 (2) Entrance
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139 Carlon Drive
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Entrance 1
Zone 1 and Zone 2 I ii 1 I 3 9A Carlon
39A Carlon Drive i n r J
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Zone 1 39A Pullstations I El �. ,
Zone 2 39A Smoke Detectors S S S
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Zone 3 39 Carlon Drive ( WWI;
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Smoke Detectors and Pullstations Ps s = T. J
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PS ST z PS I 1
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Fire Alarm Control Panel
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information /25y � �/� Please Print Legibly
Name ( Business /Organization/Individual): CO V J1 "� 7�T / L'
Address: a/ Al , uii S
. T1�14 LI.1
City /State /Zip: /41 4 / 6 Phone #: �� a 7 - 5 6
Aree you an employer? Check the appropriate box: Type of project (required):
g
1. I_g I am a employer with LI 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2. El I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
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 12.0 Roof rep�rs
insurance required.] t c. 152, § 1(4), and we have no
13. ❑ Other /�C.✓o ✓/�T7 D�
employees. [No workers'
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. �, I
Insurance Company Name: 0773 '_ i5
Policy # or Self -ins. Lic. #: 5 3 (Ca 1 `j I Expiration Date: WI/ /,j
Job Site Address: 3 1 `441 -0/4 � 4, City /State /Zip: /dO/L 7¢ P/'an1, /44 . D/O (
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 fy undfx the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: �/ F /
Phone #: 7
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 #:
t
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
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, i fiiiity `J . 4ss4,
_ _.. ___.. , ...._ .. . . a .............. as Owner of the subject property
hereby authorize et) i LAS
act on my alf, in all m tters relative to work authorized by this building permit application. _ __ µ„___ __,..__.. x....__.__ __._____..r._,_..__......__
Signature of w(� O Date
, 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 Perlu } !
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: D c� io 7 6 3 � Not Applicable ❑
/
Name of License Holder : _ __. _Z_... ! ! 1 _� �:. we.w .w . w._... ...._ .__
License Number
Address A/ Expiration Date 19"..7X. ��L �� .Yr 3 . ... a 5 6toc_,,
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 buildi ermit.
Signed Affidavit Attached Yes ��J 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 Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor //
... ...._ __.., ! it ....._._ ..,....�_,.,.._..._ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address �` +�rf S-0
Signature Telephone
1
1
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING Na ti-it,/ (14
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size .
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces -_. ---
Fill:
(volume & Location) _ ... ._...._ _ .___._ _.
A. Has a S ecial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was t e permit recorded at the Registry of Deeds?
NO DONT KNOW 0 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 (3 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained (3 , Date Issued:
C. Do any signs exist on the property? YES d NO 0
IF YES, describe size, type and location: A k "I'irr& y:6liv5
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, ex ation, 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.
1
Version1.7 Commercial Building Permit May 15, 2000 t
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 j
CUBIC FEET OF ENCLOSED SPACE /
M
Interior Alterations E -Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Acces Bulkijng 0 4
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing El Change of Use ❑ Other , "-
Brief Description Enter a brief description here. �; L n- e'�-�l C L-
Of Proposed Work: ,
P,Z�,,��y ���lsT,�� �(��c� �,� Ceps ✓mot' �,�
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly El A -1 ❑ A -2 ❑ A -3 ID 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business Z
2A Ii3
E Educational ❑ 2B iv ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I -1 ❑ 1-2 ❑ 1-3 ❑ � 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B [ ❑
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): , v . ._.._.__ __ ,_ 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)
do c hp* . /A) S0 .,_ ,
K 4
1 1
5 st
l- . !_. _ 0..0. 4 14c€_ �._.a... _ ,.
2nd 2 jX. 15 .....__ d i4-
3rd
4 _ _,.._._ . ..._ ..
Total Area (sf) Total Proposed New Construction fsf)„
Total Height (ft)
Total Height ft
7. Water pply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: / 7.3 Sewage posai System:
Public [ Private ❑ Zone Outside Flood Zone[f] Municipal On site disposal system
V O Versionl.7 Commercial Building Permit May 15, 2000
! ' � Aepartment use only s
G � ty of Northampton
- ding Department
fai1, 12 Main Street Sewere�ptiAvarlaotl ; ,
(( Room 100 WateElell Aatlabtilt `4
� Northampton, MA 01060 Two Sefs of StructuraF!'lans
,; one 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Stte Pranss'
er Specify
APPLIC TION 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
3 9 c4-44.01‘) \ e is Map Lot Unit
, ) lltvlie 7914 , � Q ' 0410 Zone Overlay District
- Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
! .... 4 tF
Name (Print) ' j ' ,4L T M CS � ,,L Current Mailing Address
I _l 'ti / 3 Mry IcaC
Signature 4s ----- Telephone
2.2 Authorized Agent
7 �
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 00 5 o0 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
025 Construction from (6) ._ ..._ _..
3. Plumbing Oj Building Permit Fee
4. Mechanical (HVAC) +°
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 3 7gb Check Number p /9 J3
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0697
APPLICANT /CONTACT PERSON ROY OMASTA
ADDRESS/PHONE 21 North St HATFIELD (413) 247 -5666
PROPERTY LOCATION 39 CARLON DR
MAP 24B PARCEL 083 001 ZONE HB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid �W ��
Building Permit Filled out 0
Fee Paid 7 77
Typeof Construction: ADD 3 PRIVACY ROOMS FOR CONSULATATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
CZ' / 3 /Z ) )
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.
39 CARLON DR BP-2011-0697
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B - 083 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0697
Project # JS- 2011- 001096
Est. Cost: $3750.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sq. ft.): 32539.32 Owner: MESSER INVESTMENTS INC
Zoning: HB(100)/ Applicant: ROY OMASTA
AT: 39 CARLON DR
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:3/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 3 PRIVACY ROOMS FOR
CONSULATATION
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 3/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner