31B-158 (3) Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA
I request that you grant a modification to waive the requirement for control
at q King Street, Northampton, MA, because the work is of a minor nature, will not affect health,
accessibility, life and fire safety, or structural requirements and is construction for the project
construction is considerable when compared to the cost of the proposed work. (I
stamped letter from Siegfried when compared
Principal, Porth cost of p r impractical in (I have a the rovt ide e d a of control
a prov
for your consideration, efts in support ort of this request.). Thank you
Respectfully,
!� ^y
James F. Roberts
Roberts Roofing
30 Edwards Road
Westhampton, MA 01027
The Commonwealth of Massachusetts
Department of Industrial Accidents
t ; 0" = 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/lnsividual): �� ,, ia. _
Address: � d ATM '
,z_ ,/6
City /State /Zip: Af LEA,^ /� . onei #: _ , _
Are you an employer? Check the . • pr • • riate • ox: Type of project (requi
1. ❑ I am a er with employer 4. ❑ I am a general contractor and I
P Y 6. ❑ New construction
emp s (full and/or part- time).* have hired the sub - contractors
2_ . m a sole proprietor or partner- listed 'on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
p•
officers have exercised their 11.❑ Plumbing repairs or additions
3. [1 I am a homeowner doing all work
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. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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 co py of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and nalties of perjury that the information provided above is true and correct.
Signature: ^-4-4o 7— Date:
Phone #:
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 #:
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 No
SECTION 11 OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ A t ... : 4 ...... _._ . _ - ... _ , as Owner of the subject property
hereby authorize .....___ !� 41/
act on my behalf, in all ma Is relative to work authorized by this building permit application _
Signatu - of'twner Date
I, , as Owner /Authorized
Agent hereby eclare 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 .penaltiesof• - rfug.
Print Nam _.__ ..._. ._.
4y-,(5 Signature ner /Agent Date
SECTION 1 - CONSTRUCTION SERVICES '..
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ..w_ ��_ . .,
License NGmb r _.. � ,� ! s
� '
.... ;.._._._
Address ..... Expiration Date
elephone
SE TION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTIONSERVICES - FOR BUILDINGS -AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF EWLOSED SPACE)
9.1 Registered Architect:
_. ____________ ____,._, _ M.. ___. _. Not Applicable ❑
Name(Registrant): ............... .__....M._..,.,..__..._.._._ __,.___ ..,...___._..._ , .
_. _ _... _. w .
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
. �. — - .- ...------ -.. , -- _. : _.., _ _,_..... ._ .W_.
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column thre tore 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)
I
# of Parking Spaces Y
i '' - --- -'
Fill:
(volume & Location) __ .w.:,_..____. ___ .,._,__._
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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 (3 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.
x R
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 ❑ dditions ❑ Accessory Building ❑,
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs 0 Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 1:1 A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A-4 ❑ A -5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B , r ❑
F Factory ❑ F -1 ❑ F -2 ❑ • 2C ❑ •
H High Hazard ❑ 3A ❑
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: r .. ...__w __._..w..___
M Mixed Use ❑ Specify
S Special Use ❑ Specify:
..a __.........- .. -..�, ..�...__ _s�._ __, ,... ...._...._., .. ....�...�.....�
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS ANDJOR CHANGE IN USE
Existing Use Group: ___ __..___. ...___ _-_ .. _ _._' Proposed Use Group: __ __..._._.__..___ _______. ._..__..._..__ .__._.
Existing Hazard Index 780 CMR 34) __..,,_H _r w_ ._ 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)
1 st
1
2nd __.... 2 nd
3rd _._ 3 , d ,
Total Areas ' Total Proposed New Construction s
Total Height (ft) -_ _._ _....._
Total Height ft ,m.
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone _Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone _ a _,_ _ Outside Flood Zone❑ Municipal ❑ On site disposal system E]
•
• •
Versionl.7 Commercial Building Permit May 15, 2000
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: . a *ton, MA 01060
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_ 240 Fax 413-587-1272
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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
,....._ „ Map Lot Unit
• 6741 -
Zone
Overlay District
EJm St. District C9 Dstrict
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT . ' ••
2.1 Owner of Re . rd:
Name (Print) Current Mailing Address:
_ ■ / ,.---- /
Signature
v _ , 4 ...„ _ , -44 Telephone
-
2.2 Authorized Agent:
_
____ .
14-14.6- '
Name (Print) Current Mailing_Address: _
Signature ,,
111F ...44(..., • ". -/. ' 1s-11 Telephone
SECTION 1 STIMATED.CONSTRUCT1ON COSTS
1r
Item Estimated Cost (Dollars) to be . . Official :Use Only
corn' ted by permit applicant
.
1. Building ! . (a) Building Permit Fee
- ? : . : !
.-- ---
2. Electrical (b).EstimateciTotal Cost of
Construction from (6)
.„__„„________________________, ... .. .
3. Plumbing Building-Permit Fee
4. Mechanical (HVAC) ..„._ . „___________
5. Fire Protection
,..„...„...„____„„ ...., _._ •. „.___ _ _ ____, A
6. Total=(1+2 +3+4+5) Check Number 40 ( V 44516
This Section For Official Use Only
Building Permit Number . Date
.. : Issued
Signature:
Building Commissioner/Inspector of Buildings . Date
•
File # BP- 2013 -0788
APPLICANT /CONTACT PERSON JAMES ROBERTS
ADDRESS/PHONE 30 Edwards Rd WESTHAMPTON (413) 527 -6078
PROPERTY LOCATION 94 KING ST
MAP 31B PARCEL 158 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / O1 U h �
Fee Paid ( Q
Typeof Construction: REMOVE SECTION OF ROOF & RESHINGLE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 99404
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9PAIATION 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
ignature of Bu ding Officio
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.
94 KING ST BP- 2013 -0788
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 158 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 -0788
Project # JS- 2013- 001349
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 5227.20 Owner: GAEV BENNETT N & LIILY
Zoning: GB(100)/ Applicant: JAMES ROBERTS
AT: 94 KING ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
WESTHAMPTONMA01027 ISSUED ON:3/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE SECTION OF ROOF & RESHINGLE
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 3/5/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner