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24D-241 (3) 119" - 30" ' 15" 30" - 12" - 30" 3n 1 45 n 42" 17" i 4 30 15" 30" , -_ 12" . - 32" - r _ iN iv W3024 W1536L W3018 W1236F W3018 ■ n) - - . 3r w N �1 o M . � B15 B12R 1 30R -REF co -I 11 CD I All dimensions size designations given are 20 This is an original design and must not be Des 5/8/2009 subject to verification on job site and TECHNOLOGIES J released or copied unless applicable fee has Printed: 8/22/2009 adjustment to fit job conditions. been paid or job order placed. i I KathyApt. All Drawing #: 1 - - -- -- - - - - -- ------- - - - - -- I I I • , „„_,I, jar- _ I I ! L ________ J --- ' t____ e ,,,, 1 14. s....\,,, j■■ 1 71 j I 1 I111 I ______....----• 1 i' _ F,_J ----{ - -- _-_--- Note: This drawing is an artistic 2 0 i Designed: 5/8/2009 j interpretation of the general appearance of TECHNOLOGIES 4 Printed: 8/22/2009 the design. It is not meant to be an exact rendition. I I KathyApt. All I Drawing #: 1 The Commonwealth of Massachusetts Department of Industrial Accidents II ,vet = Office of Investigations ' l= d 600 Washington Street • r� = Boston, MA 02111 �� w ww.mass . aov /dia a ,-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): n4 i ,(,c4, t / K,f' ( /0"te.fo0.- Address: ?t2 Z 0 O2 - 7 /'.3 LS0()I/ 6 f . City /State /Zip: C '' Ps1 / 1(06W4 0/0/ 2_ Phone #: 9/3— 29 7 —� j W 4 / Are you an employer? Check the appropriate box: Type of project (required): T2(1 1. a employer with /9 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. (]� Remodeling ship and have no employees These sub - contractors have g. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3.0 I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] I I *Any applicant that cheeks 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 submi affidavit indicating such. 1 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: i/66 '&1'y A '//4"/ f . <<, , Policy # or Self -ins. Lic. #: A/ Z 3/5= 362 / 99 — 0/7 Expiration Date: - s— 26 — 020/0 Job Site Address: 9/ G/cPse-// S'i /YGlt / City/State/Zip: Q /66 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 Investizations of the DIA for insurance coverage verification. I do hereby certify under the pains and penal tip of jury that the information provided above is true and correct Signature: GG ,% Date: 4, /7 i / _ Phone #: 9/5- 29 5 76y / ?j 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 t SECTION 10-= STRUCTURAL_ - PEER REVIEW 180 CMR 1.1011 Independent Structural Engineering Structural Peer Review Required Yes 0 No Q SECTION 11- - OWNER " AUTHORIZATION -= TO- BE- COMPLETED` WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING • I, V 164 Wly 7 /4 /e kiski , as Owner of the subject property hereby authorize ! — 7 - 511 4 } to act on my behalf, in all matters relative to work authorized by this building permit application. _ \ P i // may __�.. _.._. �y Signature of Owner Date I, 1 4 iti / , 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. a �s o4'4,4/ C tNamA r � 4 4 /0/01 ` Signature of Owner /Agent Date -SECTION 1.2 - CONSTRUCTION SERV10ES ` 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : A),1,4 License Number gip, ‘, ,19-7 d /0/ z- Address L � � `- - Expiration Date A— WS-297 Si atur Telephone SECTION 13 - WORKERS' COMPENSATION= INSURANCEAFFIDAVrr(M i- c 152;_ § » 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 r R Versionl .7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FORIBUILDINGS.AND STRUCTURESSUBJECT.TO CONSTRUCTION CONTROL PURSUANT'TO 780 =CMR 116 (CONTAINING MORE THAN 5,009 C.F. OF ENCLOSED- SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number I Address i i I Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number I a i Signature Telephone Expiration Date Name Area of Responsibility i 1 Address Registration Number I 1 j Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility . Address Registration Number 1 i i ; i I Signature Telephone Expiration Date 9.3 General Contractor , , 2� D('J,T ‘1deva/tvi (O/1 /&AC1b R Not Applicable ❑ Company Name: ' G /2 i Responsible In Charge of Construction 7 Dal/ii/ r Address - �'�.- -- I Y /:3 — 29 J16/ Si tur Telephone ., Versionl .7 Commercial Building Permit May 15, 2000 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size I I i Frontage Setbacks Front I i 1 3 I Side L:° 1 R:Z I L: R:7I ' . I r ^ Rear 1 r - ifuildmg Height I i '+_ Bldg. Square Footage i i %1 Open Space Footage % , (Lot area minus bldg & paved j I it a parking) # of Parking Spaces , i ' # Fill: ' I' I (volume & Location) A. Has a Special Permit/Variance /Finding ever been issued for /on the site? • NO 0 DON'T KNOW 0 YES 0 ' IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page; and /or Docume # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 0 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 0 IF YES, describe size, type and location: 1 1 i 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 SERVICE F O RPR _ OJECT SLE S ST H AN 3 5, 000 CUB10EEETOF.ENCLQSED:SP.AGE - Interior Alterations ❑ Existing Wall Signs 0 Demolition ❑ Repairs l2 Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing 0 Change of Use ❑ Other ❑ Brief Description Enter a brief description here. 6uvli Tvb 56/0...va06.1"oki "./d75 Of Proposed Work: ,les'�" I� tveiti . SECTION 5-- USE =GROURANDCONSTRUGTIO PE' . USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 El 1A I ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 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 l ❑ U Utility ❑ Specify:I M Mixed Use ❑ Specify: i S Special Use 0 Specify: I COMPLEIE THISSECTIONTF ;EXISTING BUILDING IX, DERGO `1NGRENOVATIONS,:ADDmONS-AND /OR CHANGE >IN 11SE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): t i Proposed Hazard Index 780 CMR 34): I SECTION 6BUILD1NG I AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION _ ` ; ,, LX.;-� Floor Area per Floor (sf)a -e r ; �-'' 4*-ti-,74 � 2 - 1 red r agree +i, . , r , " c **^ - red i 2 It i 4 P 44-7- t 3 M �' P � Total Areas ii . � «. % 4 . 7 ^" ( f) Total Proposed New Construction (s 1 } Total Height (ft) ` i � � � ( t. . Total Height ft - . ; 5% 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 0 Zone ; Outside Flood Zone❑ Municipal ❑ On site disposal system 1 Versionl.7 Commercial Buildin_ Permit Ma 15, 2000 r���: -^ pity of Northampton p s i --° �; _; ' ` bti ilding Department a � 9 f - 09 `'2 2 Main Street oom `100 tH ! ,� 9r le ,. PSG i rtha pton, MA 01060 - IFS . -. � G. ♦ - \- pine 4 a3- - 240 Fax 413- 587 -1272 ,, i,� ' � w kP LICATIoN TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 = SITEINFORMATION r - .^This " section'to be comple ted by offic - 7 -- t1 Propertvy4ddress f i, J Q � rx2 9 CRe eii> 1 c5 j Al y � map - o Un i / vi•e ? Girdl,./e/� i one Dyson leis rrct< r � , ' EIm St Distric k - B District - t SECTION 2 PROPER OWNERSHIP/AIJTF1oRIZED AGENT 2.1 Owner of Record: X 4'`ti/ /14 / (7ws�/ 1 ,- >ec3 ,ludo 5 / PD Name (Print) . Current Mailing Address: ` keec'5 g /. 12/° C3 Signature (/ L i Telephone 2.2 Authorized Agent: I �o'hi /7v /s/A7 6,01/ i. 6r .7 , O . &' 'y7 Name (Print) Current Mailing Address: - i C / 4 . , 0 S / P re L/e %( i 0 /o /2-- Signa ' :-_ Jo' 4.4(.. / . .7 Telephone 4 //3-297 4 / .SECTION -3 - ESTIMATED "CONSTRUCTION COSTS' Item Estimated Cost (Dollars) to be .Official. Use -O,nlp completed by permit applicant 1. Building 1 7 O f' e i (ay-BUiIding- Permit Fee i } 2. Electrical I v ; (b)Estimated'Total "Cost of Construction firom_(6) '" 3. Plumbing j � � I Building.Pei niCFee 4. Mechanical (HVAC) 1 © ' . 5. Fire Protection I f 6. Total = (1 + 2 + 3 +4+ 5) 44 % 5 `- -Check Number 6 2 0 5-6 This-Section 'For Official °Use Only : B u ild ingi' e r m l t Nu Date • - -- . .4-sued Signature: Building Commissionerllnspector of Buildings - Date File # BP- 2010 -0205 APPLICANT /CONTACT PERSON THOMAS DOLAN ADDRESS/PHONE P 0 BOX 297 CHESTERFIELD (413) 585 -0612 Q PROPERTY LOCATION 91 CRESCENT ST - UNIT 4 MAP 24D PARCEL 241 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out GPI 45,,s- Fee Paid Typeof Construction: REMODL KIT HENBATH New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 039281 3 sets of Plans / Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 ` 8 LOd' 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. 91 CRESCENT ST - UNIT 4 BP- 2010 -0205 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 241 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 -0205 Project # JS-2010-000252 Est. Cost: $8950.00 Fee: $80.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS DOLAN 039281 Lot Size(sq. ft.): 19689.12 Owner: MAIEWSKI KATHY Zoning: URC(100)/ Applicant: THOMAS DOLAN AT: 91 CRESCENT ST - UNIT 4 Applicant Address: Phone: Insurance: P O BOX 297 (413) 585 -0612 0 Workers Compensation CH ESTERFIELDMA01012 ISSUED ON:8/25/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN /BATH 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: 91/p/r.041 r‘ House # Foundation: Driveway Final: Final: V -/ d f r I ( Final: i /f /9� i I Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 0 K - - -6 f C THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS R RULES ESANDRE , , IO . • 44U" 401400440 Certificate of Occupanc ignature: FeeType: Date Paid: Amount: Building 8/25/2009 0:00:00 $80.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck - Building Commissioner