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38B-050 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 ❑ 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 Reg istration 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 Not Applicable ❑ Company Name: Responsible In Charge of Construction Address .nature Telephone • Versionl.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 ® DONT KNOW Q YES Q 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES (3 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 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. 4 The Commonwealth ofMassachusetis _ Department of Industrial Accidents wµ;h =?_:% ;a— r Office of Investigations ��� . 600 Washinaton Street N Boston,M4 02111 - www.mass gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers ADalicant Information Please Print Legibly C• & ' Name (Ei;sines,'Organisation/Individual):^��1�� � �w',.. �'11�.„,„,1 __Ic1C. Address: -tz `\\-�C, , �_ _/4-...„,11 City/State/Zip: Phone.#: r "1- 1\i) Are you an employer?Check the appropriate box: i Type of project(required): 1.0 I am a employer with '- ❑ I am a general contractor and I employees (full and/or part-time).*tn have hired the sub-contractors 6. [1]New camstrscsam 2.❑ I am a sole proprietor or parer- listed on the attached sheet. 7. Remodeling ship and have no e-^^7oyees These sub contractors have S. ❑Demolition working for me in any capacity. employees and have workers' comp. insr nce.t [No workers' comp.insurance 9. ❑Building addition required.] 5. ❑ We are a corpoiation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 10 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13. employees.[No workers' Q Other `•. ..4 ,:`a c: comp.insurance required.] I 1 Any applicant that checks box#1 nnTct also fill out the soon below showing their workers'compe-,.znlion policy information_ t Homeowners who submit this affidavit indicating they are doing all word 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-contactors have employees,they must provide their'workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Ins anee Company Name: ct ,. r , i Policy or Self-ins.Lic. #: e C c�-:y �`S-k-11\C Expiration Date: -\- Job Site Address:°.-I' \-,1tY -, City/State/Zip: NC'C - .x. s �T'fi\. \,t3\2 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 Iead 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 DLA for insurance coverage verification. I do hereby certi 'under the pains and penalties of perjury that the information provided above is true and correct. Sicnat re: a (.er ` - Date: - ; Phone r•: 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. CityITown Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other = Contact Person: Phone ii: Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) I Independent Structural Engineering Structural Peer Review Required Yes n No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,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 I, ,,IVV\ , ,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 a 9 elief. Signed under the pains and penalties of perjury. Print Name Si at of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number r� A Expiration Date r T '.nature 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 r1 No 0 • Versionl.7 Commercial Building Permit May 15,2000 ISECTION 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❑ New Signs❑ Roofing 0 Change of Use❑ Other lia Brief Description Enter a brief description here. cc1 c�, Of Proposed Work: �-� v ,C'*- %`;,'�'GA :::`�tC -3 "sue`_: \'-Ne.1.s,:* ' •t<C∎ js eta SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE _ A Assembly A-1 ❑ 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 ❑ I 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 n Specify u M Mixed Use ❑ 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 2nd 2nd 3rd 3rd .: th _. ...,.. 4th 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 ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15. 2000 Department use only City of Northampton Status of Permit: cvR o Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer/Septic Availability '' Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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• 'al \--,■i CI N Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C N .O Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: \C +a,-1 Signature /�) e -1)1g'' Tele hone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building -\'5,.a (a)Building Permit Fee 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) \c t' ,C., Check Number Z This Section For Official,Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date • File#BP-2008-0605 APPLICANT/CONTACT PERSON Kevin Netto Construction Inc. ADDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413) 527-3168 PROPERTY LOCATION 27B LYMAN RD MAP 38B PARCEL 050 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out c ���p (�{� Fee Paid 7 lA Typeof Construction: ADD CLOSET,NEW STAIRS TO 3RD FIR,KITCHEN CABINETS/COUNTERTOPS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 001317 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 L 2090 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. ,..x �,`.* BP-2008-0605 GIS#: COMMONWEALTH OF MASSACHUSETTS 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-2008-0605 Proiect# JS-2007-001360 Est. Cost: $15200.00 lee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Kevin Netto Construction Inc. 001317 Lot Size(sd ft.): 0.00 Owner: NORTHEAST ENTERPRISES Zoning: URB Applicant: Kevin Netto Construction Inc. AT: 27B LYMAN RD Applicant Address: Phone: Insurance: 90 Southampton Rd. (413) 527-3168 Workers Compensation WESTHAMPTONMA01027 ISSUED ON:1/3/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD CLOSET, NEW STAIRS TO 3RD FLR, KITCHEN CABINETS/COUNTERTOPS 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 1/3/2008 0:00:00 $75.005961 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo