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32C-140 (4)
THE HAMPSHIRE PROPERTY MANAGEMENT GROUP, INC. RECEIVED 30)C- � I 9.0 JUNI - 1 2011 _• . OF BUILDING INSPECTIONS • • MAo1000 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 Ater hpmgnoho.com. I appreciate your time and consideration in this matter. Sincerely, _.,,,,,, z______ Patricia Tayl 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 �`' The Commonwealth of Massachusetts " °". - Department of Industrial Accidents a; - Office of Investigations -r' 600 Washington Street y Boston, MA 02111 '' ri. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly • Name ( Business /Organization/Individual): /it Ca/Y.S TavG 7-rd— t G C Address: 3, /7-..4 i ,.e; T City /State /Zip: sa TU,w,,vrli O Mo ?Phone #: qf 3- S u Y7 7 V Are you an employer? Check the appropriate box: Type of project (required): 1.0 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. ❑ New construction listed on the attached sheet. 7. [l<LRemodeling 2. ❑ I am a sole proprietor or partner- 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.] 5.4 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. 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. ❑ 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 u er the pains and p of perjury that the information provided above is true and correct. Signature: �fi''"u'. , Date: ?-c 2 - v / 1 Phone #: it/ 3 1--.5 -- Tel f9,5' 1—s — c) — 7 1 7 ys 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 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 �J ,----- I, `t1 -fr...�._,,. h I 1 / e _. , 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 penaltiesofperjui Print :fi • r ■111111 -.. diJ yL . .. i 6 -- / - .... ..................._ Signat , e of Owner /Agent I " Date SECTION 12 - CONSTRUCTIO i ERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ ■ 7 :, Name of License Holder : .. ,e7, 444'_1'3. ... Y tOS, f....._...... ._ ..... .c /.._., Qo . y ? . License Number - 3 Z ' I " H T __..... W w4gr -efy l- D / 0 3 y / 0 __..... / , ' o i Address # Expiration Date 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 buil ing 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 ii 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 if e c0 ° ` _5 ! .. AL (... t y "--- L L 6. Not Applicable ❑ Company Name: tr Responsible In Charge of Construction Addre .-Y)-11-.L.....// — . — , - Signs Telephone Version1.7 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 0 YES C 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 Document # 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 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q 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 e 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 Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs f6. Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of se ❑ Other ❑ Brief Description Enter a brief description �!° here. /%` " _ w ` Oc+� Of Proposed Work: Ae — SKY 4t l 47 • /Q c�.ii a c '47 O f' #fe . y 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 ❑ 18 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional El 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: S �0 v2- d 11 y f 0 c M Mixed Use Specify: ' a' 7 , � ( vd � / Q eSi , _,-- / — _ .. ____.. _._.._. ___. S Special Use ❑ Specify: ,ve�- 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 1st 2nd „ __ .._..__ ,__ __.__ _ „ _ . , _, 2nd 3rd _. ._ 3r 4th _ 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 0 Zone Outside Flood ZoneD Municipal ❑ On site disposal system I:1 Versionl.7 Commercial Building Permit May 15, 2000 4 Depaxtr ienttau :e only RECEIVED' of Northampton S tk '� er A >5 ` ui • ng 3 epartment ..L,,,,4:>,;:',1:\--t'.•._,, urb C q uU rtrieway',P erm� ,v �� s p a '- .; MAY .- ; 2011 M. Street sever /Septt A4aaabt#i g . Ro • 100 Waterllf fell Avatlabillty * , S Northa pt r n, MA 01060 Two ets of Struct u raiPlan s ,,. DEPT. OF B I „� NOR ► I` -12 0 Fax 413 -587 -1272 Plot/ Plans Other Specify x 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 .35—/ "(4245 4'4'1-- '1.-- C/ec i`T / `.- Map Lot Unit ©/06 �/o.� ,4 ,•1,07 MI Zone Overlay District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /ti %"' + 6 G, _.. 7_._ .._ !'� e4,',$ -^-T._ Vii < Name (Print) Current Mailing Address so r� ,mo ,4 f _._._. /0..75_ Signature Telephone / / 3 " S _ l 3 7 3 ? SS 2.2 Authorized Agent: }} Name (Print) "err M's e / 71y/. Current Mailing Address --. tia �r �.�► 7 �ati s�� / a / g ill / Telephone .. 3 — ,' ..._ / 9 7 - U .e xT ... / __ Signature z z-� -C—C'' / le h y ( 6 9 0 p SECTION 3 - ESTIMATED CONSTRUCT%N COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building d ' a Buildi Permit Fee 9 s0 O 0 y' O 9 • -- - -- __..__. �.___._._.__ • - 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 / - 0 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0969 APPLICANT /CONTACT PERSON THOMAS J KORYTOSKI ADDRESS/PHONE 359 BARDWELL ST BELCHERTOWN (413) 850 -8095 0 PROPERTY LOCATION 351 PLEASANT ST - UNIT 12 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 �7�� $� x Fee Paid 66 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 /t/ 611/II 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. t' {" GPt� 351 PLEASANT ST - UNIT 12 BP-2011-0969 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 -0969 Project # JS- 2011- 001589 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: LANGE KIMBERLY Zoning: GB/URC/WP Applicant: THOMAS J KORYTOSKI AT: 351 PLEASANT ST - UNIT 12 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