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31B-310 (4) 1• , 1 • 45 - A . E �tasanrhncelta' ,_ �j^.. - _ o DEPARTMENT OP BUILDING INSPECTIONS • -- ' 212 Main Street • Municipal Building Northampton, Mass. 01060 \-:-.--- -7 ir`.., WORKER'S COM?ENSATION, LNSUIZANCK AFI'DDAYYI' I, _,E F:42-- (lice sxlperrnittcc t>_,itfi- p-r i-p�-pl-awe-ef�usl>a��s/-residen-Gc—zt: �'°��� %/©e�� c .2-or.% 41 ev r? 1 cr (phone ) Z5- 27J (su ricity/staicra p) do hereby certify, under the pains and penalties of perjury, :hal . VI- an employer providing the followinQ 0..orkcr's compensation coverage for my employees worldng on this job: , /rt / (�r—a r (_- c�,,� 1 z. UG (Insure Conracv) • (Policy Nt. r) (:7 -pint on Dale) • ( ) I am a sole proprietor, general contractor or homeowner(ccie one) and have hired the contractors listed below who hive the following worker's c-onoensadon policies: (Name of Contractor.) (Insurance Cornoanyi?oUC'• NuSibc ) (E:p r-uon Date) (Name of C000-aclor) -- (insurance ComoanvPoUC; Number) (iixi irtion Dare) (?`tame of Contractor) (Lnsuranc: Company/Polio- Numbu) (Espirdon Datc), (Name of Contractor) (I.Dsurancz Company/Policy Numbc-r) - (Expiration Da.tc). (eaaeb -'tit:c..JJ s'_a'oC ifnecaary to and &inforcraoo pertaining to.11 euc-r-moors) • ( ) I am a sole proprietor and have no one worldng for me. ' ( ) I am.a home owner performing all the work myself. NOTE:plea be ew-atc ifi•1 lob.-.le homeowners lobo employ per.oc to do c.•;.-, tcs.:et o c repair work oo a d.•cn_y of not more than t'.ntr-=its is te1icb the botnoowocr raid oc oo the ground,appurtenarn the-do�-c pot filly oe ido-ed to be employed undo.Sc t t aci;rt o=mp -+'m Au(G Lt 5:233 I(S)),rppliaroo by a boo fox c lice_or permit r>=y evidence the 1ego1 mans,of as exployyr under dap Wo&ca'a Coarp<,m.tioa Aot. I undcaand that a oopy of tbi.mt�m.„zd 03ay be foco+o.rded to tbo Dryertmcat of Iol...erial Acodcav'Ofrioa of tnvor'ooa for the cove+-Sc verif trtioa and that f_iltzc to secure\coverage toxdCf section 25A of M(L 152 out lead to the imposition of criminal penalties eomisiug of a sine of up to S1.500.00.ndroc inoprioecooncal of up to one year and civil paultia in dye form of a Slop Wort Ordcr and s frm 0(5100.00 a thy apiasl tnc For�n--.t u,c only / / Pci-[Itlt 1`Iwnbcr .� // ,6�r2 Map:: Lot Sign.-A" of Li.— °crmittcc L)3te s } Version1.7 Commercial Building Permit May 15,2000 SECTION 10=STRUCTURALREER REVIEW(780 CIUIR 1ti 011 Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11-OWNER AUTHORIZATION,-=TO-BE COMPLETED WHEN' OWNERS.AGENT OR CONTRACTOR APPLIES FOR=BUILD]NG`PERMIT I, i ',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 /f/'�'=!/�I '"4 �L'/ice/� i ._: �.� L111 ' ,as Owner/Authorized iz �7 " y Agent hereby declare that the statements and information on the for-acing app ication %-true art• a curate,to the best of my knowledge and belief. Signed under the •ains and •enalties of•e'u . Print Name 12e0r_ T f 1)1 C)itit y(f/e2c Signature of Owner/Agent ate .SECTION.12-CONSTRUCTION SERVICES. 10.1 Licensed Construction Supervisor: 7� Not Applicable ❑ Name of License Holder:' { C% ✓ J C License Number /24e5 /0ex 3o ? Vi (...® ( - f - 0at02 1 Y/°Z47 49 ) Address Expiration Date Signature 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 b t. uilding permit Affidavit Attached Yes !7 ui No 0 r • Version1.7 Commercial Building Permit May 15,2000 SECTION .9-PROFESSIONAL DESIGN.AND CONSTRUCTION SERVICES F..OR BUILDINGS AND STUURESS IBJECT:tO CONSTRUCTION CONTROL PURSUANT 116(CONTAINING MORE TA 35OOO C F.OF ENCOSED SACE) 9.1 Registered Architect • ! Not Applicable ❑ Name(Registrant): Registration Number Address I Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): i Name Area of Responsibility Address Registration Number { Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number I I Signature Telephone Expiration Date i Name Area of Responsibility I 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: ,1 Responsible In Charge of Construction Address s S-2;°302 e1 j Sig Telephone Versionl.7 Commercial Building Permit May 15,2000 F,o. 1 1; r' Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size • i : i Frontage Setbacks Front 6 I 1 j Side L:1 ' R:' L:1 1 R:1 I 1 !____.___J 1 Rear B i1&ng Height— j i i 1_1 Bldg.Square Footage i i I I % i 1 1 . Open Space Footage (Lot area minus bldg&paved 1_1, 1-1 1 1 parking) #of Parking Spaces I 1 I I Fill: ' I ii (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 IF YES, date issued: i 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 I IF YES: enter Book Pase and/or Document# I B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Date Issued: C. Do any signs exist on the property? YES Q NO Q - IF YES, describe size, type and location: 1 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: I E. Will the construction activity disturb(cleating,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_FFRPROdECTS;CESS"THAN 35,000 CUBIC EETOF?ENCCOSED-SEs..ACE. , Interior Alterations ❑ Existing Wall Signs El Demolition❑ Repairs El Additions El Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use El Other❑ Brief Description ;Enter a brief description here. .16----/040'/W '//2e 1-2.67,441‘,6.---,.//d Jrie., 7z 2e t Of Proposed Work:1/0/C- aTi/- . /N0rS `-See---1----;r lZac ' — L2 Gp/l'G — .�.6'/.f/7 k _"SECTION 5 USE GROUP AND_CONSTRUCTId1TY,PE- . USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑ _ El A-4 El A-5 ❑ 1B ❑ B Business El 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C El H High Hazard ❑ 3A ❑ — I Institutional ❑ I-1 ❑ 1-2 El 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:I M Mixed Use El Specify: S Special Use ❑ Specify 1 COMPLETE THIS'SECTION IF EXISTING BUILDING-UNDEI GO1NG RENObVAT[ONS, 1DDFTIONS Ab1D�OR{CFfANGE IN USE Existing Use Group: I I Proposed Use Group: t Existing Hazard Index 780 CMR 34):1 I Proposed Hazard Index 780 CMR 34):j I SECTION BUILDING HEIGHT ANDAREA; BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION i `` 4 Floor Area per Floor(sf) 4 "' -- -t ! 1 r w *4 ` .1st � , . " 2nd; 2nd I �T -.. Std I x'"", v- '` c a `" —5"S. t `�, ..., 3rd ' ` d 1 "k ,� ;'w'� + 4m , 1 4th f , Total Area(sf) Total Proposed New Construction(sf) .� a ,- t , Z ,sus Total Height(ft) ' � _ �� "� Total Height ft 1 4ea ' . :- ., fir_ I._ ` - :z 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public El Private ❑ Zone l ! Outside Flood Zone❑ Municipal ❑ On site disposal system • Versioni.7 Commercial Building Permit Ma 15,2000 f,. °z, ? - t i 8. .' ,\ \°' City of Northampton ,. - -` �Building Department ' isa?. Y 212 Main Street e n g _ ~ S ' A '. - b 2005 Room 100 a e C Northampton, MA 01060 ' a r .. .1 phpr-413=587-1 0 Fax 413-587-1272 Ploo. : : � - ' 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. SITEINFORMATION --- --I:1 Propertv-4ddress: This section to�be comp`feted by office - -' N 7/ ,.5 l�la S f i Px tot 6 Unit' l j ne m,Overlay D19trict z` ` Y otk,pt 1Dioir °e CBD'stnct; " SECTION 2 :PROPERTY OWNERSHIP/AUTHORIZED,AGENT 2.1 Owner of Record: d/i'L ov Ca1 P ; _ 5 4./A7_.-ek,,ft Sr' Yex '' Name(Print) ' . Current Mailing Address: i Signature Telephone 2.2 Authorized Anent: ''aitmi G il 4 o/`d i c a Zci I /`O. A-30x 30Z &T /'1 4' Name(Print) Current Mailing Address: 0,d ■4 Signature Telephone SECTION:3.-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official-Use-Only completed by permit applicant '.. 1. Building . j '`(a}°Building;Permit.Fee /,9 / 0 a ! 2. Electrical i ; (o)Estimated Total Cost of i . _ _ /1f JO 7 I J 6 o D _ y E Gonstruction:from(6) 3. Plumbing I S.0 6 i Building.PermitFee 3 .. 4. Mechanical(HVAC) i 5.Fire Protection i i ° `- 6. Total=(1+2+3+4+5) /C, -5'00 --Check Number 0/6-7V/ 9, = . ThisSection.For Officiat Use Only Building Pecmt lfnib . Issued 7- Signature; Building Commissioner/Inspector of Buildings . Date File#BP-2005-0940 APPLICANT/CONTACT PERSON PROSPECT BUILDERS INC ADDRESS/PHONE P 0 BOX 302 EAST LONGMEADOW (800)486-4976 PROPERTY LOCATION 71 STATE ST-UNIT 105 MAP 31B PARCEL 310 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out .07679(71 Fee Paid Typeof Construction: REPAIR FIRE DAMAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 017699 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Commis on ..,,—./ k., ,,e, ,‘ f .es ‘i 7//? Cr'13 -- 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. 2 '8 1 6 BP-2005-0940 71 STATE ST-UNIT 105 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B-310 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2005-0940 Project# JS-2005-1310 Est. Cost: $16500.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PROSPECT BUILDERS INC 017699 Lot Size(sq. ft.): 90735.48 Owner: MICHAEL ASSOCIATES Zoning:URC Applicant: PROSPECT BUILDERS INC AT: 71 STATE ST - UNIT 105 Applicant Address: Phone: Insurance: P 0 BOX 302 (800) 486-4976 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:4/8/05 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR FIRE DAMAGE 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 4/8/05 0:00:00 $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo