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�� DEPARTMENT OF BUILDING INSPECTIONS 4 w _ {t'j' — T
•
• 212 Main Street • Municipal Building
-�-
p g
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFB'U)AVTT
1, Pioneer Contractors
Oicens /permittee)
with a principal place of business/residence at:
•
.Box 114C Northampton, VA 01061 --(phone) 586 5491
(strct/ci ty/ sta.tnlzi p )
do hereby certify, under the pains and penalties of perjury, that:
(V I am an employer providing the following worker's compensation coverage for my
employees working on this job:
•
Wcc 50059570120C12
Asset -i ated T mp1 oyprs Insurance Co - -- -
(Insurance Company) (Polic) Number) (E_.-piration Dam)
•
( ) I 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)
• r
(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 additional sleet ifnocensary to include information pertaining to all 000traaon)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
•
NOTE: please be aware thxt while be cowacra who employ pers ns to do onaiectotance, construction or repair work on a dwelling of
not mat than throe waits in which the homeowner rmida oc oa the grounds appurtenant thereto arc not geoc ally 000aidcrcd to be
employera under the worker's ration Ad (GL152,s3 1(5)), application by a homeowner fora license a permit may evidence the
legal status of an employer under the• Worker's Compomatiosi Act
1 understand that copy of this sateen aimay be forwarded to tbo Department of Industrial Aocidente Offioe of louuznoe for the
cove vszi&cstiaa and that failtuc to seatree eovcrngo uo ter scion 25A of MOL 152 can lead to the imposition 01 penalties
consisting of a fine of up to S 1,500.00 and/oc impr' otnn t of up to ace year and civil penalties in rise form of it Stop Work Order and a
find o(5100.00 • day against etc.
Al
t Fc(dcpuurrdsl than only
Permit Number
I
L As
�� � �� of ti
rr . Sly nue ofLtc sce/Permi e
•
Version1.7 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 ifK
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, P\av~A) WA _ ._V 1r.e _.. as Owner of the subject property
hereby authorize ° , _ l � ,!�.. 4. I,,tf to
act on my behalf, in all matters relative to work authorized by this building permit application. C---- / /A6A0/ )/-
Signature of Ow erg r Date
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.
Signed under the pains and penalties of perjury.
Print Name /
�" �V I filr �/ 2d f2o/ Y Signatur of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : David Claxton CS- 017890
License Number
IP.O. Box 1145 Northampton, MA. 01061 01/19/2014
Address x Expiration Date
,(413) 626 7267
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 0 No 0
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 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 0 DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained O , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: ; See Photo Attached
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 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
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign 0 New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description ;Enter a brief description here. Repair existing sign structure. No change to sign itself. Sign is
Of Proposed Work: located on property between Hotel & 7 -11
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 El A-2 ❑ A -3 ❑ 1A I
A-4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ( ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A 0
Institutional ❑ 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: Assembly 1st Fl. p
M Mixed Use p specify: ; Residential floors 2 -5 A
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Mixed Proposed Use Group: Mixed
Existing Hazard Index 780 CMR 34): .LOW Proposed Hazard Index 780 CMR 34): 'LOW
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st
1 st
2nd
2
3rd i 3rd
4
4 th
th
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 12 Private ❑ Zone > Outside Flood Zone p Municipal 12 On site disposal system❑
`
, Vc� 7 Commercial oulComm�BuUd���
Building Permit
V ' , ,lt"ifq , ointit'i i',1-xitve
' ' .1w li ' r- - '"1:70.111■Vot:AL 'All' 1 :,:te$ 1 ,:Nr ,t Atl 44'",,,601104,,i, is:„:
0 2 0 7 ., : t416 \ - oom 100 '-' .'..' -;;:' :''''..'41.0',,,q,;.i'Alf,i,'
,.i ',. w e ' . It:I iP. ,1 , , ,:t , .., 11 ,-) VIC ;„I'' .,.,, , ,a4V1.? ,, ,Wf,'10 ', Iti4, , ', ' ,:4,
i ,,,,,,,„,„:„.,,,,,,,,,,,4g,,,q,a , .6' 3 "11061"0:,g ,;;;46;
ok ;7-1240 Fax 413-587-1272
APPLIC'T 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
This section �u'��c� ^emd by office
tiP,ono�vAddress:
36 King (The Lot Unit
~ `--' Northampton) � ~
) Zone Overlay District
<
--'--- -- - --' - - - ---'---'-----~,� St. District CB District
SECTION 2 - PROPERTY OWNERS D AGENT
.
2.1 Owner ofRocord:
- ----- - --------- ' ------ -- ~ - --- - -- - -- - - -- -- `
Manito | � 3hy�ogStreet
Name (Print) Current Address:
(4l3)587-0l0O
Signature / Telephone --------- - -
2.2Author�edAnont
_ ____
:Pioneer Contractors i `P.O.]�Vmll45 MA. 01061
-- - --- ----- ---------'----- ------- - --- ---
Name (Print)
�� r ~.� /' �^
_____Z
^ � �
Signature � Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Doltars) to be Officia Use Only
completed by permit applicant
1. Building
$2,000.00; ` (a>Bui|di»Qp*n»itFee / (
-- - - ' ------------~ ' ------ - -
2. Electrical -- ------ (b) Estimated Totat Cost of ---- - --
( Construction from (6)
3. Plumbing � ------------------- � Building Permit Fee
L - ___ - __--__--_'
4. Mechanical (HVAC) ` --------- - -----
' L
5. Fire Protection '
6. Total =(1+2+ ' 6o Check Number in 0
This Section For Official Use OnIy
Budding Permit Number Date
Issued
Signature:
Building Commissioner/Inspecto of Buildings Date
File # BP- 2013 -0597
APPLICANT /CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586 -5491
PROPERTY LOCATION 36 KING ST
MAP 32A PARCEL 255 001 ZONE CB(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out A59-7 /. �,�(
Fee Paid tY e 5
Typeof Construction: REPAIR SIGN STRUCTURE AJ t7 i % t (:t J FA (:,C ''
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017890
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFMATION PRESENTED:
A pproved 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
/ 27 I -_--
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.
36 KING ST BP- 2013 -0597
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 255 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 -0597
Project # JS- 2013- 000958
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 72745.20 Owner: Mananto Holdings LLP
Zoning: C130100)/ Applicant: PIONEER CONTRACTORS
AT: 36 KING ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586 -5491 Workers Compensation
NORTHAMPTONMAO1061 ISSUED ON:11/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR SIGN STRUCTURE
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 11/28/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner