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10D-046 (4) Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 I request that you grant a th p at 135 Mat h Street in Leeds because Lion to wor k is of a project roje ibiJi waive the requirement nature, will construction for ty, life and fire safety, or structural re a ccessibility, c onstruction Ii ed fire is safety, considerable st structural when compared ar minor n the requirements and is impractical not affect health, your con sideraion. practical in that the P ed to the cost of the cost of controlled Proposed work. Thank you for Re spectfully, C Timothy J. Luce PO Box 14 Leeds, MA 01053 Re eontoptck,w)e °dC �"` L i cense or registration valid for individul use only Office of Consumer Affairs & B Mess Regulation y r HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: t Registration: 140288 Type: Office of Consumer Affairs and Business Regulation ‘Stie ,__ >. Expiration: 12/15/2013 Individual 10 Park Plaza - Suite 5170 y� Boston, MA 02116 TIM l'HY J LUCE TIMOTHY LUCE ✓� 122 AUDBON RD. LEEDS, MA 01053 Undersecretary / Not ' I without signature J Massachusetts - Department of Public Safety Fold. Then Detach Along AU Perforations Board of Building Regulations and Standards COMMONWEALTH OF MASSACHUSETTS ( nn.tructiun SuperA Nor DIVISION OF PROFESSIONAL LICENSURE - BOARD OF License: CS 100515 BOARD SHEET METAL WORKERS " ` i SM AS A MASTER - UNRESTRICTED TIMOTHY J LUDO" ISSUES THE ABOVE LICENSE TO PO BOX 14 LEEDS MA 01033 ' = TYPE TIMOTHY J LUCE s ✓,,,�,,,.�1 '''''' Expiration M 1 PO BOX 14 Commissioner 07/15/2014 LEEDS MA 01053 -0014 234669 13395 07/28/14 234669 L LICENSE NO. EXPIRATION DATE SERIAL NO. Fcid Then Detach Along All Perforations oet. The Commonwealth of Massachusetts Department of Industrial Accidents ,:. Office of Investigations .∎ 600 W Street a • Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organizati ndividuate_ Address: Po rgo;ti t q 1 City /State /Zip: S ✓ Q 5 3 Phone #: /3 ? V Are you an employer? Check the appropriate box: Type of project (required): 4. I am a general contractor and I 1. E] I am a employer with 6. 0 New construction em ees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. 0 Remodeling • 2. am a sole proprietor or partner- • ship and have no employees These sub - contractors have 8. [] Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. Ej We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 P1 ing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. 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 • • • pain and penalties of perjury that the information provided above is true and correct. Si•na Date: C Phone #: P /3 / /J t912 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, P-03 - er _ 3, _ __..13Ef !C_ E4c I __ _ - _...... _ , as Owner of the subject property hereby authorize -. _i_v!".° ._. ___:_ .. _d 1 __ e...9. -� w- - -� to act on my b- half, all mat -rs r ive to Iv. .. uthorized by this building permit application. Signature of Owner ' Date V J _. _ _ __ _ . _ __ as Owner /Authorized Agent hereby declaratthe statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed the pains andpenalties of�erju y Print Name Signature of Owner gen Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder . _ .....�.. 9 �.,..,.. License Number Address Expiration Date Signa ure Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit m t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi ermit. Signed Affidavit Attached Yes No • Versionl.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 EILOSED 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 General Contractor Not Applicable ❑ Company Na . Responsible InCarge of Construction po ' / 1 _,_.. /''! __. U J4` ' l Address _ 113__ Jew lure Telephone Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON. ZONING Existing Proposed Required by Zoning This column to re filled in by Building Department Lot Size Frontage Setbacks Front Side L. _ ".__ R. ,__.____? L: ._ t R: Rear Building Height Bldg. Square Footage Open Space Footage , _ __. % 6 (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Hasa Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 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 0 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 t CUBIC FEET OF ENCLOSED SPACE . " Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing II Change of Use ❑ Other ❑ Brief Description Enter a brief description here. el it r . Of Proposed Work: p 4, rr-�- (a vut br e, r� - a"^- �' r ! ©,v — S ys L . 4 " 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 0 H High Hazard ❑ T 3A ❑ i 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 0 R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ s Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑ U Utility ❑ Specify: -- M Mixed Use El 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 OFFICE USE ONLY Floor Area per Floor (sf) 1st__. �. 1 st _. 2 nd 2 . 3`d 3 _ ._ ._..__ ..._ 4m 4th ` Total Area (sf) Total Proposed New ConstructionIsf) _ _ „„ 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 ❑ Zone _ ,_.,_.•_,___• Outside Flood Zone❑ Municipal ❑ On site disposal system E] Version1.7 Commercial Building Permit May 15, Department use i. ity of Northampton Status ctf Perm 0) A ' ' r -_ ' P= = `= - � :uilding Department Ctrfib u t/Dttsrevrrat P $ et t, 20 ,2 212 Main Street Sewer /Sept► A atiththty s , t' C` t Room 100 Waierl ell Awa4614't -sort - m pton, MA 01060 Ew e s rofi i c � turaCP1aos � _ 3 . � T o e .,�;_ D , N I� ®•. _ -1240 Fax 413 - 587 -1272 a t/ S te Pla DEPNOR -wips Pl Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMIL MSNILrge7E. 1\1::::: D SECTION 1 - SITE INFORMATION Thi secnee t4 Iff toeieted b office 1.1 Property Address: , /.3 J oirt 1- - �/� Ma Lot Unit S DEPT. OF BUILDING INSPECTIONS Zone NORTHP PTO�1 ° _ = . .n .w r_ °_o, ...._, .—.. _....°. a_..__ - _ .. .�G, -- EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED-AGENT 2.1 Owner of Record: _ ,; 7,7 , ,„ ._ _ „ ,„._ _ Name (Print) Current Mailing Address Signature R0 7 ' beir KAc Telephone 2.2 Authorized Agent _. Name (Print) Current Mailing Address: _ , v_ ___ Signature T elephone SECTION 3' - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ' 00 - I (a) Building' Permit Fee 2. Electrical _.-_____.._..,_.u.... ____.._ (b)'Estimated Total Cost of Construction from (6) _ ,..._,.... 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) _ _._._........- ....._.w.._ ____ ._._ _ _.__ 5. Fire Protection _...,. . „, �' `" C heck Nu mber //0�//� 6. Total= (1 +2 +3 +4 +5) � �`� (I!/t0 7��� I This, Section For Official Use Oniy Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0661 APPLICANT /CONTACT PERSON TIMOTHY J LUCE ADDRESS/PHONE P 0 BOX 14 LEEDS (413) 387 -9800 PROPERTY LOCATION 135 MAIN ST MAP 10D PARCEL 046 001 ZONE URA(116)/WP(40)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 6 649 Or 65— Fee Paid Typeof Construction: REPLACE REAR MEMBRANE ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 100515 3 sets of Plans / Plot Plan THE FOLLOW NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: 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 � /ft /,9 -/# 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. 135 MAIN ST BP- 2013 -0661 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10D - 046 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0661 Project # JS- 2013 - 001096 Est. Cost: $8100.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY J LUCE 100515 Lot Size(sq. ft.): Owner: WALKO MANAGEMENT INC Zoning: URA(116)/WP(40)/ Applicant: TIMOTHY J LUCE AT: 135 MAIN ST Applicant Address: Phone: Insurance: P 0 BOX 14 (413) 387 -9800 LEEDSMA01053 ISSUED ON:12/20/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE REAR MEMBRANE 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 12/20/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner