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-77 '"Vcipii
- DEPARTMENT OF BUILDING INSPECTIONS r= s
212 Main Street Municipal Building /-
Northampton, Mass. 01060 r S
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
Pioneer Contractors/PI Con, Inc.
(li censeeIpera1 i ttee)
with a principal place of business/residence at:
J 0 box 11Li5 Northampton, NA: 01061 (p11one«)586,,5491
(act ent/city/statcinP)
do hereby certify, under the pains and penalties of perjury, that.
(X) I am an employer providing the following worker's compensation coverage for my
employees worldng on this job:
_ � pop � _ _ WC5-315-499822-053 ----- - 6/30/0/i -
(Policy Number) (Expiration Dare)
( ) 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) ( xTiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Nurnber) (Expiration Date)
(Name of Contractor) (Insurance Compairy/Policy Number) (Expiration Date)
(attach additioanl sheet if ncocsaary to incdudc information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptcasc be ague that while homeowners who employ persona to do mairdisnanos,cor sTtudion or rcpair work on is dwelling of
not mcco than throe units in whcich tlx homeowner resides or cc the grounds appurtenant thereto arc not gcr rally coosideroj to be
employes under the worker's won Act(GL152�s1(5)),application by a homeowner for a license cc permit tray avid-ns the
legal stains of an employes-under the Worlcar'e Compemation Act_
I understand that a copy of this c atemeni may be forwarded to the Depeauncat of I Trial A S r 1 Offioo of losuc ooe for the
covaagc verification and that failure to scant covetagro under section 25A of MGL 152 can Icad to the impasitiou of aiminsl penalties
000sisiiug of a floe of up to S 1,500.00 andlor ixtrprizoonscart of Up to one}Tar and civil penalties in the form of a Stop Work Order and a
fine ofS100.00a day spinAroc.
i
For__pisct TMTtel uac only
/ Permit Number
?(O Map# lot rc
Si asr,tzure of Liccn.ee/permittee Da e
Versionl.7 Commercial Building Permit May 15,2000
ECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
dependent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
ECTION 11- OWNER AUTHORIZATION -TO BE COMPLETED WHEN
WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Star -N-err thampton, Inc-. , as Owner of the subject property
3reby authorize H nnAPr Cnntractors to act on
ly behalf, in II ma irselative r to work authorized by this building permit application.
/1 6 1 ,^ —/"-, 5/7/04
nature o Owner Date
Pioneer Contractors , as c�v�?4rr/Authorized Agent
�reby declare that the statements and information on the foregoing application are true and accurate, to the best of my
aowledge and belief.
igned under the pains and penalties of perjury.
David A. Claxton
-int Nam -L-------)
A i Is d 5/7/04
gna ure of Owner/Agent Date
;ECTION 12 CONSTRUCTION SERVICES
0.1 Licensed Construction Supervisor: Not Applicable ❑
lame of License Holder: David A. Claxton 017890
License Number
P.O. Box 1145 Northampton, MA. 01061 1/19/06
d L'i ( )�� Expiration Date
ress
4.- ^ 586-5491
on ure Telephone
)ECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Vorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
vill result in the denial of the issuance of the building permit.
signed Affidavit Attached Yes 1(l No ❑
Version 1.7 Commercial Building Permit May 15, 2000
ECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
.ONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 CS. OF ENCLOSED SPACE)
.1 Registered Architect:
Not Applicable ❑
ame(Registrant):
Registration Number
idress
Expiration Date
gnature Telephone
2 Registered Professional Engineer(s):
ame Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
ame Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
ame Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
:ame Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
3 General Contractor
Pioneer Contractors Not Applicable ❑
ompany ame:
P.O. Box 1145 Northampton, MA. 01061
esponsible In Charge of Construction
David A_ Plaxf-nn
idress I
586-5Cr91
gnature/ Telephone
Version1.7 Commercial Building Permit May 15,2000
Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
ublic ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
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 °ro
(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 DON'T KNOW V YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW _ YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 4 DON'T KNOW
YES
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 NO 1/
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Version 1.7 Commercial Building Permit May 15,2000
ECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
•UBIC FEET OF ENCLOSED SPACE
Iterior Alterations Existing Wall Si ns Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
xterior Alterations Demolition New Signs [ ] Change of Use [ ] Other [ ]
❑ — Accessory Building [ ] Repairs [ ]
, f-f-- -DESC(- -P-zd,J; S CVr u��
ECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
Assembly I ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
Business / ❑
Educational ❑ 2B I ❑
Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
High Hazard ❑ 3A ❑
Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
Mercantile ❑ 4 ❑
Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
Utility ❑ Specify:
Mixed Use ❑ Specify:
Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
[sting Use Group: Proposed Use Group:
fisting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
ECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
oor Area per Floor(sf) 1st
2nd
3rd
Id
4th
d
th
otal Area(sf) Total Proposed New Construction (sf)
otal Height (ft) '
Total Height ft
•
Version1.7 Commercial Building Permit May 15,2000
City of Northampton
Building Department C��• ��-l:�t�rl ay�P ' � ��� ��.��, �� z
212 Main Street Bever‘Se•ta : 11a k 144.44
Room 100 'x 4
Northampton, MA 01060 Tw•� et • � il t .
phone 413-587-1240 Fax 41.3-587-1272 . St
it ( n 7 �� s d L p ,404,.0•it �J7 •1 �s t ,z' R. o
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CIHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE'OR TWO FAMILY DWELLING
t1 t1 U -
SECTION 1 -SITE INFORMATION 1 • ;
This section to be completes# bygffice
1.1 Property Address:
L3/,,L a Q
Ma Lot µ 14pit` h
45 Gothic St. P
Zone Overlay District
Northampton, MA, 01060 '_
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZEDAGENT
2.1 Owner of Record:
. . : , Inc. 6 Kirin St Northampton, MA. 01060
Jame(Print) current Nailing A Idress:
413-586-3100
signature Telephone
2.2 Authorized Agent:
P.O. box 1145 Northampton, MA. [11061
:,-,i1Dnio fl J) Contractors Current Mailing Address:
586-5491
Signature Telephone
SECTION 3-- ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
Building (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) Check Number 9A5.5- gip_
This Section For Official Use Only
Building Permit Number: 7SPOif /1197 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1109
APPLICANT/CONTACT PERSON Pioneer Contractors
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586-5491
PROPERTY LOCATION 45 GOTHIC ST
MAP 31B PARCEL 309 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c5 )0.5-0
Typeof Construction: INTERIOR DEMOLITION
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 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 Commi
2 D
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.
45 GOTHIC ST BP-2004-1109
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-309 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1109
Project# JS-2004-1656
Est.Cost:
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Pioneer Contractors 017890
Lot Size(sq.ft.): 6011.28 Owner: STAR NORTHAMPTON INC
Zonin■ :_^B Applicant: Pioneer Contractors
AT: 45 GOTHIC ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers
Compensation
NORTHAMPTONMAO1061 ISSUED ON:5/11/04 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION
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:
:tough: �f%i: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL: IONS.
4 �� •
Certificate of Occu Ban 1 ► ` ' Signature:
FeeT s e: Recei i t No: Date Paid: Check No: Amount:
Building 5/11/04 0:00:00 9055 $50.90
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo