05-001 (25) • •
.. , ••• . ...- .
, .
. . 'to ••• 1-- 1
I
. •
lit 4 p 2., 1 - •
• -05CL °4- , '
- er.,■- # ‘ -_
460
Tiii Of Portliainpoil 1 •= lir =• =_
A e ,tzw...47 c f ....m„„„chn,rti,„•
,,V..4.2,,ett, - -.
l' alfir • .',' ,
DEPARTMENT OP BUILDING INSPECTIONS • — ----*
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COIVEPENSATION. DISURAINCE AITTIDAY. .
1, SA-tqL. ../* .; A i , t s .... lk- .1‘ .s, c cec „, Lc 5 -z,—)
(-iicc-aspertniticc)
wit1.1_2. al-F4-ace. of bu&i_ge-str-tsidenc-e at.
- (phone) 4+3
(s-cr=uc-ity/natelrip)
do here y certify, under the pains and penalties of perjury, ilia!
) I arn an employer providing the following_ \', compensaLion coverage for iny
employees worIng on this job_
... ,
(insurin= Compo_ny) . (Polic• Numbor) (lixpination Dar...)
( ) I am a sole proprietor, general contractor r homeowner (csc;e one) and have hired
the cootractors Listed below who have the following worker's cat policies:
(1•-lanic of Coco l (Insuranco. Coinpanyrf'olic, Nutally.::) CExpir Datc)
(Name of Coo trac (nsuranc:_. Cornoany/Policv Nune‹...r) (Exoir.ilion Date)
. - -
. •
(Name of Connracto7) (Lasurancz Company/Policy Nam) (Expiratioo Datc)
-
. i
(Name of Connac (Ibsuran� Comparry/Policy Numbs) - (Expis .'
(an.a.cb eckii�..1 tho=t dococsary to xMd niormaEoo pertcining to .11 oeccre.c.ors) .
. .
. t
■.
( ) 1 aM a sole proprietor and have no one working for me.
( ) 1 21 home owner performing all the work myself.
NOTE: plc_se bc cw-r, Lb.:. ..11-..) o booncowocra wbo cooploy pa-zocts to do m.xicrezaance, m--...r-- a- repair work oo a dwdlinz of
OIX InOCz 114,0 .1 - 1. -" , • =its in which the bornocr reticle= o< oo the p-octodr r_ppurtents=t tbc-r...o -r ox L--x-01.1y cc•crid.o-ed to be
cloy a71 the wca-kcel ecomp Act (GL1k.,..a1(5)). opptir ciao by c. booacoo.-oa for t Liczr._-.: cc p rr...ty c- the
i,.1 et_aall of co explorx under dao Work..of a Co<opectnati.ost Ant
1 toxic:I-stand tbad. a. copy of thi.. craccocat may too forwordod to to Doportnocor of 1, AnzicicaLY OfLoo of Ircattmoco for th .
covcra..gc voific=tioo and (het Ctiltzt to securt 1x)vent,s.c utocicr section 25 A of 1.10L 152 cui Itzd to the imposition of cimins 1 pm
comicial; of a. floc °Cup to S1_300.00 and/or im:prio °Cup to aoc yr.or e_nd tzi papaIlia in dat focal of. Stop Work Order and a
(Intl 0( SI .00 a aty xpirta. CDG.
L For dcpartrrastr-s.' 1 oac
Pcrali e'il — --
--- —
Sigmaturt of LicansecfPcroliucc Date
--. --
-.% .
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10= STRUCTURAL PEER REVIEW (780 CMR 11011)
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, I as as Owner of the subject property
1
hereby authorize ' !to
act on my behalf, in all matters relative to work authorized by this building permit application.
i
Signature of Owner Date
I
I, ; , 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.
Sign under the pains and •enalties of se 'u .
Print Name
I
I
Signature of Owner /Agent Date
SECTION" 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
i
Name of License Holder : `■C,� *-•1 �� ` ` S ,
License Number
I 7 -.1 /V- 101LQ- S\- c9SYn.t.e 'l' JtUt2 1 1 CsS- G Q
Address A___ i Expiration Date
-., \---- I � $it, --14Ll
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE" AFFIDAVIT(M.G.L c. 152, §•2SC(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 0 No 0
r
M
Version1.7 Commercial Building Permit May 15, 2000
r
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION - - SERVICES FORBCUILDINGS;AND STRUCTURES SUBJE
CONSTRUCTION CONTROL PURSUANT TO 78D :CNIR-I 0 (CONTAI'I,NG MORE TIAN 35;000 C F:,OF ENCLOSED- SPACE
9.1 Registered Architect
Not Applicable ❑
i i
Name (Registrant): I
I 1 Registration Number
Address
I Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
1 ---
Name Area of Responsibility
I 1 I
Address Registration Number
i
Signature Telephone Expiration Date
I
7
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
I i
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
1 14. k- s_ C,, N. S<'.-"C `.■•. <: J • c..S
Not Applicable ❑
Company Name: '
Responsible In Charge of Construction `r
• %/-- s CL ) l, - Q�w. r-,\,�b o5L I .
Address % `
1t1t; S7L -1569 !
Signature Telephone
I
. ,
• Version1.7 Commercial Building Permit May 15, 2000
team. 1 1 ''3-. :. Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
s Ii
Frontage 1 ► l
Setbacks Front
Side L: - L:1 iR1 1 1—
Rear
i i
Buildmg ei
Bldg. Square Footage % I 1
Open Space Footage % _, ;
(Lot area minus bldg & paved i i i { � I
parking)
# of Parking Spaces I i ' i
Fill: ' ;
(volume& Location) i i `
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book ! Page; ; and /or Document #
, i
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
1
C. Do any signs exist on the property? YES Q NO Q -
s
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 Q
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 Q ' NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15, 2000
i..
SEetribl C* ,1 --- UC10 SERV[ICESf9.I P R4JECi ESSTH 35;000 '
CUBI!CTE,M F;ENCLOSEI) S PACE _.
Interior Alterations 0 Existing Wal Si gns LyJ "'Demolition ❑ Repairs ❑ Additions 0 Accessory Building ❑
Exterior Alteration 2rExisting Ground Sign ❑ , New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
I
Brief Description ;Enter a brief description here.
Of Proposed Work: j j
l L _ I c�scC �. ,C ��C , ..),,It ��`5�. w .. ; ,j 0...0 S
SECTIONS.- 'U SE GRO UPLAND CONSTRUCZON TYPES
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A 3 ❑ 1A
- - -- — A-4 ❑ A -5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑
H High Hazard ❑ 3A I ❑
1 Institutional 1 -1 0 1 -2 ❑ 1 -3 ❑ 3B 1 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ( ❑
U Utility ❑ Specify:1 1
M Mixed Use 0 Specify: I
S Special Use 0 Specify: 1
y 7-7
COMPLETETH SECTIONJFEXISTIN B UILDING -UN Gp1 R /A /OR CHANGE I N USE
Existing Use Group: 1 Proposed Use Group:
Existing Hazard Index 780 CMR 34):1 1 Proposed Hazard Index 780 CMR 34). .1 I
:SECTION' 6'BUILDING'tiE1GHi' ANDREA,
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION �, - t : - . :Fa-4
. Floor Area per Floor (sf)'
st 1st a ,� •; .jam . . i spa 0-.i
�, jam`"'.
3 m r ��
3 rd 1 4th i r^T y , , "sr" T' , v " s
4 .
4th i i � '.- ,�. . " ti
Total Area (sf) i T otal Proposed New Construction (sf) j -a,,' , i-, .,
Total Height (ft) l -, `. 1 -,, t - . t s
Total Height ft 1 * .
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone= 1 Outside Flood Zone0 Municipal ❑ On site disposal system❑
A
= ' Version1.7 Commercial Buildin: Permit Ma 15, 2000
r ., ( �1 r I {1 e f ,. �'t ��r - y � Z� `` a '` l a a a� � a„� 44 y � m. -s..x.' �
\ t^ t r 7 ' # �' i - -f ` a-,
- ' - City of Northampton � ,
Building Department :
AP 11 7 9005 212- ain Street m e .. . _ .
Ro m' 100 F
■ _. ; ,, Nortttampt n, MA 01060 , - A F
$ �. � g r ESK � �. ,
pltioi 413.5'87 -12 0 Fax 413- 587 -1272 m n _a z. _ {` i, ' , ; � -
_,�- `� ; >-. ' n .. _ _ .���'�;.� Eez _ s a ms
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTJONt 1 SITEINFORMATIOlI
- LI-Properly Address:
.' ``" Thi �sectro n-to-b e corrm by o ff ice . =: ,
t' 1 k 't Y
A PIN CA-yc 1, t aP o U nrt
s 'ZZ' Oveilay`Diitric
i Ue - ? te a:- W " ° , ' • EIm St D.rsfrict •.: ` 4 c GCB- Dis£nct
SECTION 2;= PROPERTY OWNER AGENT
2.1 Owner of Record:
I I q q .1i4 , A) s% C w,er I-leasE
Name (Print) /4,i Rstii,QC (oc),AIL. o P Current Mailing Address:
GA JG�� #4 &-x-r- A)0A i MPYV A , rMA O/O 66
Signature Telephone 113 — ,j e " f 0 J 16;
2.2 Authorized Agent:
1 ,2g 2 RI dc_)2 4 6 L,eEts S 0-TA o /0, 3
Name (Print) ---1 0,,t . 5 ,if—A i 4"'7/ Current Mailing Address:
c_- `
Signature ), Telephone `it 3 6 y O rfS _ 2
- SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be -_ Official UseOnly
completed by permit applicant ,_' .
1. Building - Co, �3q . o � 1 (a Building Per s
mit' Fee
t
r
2. Electrical I { (b) Estimated Total Cost of
I r<Constructionfrom'(6) '.
3. Plumbing 1 Builamg_PermItJee
4. Mechanical (HVAC) l i -__ t
i
5. Fire Protection ( #
6. Total =(1 +2 +3 +4 +5) Check Number /7; (
.,....:v _.._. `'� -: .,.. _ This - Section For Official' Use Only
Building Permit Number. 'date
+issued
r
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2005 -0952
APPLICANT /CONTACT PERSON STEPHEN PHILLIPS
ADDRESS/PHONE P 0 BOX 566 NORTHAMPTON (413) 586 -1969
PROPERTY LOCATION 222 RIVER RD - HAMPSHIRE CARE
MAP 05 PARCEL 001 304 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /A1 T 1
Tvpeof Construction: CONSTRUCT 3 NEW OPENINGS IN BRICK FOR WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 063607
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOAVIATION 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 Co ' sion
_ a s--
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.
222 RIVER RD - HAMPSHIRE CARE BP- 2005 -0952
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 001 CITY OF NORTHAMPTON
Lot: -304
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2005 -0952
Project # 3S- 2005 -1325
Est. Cost: $6238.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN PHILLIPS 063607
Lot Size(sq. ft.): 0.00 Owner: HAMPSHIRE COUNTY
Zoning: RR Applicant: STEPHEN PHILLIPS
AT: 222 RIVER RD - HAMPSHIRE CARE
Applicant Address: Phone: Insurance:
P 0 BOX 566 (413) 586 -1969
NORTHAMPTON MAO 1061 ISSUED ON:4/8/05 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 3 NEW OPENINGS IN BRICK FOR
WINDOWS
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 4/8/05 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo