32C-067 (12) ,
Jk -6 al 1 ` /< 0♦ r ' )"I
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� t One Ashburton Puce - Room 1301
Boston. Massachusetts 02108
Home improvement ` Contractor Registration
= Registration: 112607
Type: Private GorVaratian
Expiration: 51412011 Tr# 284886
CHAR(STA REAL ESTATE INV.. fNC. -
WAYNE BERGERON
PO BOX 706i 38 HARKNESS AVE �: --
E LONGMEADOW. MA 01028 - __.__
Update Address and return card. Mark reason for change.
_. Add ress Renewal r Employment � Lost Card
:F,5•:;' -'. Ct 4-Vt-36-0E -uEEL 4 -1MC — C€2"2C{¢
B of :u . ' _ . - do c - , . . : • License or registration valid for individui use only
* I HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
1a - :
Board of Building Regulations and Standards
,_ M an 112607 One Ashburton Place Rm 1301
.,, 5f4(i0 t Tiff 9488fi Boston, Ma. 02108
- fiPate Corporation
CHARS±/ REALESFAT'E , WC.
WAYNE BERGERON _ _
PC BOX 7061343 EiAR £ ` _. _
E. LONGMEADOW, M - 'S Administrator Not valid without signature
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PO BOX 1356/18 FOREST ST .:
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DEPARTMENT OF BUILDING INSPECTIONS , __��M
212 Main Street • Munici�jSal Building ` =
Northampton, Mass. 01060 `' '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
U S e - � , ......-eUAvk-A
(li censecipcmii ttce)
with a principal place of business/residence at
G / pLe) -V •
3 0 0,f- klA-C £ — E 1. o • MA (phoney #) 4R-SaS 11?S
(stied /cit /staid, zip)
do hereby certify, under the pains and penalties of perjury, that:
X 1 am an employer providing the following workers compensation coverage for my
employees working on this job:
�FJ��\SS�h c e T . \/ l� C O 006 8 6 O — g ._
(Insurance Company) (Policy Number) (F_xpiration Date)
( ) 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shoe if ere ss.ary to include information pertaining to all contractors)
( ) 1 am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE: please be aware that while bcc x wners who employ person: to do mainicnartce, coostrutiota or repair work on a dwelling of
not more than throe units in which the homeowner raids or on tax grounds appurtenant thereto art not generally considered to be
employers under the worker's camp ion Act (GL152,ss 1(5)), application by a homeowner for a tiernsc oc permit may evidence the
legit status of as employer under the Workers Compensation Ad.
I understand that a copy of this uatcmeut may be forwarded to tho Departar_at of Industrial Accidents' Offioo of Iraorioce for the
cove ige verification and that failure to secure coverage under section 25A of MQL 152 can lead to the imposition of criminal penalties
000sisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine 0( 5100.00 a day :. "c.• tux"
; 4 For dcpartrn�al uac only
j .7 _ Permit Number
('Z — C3 T map�y I,at #
lure of Liccn_Sec /Pcrmittee
Is e
. ,...,.L
' Versionl.7 Commercial Building Permit May 15, 2000
•
SECTION 10 STRUCTURAL PEER REVIEW (780CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION -11 - OWNER AUTHORIZATION - TO'B,E COMPLETED WHEN r
• '£RS' AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, f - y' , ` , as Owner of the subject property
- aet'on
4 CIJG
h
- eby authori
� � � SQ � . : '_� ! � — . �
behalf, in all s re -tive to w:�.uthorized by ti'is building per it - �plication
Signature of 0m. ner • ate 0
I, e f�� V■rV..,^p C as Owner /Authorized Agent
hereby declare that the statements and infor ation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
n4. r -e . ‘4 kkii1/4_%e c
Print ame 4e----. ,,,, --7_,` — 0 ?
Signa 4, of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicaablle ❑
Name of License Holder :7 -63. �()L 1 vkt"*P O S
� 4 C K 0
R ` N,,
License Number
,ddress r l Expiration Date
j ature Telephone
SECTION 13 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 3.52, § 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 LG- No ❑
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 CMR1116- (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):
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
CL &r& C u ck Not Applicable ❑
Com any Name: \
Responsible In'Char of Construction
A cv - ta._1)
ddress
mar ► __ /r c3 -gas 1)/"" nature Telephone
Versionl.7 Commercial Building Permit May 15, 2000
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 ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
, Building Department
r
Lot Size
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 / 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 Iocation:ACa�io.. $ S o. w1t+ 4
k S avw.2.V2a✓4.5
D. Ar there any proposed changes to or additions of signs inten e for the property ?YES
No
IF YES, describe size, type and location:_
Annew
•
` Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC'FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑ ,
Exterior Alterations Demolition❑ New Signs [ ] Change*bf Use [ ] Other [ ]
❑ Accessory Building [ ] Repairs
Egcw p �p���•�: ' o • \ov , s in P re Cie. 6tn to5
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1 -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 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, r y< e
Floor Area per Floor (sf) 1St , k c , ' i ,i
2nd � �
1st — f s� , €'� e
x�a a
3 rd , , ,„ l':, ., _ r
2nd - s
k
3rd 4th
3 ,
x q ,'!,":" . 0_ ':
4th
Total Area (sf) Total Proposed New Construc (sf) -
Total Height (ft) _:
Total Height ft I
0
Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton -� flf
Building Department °v4i14
212 Main Street
Room 100 f ' .. ,-
Northampton, MA 01060 ,�
phone 413-587-1240 Fax 413 - 587 -1272 . r £
v �
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, • D \ \,LI• 'ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING „/ c
't, \
SECTION 1- SITE INFORMATION ``' � �`' 'I-
-
1.1 Pro erty Addre s: ,. 1 ,s '
1n
win, ,v sa 4 cgLi) U llt
,Z_ / r1 e€
k) i n A Zone f< ,� ay triot - - P , ate
� �,
Elrn Jt 'QISf Crt:< . , ., � 3 � , �� �Str�Ct v„4,,
SECTION ; 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /) 610 �d ,3.
Cu rrent M•cling Addre s:
di ' A A' `, qt-5 5� 4 t3
Signature Telephone
2.2 Authorized A e nt: '
�as��� ���� g Cf 1X%- - L. ekodg
ame (Print) Current Mailing Address:
..�ci;,,'., ,, �_ _� 1 -11.3 - 5 l�?s
nature Telephone
SECTION 3 • ESTIM • ED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building i? 60 (a) Building Permit Fee
2. Electrical k- Q (b) Estimated Total Cost of
Construction from (6)
3. Plumbing t‘`0 Building Permit Fee
4. Mechanical (HVAC) \ '
5. Fire Protection �� C
6. Total= (1 +2 +3 +4 +5) Check Number ' 14) lf, f /io e' 0-0
This Section For Official Use Only
Building Permit Num er: Date Issued:
Signature: � �
Building Commissioner /Inspec or of Buildings Date
. _ BP- 2010 -0115
GIS #: COMMONWEALTH OF MASSACHUSETTS
rtX
- Vt.467 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 -0115
Protect # JS- 2010- 000132
Est. Cost: $18000.00
Fee: $ 108.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH KENNEDY 055440
Lot Size(sq. ft.): 30666.24 Owner: MAPLEWOOD SHOPS INC
Zoning: CB(100)/ Applicant: JOSEPH KENNEDY
AT: 2 CONZ ST
Applicant Address: Phone: Insurance:
38 HARKNESS AVE (413) 525 -1735 () Workers
Compensation
EAST LONGMEADOWMA01028 ISSUED ON:7/29/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: STRIP & SHINGLE ROOF
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 7/29/2009 0:00:00 $108.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo