32C-140 (3) THE HAMPSHIRE PROPERTY MANAGEMENT GROUP, INC.
RECEIVED ` de- —/Cs
JUN - 1 2011
oEpt BUILDING paptcnora
• - • wu►moo
111.111111111,111110, ,
May 27, 2011 ^ -�`
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
Dear Louis,
I am requesting that you grant a modification to waive the requirement for control
construction in the situation at 351 Pleasant Street because the work is minor in nature,
will not affect health, accessibility, life and fire safety, or structural requirements and is
impractical in that the cost of control construction is considerable when compared to the
cost of the proposed work.
Should you have any questions, please contact me at (413) 582 -9970 extension 106 or by
email at pat n,,hpmgnoho.com.
I appreciate your time and consideration in this matter.
Sincerely,
Patricia Taylor
Property Man. ger
As agent
THORNES MARKETPLACE, 150 MAIN STREET, SUITE 310 • P.O. Box 686 • NORTHAMPTON, MASSACHUSETTS 01061
TELEPHONE (413) 582 - 9970 • FACSIMILE (413) 582 - 9973 • EMAIL INFO @HPMGNOHO.COM
fi`
` The Commonwealth of Massachusetts ,
Department of Industrial Accidents
,' a Office of Investigations
600 Washington Street
« .
�-:- Boston, MA 02111
`` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 11 le .- Co" 5 Twt..'c Tiati L t C
Address: 351 ` .g�1' -th (/ , e � 6 7 T
City /State /Zip:6'P(.1 .62Z , A- 1 .4-: ‘ , ,Iii, al /OG7 Phone #: tit 3 _ 2 - 5 — 7v 940r5
Are you an employer? Check the appropriate box: Type of project (required):
i
1. I am a employer with 4. 0 I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. 0 New construction
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. R Remodeling
These sub - contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5• In. We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
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.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
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 certify der the pains an enalties of perjury that the information provided above is true and correct.
Simature: / fr-Opt-L. Date: 5 '2-0 ■ /f'
Phone #: 1 1/ . 3` —° LS 0 r 7D9S �s? -- Pl7fri
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 #:
` ' ' Versionl.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, __, , as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I , AT , _c ., .c.�..... „_.. la,, 4 .._: , 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 _
d'
- rint Na
.06' .. . -:A. ../ li F J ... 1/
• ig ur- of Owner /Agen ' Date
SECTION 12 - CONSTRUC ON SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder . 4 off' j T ' 4 0 77 s�t ' L 5 / a o T
License Number
`3 9 4.4 A ,._ T; x !a i ...
i �? 2
Address lo!/ 4, / Expiration Date
o to3 `ti/ 3 .._ 9, 5-x. -�. °. 5
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
•
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
/! .,,_ Ll ti .. " 4C' T ( ti G e Not Applicable ❑
Company Name:
m
Responsible In Charge of Construction
3 5
6"/A elf t7
Address 4 / 1.Gt.e `'�ti /h'f a /Q V .._w.
/ / 4y X3-5 b T og s
Sig ature Telephone
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
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 Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES 0
IF YES: enter Book ` ._, ,____...•. Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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:
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 ON
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 SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
�( i
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs jZf Additions ❑ A4cessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use Other ❑
Brief Description Enter a brief description here. 011,1 — € - ; ;
Of Proposed Work: ; Red / emu 3K Y�,y 4 r . /'�C .li`A cvq -7 04-'1 • /
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE "'"""""'`" ^^ == ... __„_
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I 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 ❑
U Utility ❑ Specify: ri it ST - /vp+� Q' c-t 5
M Mixed Use S eci
p tv -�,� 3 % oa� A l e -e-' Ti's
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Hazard Index 780 CMR 34): N,. , „ .,, _, ._ .._ . ______ _ 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 1s
2nd ._ 2 _.
3 rd 3
.,,...,.. , ,,.._.. _ _._., ......._,..,_..,.. _..,,..._,... _,..,.. th
4 th 4
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 p Zone Outside Flood Zone❑ Municipal ❑ On site disposal system CD
Versionl.7 Commercial Buildin• Permit May 15, 2000
Department use on1 z
City of Northampton stafits t1- e rt�it 5
Building Department CUrb t n
EIVED nN
21 ' Main Street
oom 100 1artl�fe Aiallabr£ 9
o ha pton, MA 01060 1`we s nl atructuraltans
NON
4IU i�W .87 1240 Fax 413- 587 -1272 Rlat/5rt Ptans
Other Specify `� .
APP CA a,;we;H'!: -',!,! IR, 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) / /e 67: ci.- i // Map Lot Unit
,t 6.f44 ,t , 71 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
t 1- � 1 ...... � .._ s ! _ „ s� r. _ 47-
. . �,_ t - T / t
� �._ of � �'
Name (Print) Current Mailing Address:
()le 6 D
Signature Telephone 1 / 0 3 _IVY- ®5 'L 2-
2.2 Authorized Agent:
./ � ski *mac , / �Z� -yam e M c,� T ° o d o y 6 p 6
Name (Print) ,*T"1 7,f / Current Mailing Address
Td� D /a6l
g ZGZt2y�' / / ?— S��Z ' ' QJ 7 0 Fj�T /D �o
Signature Telephone -
SECTION 3 - ESTIMATED CONST TION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building s m j . (a) Building Permit 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 te)”. it CO
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0970
APPLICANT /CONTACT PERSON THOMAS J KORYTOSKI
ADDRESS /PHONE 359 BARDWELL ST BELCHERTOWN (413) 850 -8095 0
PROPERTY LOCATION 351 PLEASANT ST - UNIT 11
MAP 32C PARCEL 140 000 ZONE GB/URC/WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out J n��
Fee Paid J j
Typeof Construction: INSTALL REPLACEMENT WINDOW,SKYLIGHT & REPAIR WATER DAMAGED
SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 070047
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
1 Official Date �l
Signature of Building
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.
351 PLEASANT ST - UNIT 11 • BP- 2011 -0970
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 140 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: replacement windows /siding BUILDING PERMIT
Permit # BP- 2011 -0970
Project # JS- 2011- 001591
Est. Cost: $5000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS J KORYTOSKI 070047
Lot Size(sq. ft.): _ Owner: HALL RUDOLPH J
Zoning: GB/URC/WP Applicant: THOMAS J KORYTOSKI
AT: 351 PLEASANT ST - UNIT 11
Applicant Address: Phone: Insurance:
359 BARDWELL ST (413) 250 -8095 ()
BELCHERTOWNMA01007 ISSUED ON:6/1/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW,SKYLIGHT &
REPAIR WATER DAMAGED SIDING
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 6/1/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner