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31B-226 N 7,1 `--) :ate r � "r ., a - ' �..r ...E ' M r., . , _-__,..,_,:::____.= a i U414 ., , - EE- L- ,_ ,',. , , 7i :. , nJ WAI 11-_-...=. 1 i t 1 i' I . 4 i'i i i t — .. - ,�,n A. ;' t 1 1 . t ,.— ,. ∎. n ., . — J — ,,-—L x"71 Q-9 3—__. ? 1 42., The Commonweal ,,......, ; _ Department of It �, =114, Office of Ii .: 600 Washi -- Boston, . ` .. -' www. mG Workers' Compensation Insurance Affidavi Applicant Information Name ( Business /Organization/Individual) L/ c� ft .je Address: a 3 I 7L)Icen. 1R b City /State /Zip: '(/4d/ JJ O r•-.) / iA4A Are you an employer? Check the appropriate box: 1. 2 a employer with ) 4. ❑ I am a gene employees (full and/or part-time).* have hired I 2. ❑ I am a sole proprietor or partner- listed on the ship and have no employees These sub -c working for me in any capacity. employees [No workers' comp. insurance comp. incur required.] . 5. ❑ We are a co 3. C3 I am a homeowner doing all work officers hay myself. [No workers' comp. right of exec insurance required.] t c. 152, § 1(4, employees. comp. incur: *Any applicant that checks box #1 must also fill out the section below showing ti t Homeowners who submit this affidavit indicating they are doing all work and tl :Contractors that check this box must attached an additional sheet showing the ns employees. If the sub - contractors have employees, they must provide their work I am an employer that is providing workers' compensation insa information. Insurance Company Name: G ./"q '� Policy # or Self -ins. Lic. #: C LAJC' 0 3 / 74 Job Site Address: 1 2 `- Fox P T A t Cr Attach a copy of the workers' compensation policy declaratio; Failure to secure coverage as required under Section 25A of MGI fine up to $1,500.00 and/or one -year imprisonment, as well as civ of up to $250.00 a day against the violator. Be advised that a cop; Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that Sienature: // Phone #: *3 " 6 2 G 145 i Official use only. Do not write in this area, to be completed , City or Town: P Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town 6. Other I Contact Person: ,. mix Version 1.7 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, M? _ _ _ .__.. as Owner of the subject property hereby authorize 0 4, . IT 2 9ri- to act on my behalf ' all matters relat' work authorized by this building permit application. Signature of 0 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 an penaities_ooerj . _... _ _. Print Name 7 / ; ___7„,- _ „ „ Signature of O Date SECTION 12 - CONSTRUCTION. SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder . '_ OA a- ...._.�...._. , �.....4. ._. �...��.,.....� _...,.- r�...,b -., .-m License Number ( ;A./0AMO / LT( 7/3 Address Expiration Date C 19(9 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 0 Versionl.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCT SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CM-R,11 (CONTAINING MORE THAN35,000 C.F. OF ENSLOSED SPACE) 9.1 Registered Architect: _.. — ......_ — ... ,_....___._......__._._....r. __ 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 Re9istration Number Signature Telephone Expiration Date Name Area of Responsibility t Address Registration Number Signature Telephone Expiration Date Name . , .....,_._._._._... .._.____._._.._ ..._...... Area of Responsibility Address Registration Number Signature Telephone Expiration Date General Contractor . ._ J 1��TZN ._.y:' ©__.__, ( L L.,__._._ ____ _ Not Applicable ❑ Company Name: .4 _....._... . .e ( T2,.0 .?Z—_ .._.._... . . . ... ___.__. ._._ Responsible In Charge of Construction Address_ 1'3 1424 -- Pli0 Signs re Telephone Versionl.7 Commercial Building Permit May 15, 2000 8, NORTHAMPTON ZONING • Existing Proposed Required by honing This column to filled in by Building Department Lot Size Frontage . _ _ :, .... _ ... _ ...._._..... _. ..._.. _..__.. Setbacks Front Side L. _ R._ L.M R. Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parkin g) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ver been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued IF YES: Was the permit recorded at the Regis of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and /or Document # Does the site contain a brook, body of water or wetlands? NO G" KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES (0 NO IF YES, describe size, type and location: `x D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (1:V IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excava or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO e IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 t SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN '35,000 t " CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs , ❑ Accessory Building ❑ Exterior Alteratiorj Existing Ground Sign ❑ New Signs ❑ Roofing L✓.f Change of Use ❑ Other ❑ /G ' a Jro2: /'(y Brief Description Enter a brief description here. ,609/71_, /0 �` y Of Proposed Work l o re 4,00/: — /1.447C & wirr") C 'c� ?/a r C- 5 SECTION 5 - USE GROUP AND CONSTRUCTION TYPE` • USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 28 w r El F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A , ❑ i Institutional ❑ I -1 0 1 -2 ❑ I -3 ❑ 3B ❑ M Mercantile �❑,/ 4 ❑ R Residential L7 R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 0 S -2 ❑ 5B I ❑ 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 OFFICE-USE ONLY Floor Area per Floor (sf) • : 1st .. __. 151 -- 2nd _.._.... _...._.._._._._.__,._ ._._._. 2 n d ?.. 4th _._ . �___ __ 4th __ ___ ____ _ __.__ , 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 ❑ Private ❑ Zone ____ _ Outside Flood Zone❑ Municipal ❑ On site disposal system Version 1.7 Commercial Building Permit May 15 a # ° e t use onE� city ,of Northampton Ctrs n s 6 wild g Department C f1 n eway P(rrrrt � " \)\' e�,�ob° 12 Main Street Se+�!erepcaila�� ��� ° Room 100 W� eK, ; elf rabi 5 � . -J S�rttct ' Northampton, MA 01060 Two��e�ua�t?lart� � R+ 4 � 4 °i� N° phone 413- 587 -1240 Fax 413 -587 -1272 f151 P ns Other Speer y APPLICATION 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 1 . x-13 za2 c Map Lot Unit /( /Gyi f.9 MLh1D(%) '4/1 Zone Overlay District _ - Elm St. District CB District SECTION 2- 'PROPERTY OWNERSHIP /AUTH'ORIZED AGENT 2.1 Owner of Record: h 'ji USTF $ O F 77 Name (Print) Current Mailing Address: '/ i ... _ 2 L I2- Signature C.-- Telephone 2.2 Authorized Agent: C-./ % 4 U C sT z a' L 23/ r eo 7 Get ,R,J . ,(4/tAi ), /t4i O /alf7 Name (Print) Current Mailing Address: 4 - Signature ,� Telephone SECTION 3 - ESTI ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed y permit applicant 1. Building o('O ' ! (a) Building P Fee „ „ 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) Check Number /4113 ,.5 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0070 APPLICANT /CONTACT PERSON CRAIG SWEITZER & CO LLC ADDRESS/PHONE 231 BUTLER RD MONSON (413) 626 -1498 PROPERTY LOCATION 12 BEDFORD TER MAP 31B PARCEL 226 001 ZONE EU(100)/URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out `0? Fee Paid / p! Typeof Construction: REPAIR 2 STORY PORCH & REROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 15713 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: t. 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 / 9/ 2_ 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. 12 BEDFORD TER BP- 2013 -0070 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 226 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- 2013 -0070 Project # JS- 2013 - 000100 Est. Cost: $4000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CRAIG SWEITZER & CO LLC 15713 Lot Size(sq. ft.): 8973.36 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(100)/URC(100)/ Applicant: CRAIG SWEITZER & CO LLC AT: 12 BEDFORD TER Applicant Address: Phone: Insurance: 231 BUTLER RD (413) 626 -1498 WC MONSONMA01057 ISSUED ON:7/19/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR 2 STORY PORCH & REROOF 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 7/19/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner