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= DEPARTMENT OP BUILorNc INSPECTIONS • — - _-
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'+
`l'ORR(ER'S COMPENSATION. LNSURANCE AFFIDAVIT
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—
• (1;ccus pit
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.�.ria la- o>_r-1Gi-paJ-pl-a -af -sinessl-r- s i d ens--a-t. ---
62-6 2&`7
-\o c t ,i., 1 J►' -(phonci') .>+ "
(str Ucityls-tatcizip)
do hereby certify, under the pains and penalties of perjury, .ha.t
( ) I am an employer providing the following \i'orkcr's compensauon coverage for my .
employees wodang on this job:
/1,1 hb...4. - 1\A v QolOr
,
Msurao omi zn ) (Policy Nu_ or) (Expiration Dart)
I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the cones actors listed below who have the following worker's cocnnensadon policies:
(1iomo of Contmctol (Insurnnc: ComoanyfPoiic; Nu_mhcr) (_Xnirntion Datc)
(Name of Con cr ctor) (lnsura-ncc Company/Pole; Nuns°_r) (E piration Date)
(Name of Contractor) (In_surancc Company/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insuranc Compzn-y/Policy Number) - (Expiration Date).
(aaaeh_ddi::oca.1 r_+icct if noc--z.a•-y to mdu.&iaforma000 pertainins to.11 coca--...c-ors) . if
•
( ) I am a sole proprietor and have no one working for me. 4.
( ) I am.a home owner performing all the work myself.
NOTE:pIVsc be ev rc ttic:..I Jc bom o cro u-bo employ pezoni to do r.:n-,.... c=-�.:c■oo c rrnu..oric on•dwh �of
cot more th-.n t/. o:=its in wt,-h the bornooa ocr raicfo or oa the crouor j zppurtco.ct tbc-co e.-c oot Coa--lly oocridxvd to be
critployco,vv1--the t-{,zta rim Act(GL1512 to 1(S))•app Ur,600 by a bomeoa,x for:GCri or prrmit rangy cvidmee the
• Icipd nun,,of an czployer under tho Wort..ola Compom.t.ioa Act.
I uadoszaaa dux a copy of tbi,mt.®aoo may be roc-N-or .ed to tbo pepertmcar of 1e�rrrial Acedmtl Offioo of Irzair.000 for th. '
oovezSc vrri[cnioo and that Eiltac to eoatre tcovOTyc under soetion 25 A of MC/L.152 no lad to t►x impasdieo of criminal pcndlties
000aix ing of a floc of up to S1.500.00.nd)or Craprisoozo=of up to aoc yt r z.od civil paaahie in tx form of n Stop Wort Order and.
fim of S 100..t dzy.gaintt tnc
For dcp.run---.4.1 u,c only
Permit Nunbrr
VITA 1 41: /2 3 t.{ap:; __ Lot
signatun:of LictnscclPcrr iucc f'l -- -J Ii
Versionl.7 Commercial Building Permit May 15,2000
i `
SECTION 10-STRUCTURAL:PEER REVIEW(780 CMR 11011) -' -
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 )
I, ! 1,as Owner of the subject property
hereby authorize Ito
act on my behalf,in all matters relative to work authorized by this building permit application.
I
i
Signature of Owner Date
I,( - t t/tct Qt iri,�'-P.-+(~ LoY`��+4( 1 ,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.
Si.ned under t�- 'ains and •enalti-s of.- 'u . ________,
I 40 a..>e
Print Name tz6/1/4€
/Signature -Avater/Agent Dhte
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: /� Not Applicable ❑
Name of License Holder:i t 1- ` '�i��a. % "' I ! Ol-7 G'
License mber
- Q'0, ( 17.e 1 1"Fs , --o / 1V ir' (��"C��l /' / G 6.
Address Expiration Date
Si na re �� Telephone
9
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affil vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the b 'ding permit.
Signed Affidavit Attached Yes No 0
r
i
•
Version1.7 Commercial Building Permit May 15,2000
t..
SECTION 9-PROFESSIONAL DESIGN.AND CONSTRUC-T.ION,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
I
Not Applicable
Name(Registrant):
1 Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
.
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
i � 1
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
--
I �
Name Area of Responsibility
Address Registration Number
` I t
Signature Telephone Expiration Date
9.3 General Contractor
r�,,, � '• `,�
1�1 U> ee..f' �--w\mck 0-C Not Applicable❑
Company Name:
. (>•
Responsible In Charge of Construction
P-O Bu-k,• 1 I�f�� ` �7 Of o i(
Address
6,?( , -
Signa re Telephone
Versionl.7 Commercial Building Permit May 15,2000
•FIST,®R 1 t o ® 4.1Z001-,t i' r,,.
:!:,".u" ,.*s aw. ".. ,�s, VIA4" '%41‹
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage I 1
H
I
Setbacks Front I 1 1 j I
Side L:11-----J R:= La I R:
i
Rear I i
But7dig Ireight I i j 1
Bldg.Square Footage i i 1 1 % - 1 I I
Open Space Footage
(Lot area minus bldg&paved i j j j ! I I
ping)
1 1 I, 1 I
#of Parking Spaces
Fill: ' I i t i i
(volume'&Location)
A. Has a Special Permit/Variance/Findin ver been issued for/on the site?
NO 0 DONT KNOW YES 0
1 i
IF YES, date issued: I
IF YES: Was the permit recorded at the Reg of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page —1 1 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
I
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO err
IF YES, describe size, type and location: I I
D. Are there any proposed changes to or additions of signs intended for the property? YES i NO (3(..
i 1
IF YES, describe size, type and location: 1
E. Will the construction activity disturb(clearing,grading,exca ion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® ` NO
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 ESS THAN 35,000
CUBIC FEETOF ENCLOSED SPACE
Interior Alterations isting Wall Signs El Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other❑
Brief Description !Enter a brief description here. Srrir )' 1
Of Proposed Work: j :-T-v.' ' i 4
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 CI
B Business 55/ 2A El
E Educational El 2B I El
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A El
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A El
S Storage ❑ S-1 ❑ S-2 ❑ 5B
[ ❑
U Utility ❑ Specify:I
Specify:
M Mixed Use ❑ eci I
P
F
S Special Use ❑ Specify:I
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: 1 5t�'e � Proposed Use Group: I '. hA''"'.--
Existing Hazard Index 780 CMR 34):1 I Proposed Hazard Index 780 CMR 34):
1
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION - " ,: - f
Floor Area per Floor(sf) .... "0"`,. . -� .,
St j }rw * o-+c'�. r�.4.'f-sy rCa, r r.,. s �' x ��
1st i I aa' �4t ,c3 s
ndf ( w a
2nd 2 fie`, j '�,,�,x fi
K " ..p J:4 "0, x is "
3rd ! � ham' ® , T
4tr, 1 � 2,1- 4 k P .
4"' 1 i I ��-41 '_ . ^Y
Total Area(sf) ; R Total Proposed New Construction(sf) #0 � -*�.A t -f,�, `" �'
Total Height(ft) j i f. .R f1 ::se,
Total Height ft I I � •*� Pr .. }
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone I I Outside Flood Zone❑ Municipal ❑ On site disposal system El
Version1.7 Commercial Buildin Permit Ma 15,2000
City of Northampton cti, ,
�
il Thig Department �`
--T-c7r� �,1 \ 2ManStreet
�.-' tl $s - �
,--- — Nora 'ton, MA 01060 •. •.. . ., `� x'-i 3 � � � .
U EC —•l,oq 13- -1+40 Fax 413-587-1272 =#: 4 2 p r3
PL1C,aI1ON-Tcr. RJ REPAI•,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
E,;,- C f:" T ('t'` fi11,\.t,4 = HER THAN A ONE OR TWO FAMILY DWELLING
.SECTION 1 SITE INFORMATION`
1 1 Property Address: 'This section to be completed by office
v O `1 Ci 1'Aloo., Lot Unit
{; '3 Z oned I Overlay District
I
i ,.r a
,l a `1 iu xT _: t ° '
Elm m St'Dstr CB D strict ,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED;AGENT-
2.1 Owner of Record:
r, o C n(z to / t r 7si, %,- - ,Nrfi,a,,,t,. i'ov\,N. 0046
Name(Print) 'CL k_kit-Q1)i t`Itre` p Current Mailing Addr ss:
Signature iii (;Vim" Telephone
2.2 Authorized Agent:
?) ees� 6 An:-C Yb I I P-6 d - i 14a' >:r±fio.wr •, MA ' c io (
Name(Print) 77 Current Mailing Address:
i 54)— -Li,'`' -
Signature /(ite 0 (----- _
Telephone
SECTION ESTIMATED CONSTRUCT ON COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building °
2. Electrical 1 (b)Estimated Total Cost of 1
j
! Construction from(6) I.
3. Plumbing 1 1 Building.Permit Fee
i .
4. Mechanical(HVAC) i ° i r
5.Fire Protection f
6. Total=(1 +2+3+4+5) ) 4 IJ) 0s) Check Number
This Section For.Offiicial Use Only
Building Permit Number Date'
Issued
r
Signature:
Building Commissioner/Inspector of Buildings Date
45 GOTHIC ST BP-2005-0650
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:roofmg BUILDING PERMIT
Permit# BP-2005-0650
Project# JS-2004-1656
Est. Cost: $14000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Pioneer Contractors 017890
Lot Size(sq. ft.): 6011.28 Owner: STAR NORTHAMPTON INC
7nninn: CB Applicant: Pioneer Contractors
AT: 45 GOTHIC ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers
Compensation
NORTHAMPTON MAO 1061 ISSUED ON:12/6/04 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP ROOF & INSTALL NEW RUBBER ROOF
MEMBRANE
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: d!S4
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT,I O OF
ANY OF ITS RULES AND REGULATIONS. `
Certificate of Y
Occu anc Signature:
Occupancy
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 12/6/04 0:00:00 9605 $70.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo