17C-205 Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main St.
Northampton, MA 01060
I request that you grant a modification to waive the requirement for control construction
for the project at 63 Main Street in Florence, because the work is of a minor nature, will not
affect health, accessibility, life and fire safety, or structural requirements and is impractical in
that the cost of control construction is considerable when compared to the cost of the proposed
work. Thank you for your consideration.
Respectfully,
Timothy Luce
PQ Box 14
Leeds, MA 01053
n ' '
\ The Commonwealth of Massachusetts
•
Department of Industrial Accidents
rTal
l�.
Office of Investigations
if
-� 600 Washing on Street •
"=-;.-xLt= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizati0
Address: PC 13 otie /L (
City/State/Zip: ( l-S /l/t4 6.1/6--4----9 Phone#: y/7 7- 2 F4)3
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with 6. 0 New construction
switiyees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
employees and have workers'
working for me in any capacity. 9. 0 Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.0 Pl ' g repairs or additions
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'
13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 penalties of perjury that the information provided above is true and correct
Signature7"1111( Date: / 3
Phone#: `.) `3 c CT co 3
Official use only. Do not write in this area,to be completed by thy or town official
—cityy 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 0 r No 0
SECTION 11-OWNER AUTHORIZATION-TO'BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
"` ''AC
1/_,- as Owner of the subject property
hereby authorize.'-:_ ...LI_-,c1__.___._..,J Gt- w.._ to
act o beh f, in all matters r tive to work horized by this building permit application.
ignature of Owner Dte
`M d t� M __ ___.. ' ,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.
Signed under the pains and penalties of perjury. _ _��.� .____ _,
Print Name — - --- _•-
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.'_ ...�i^^s _J......-__L Cic'r-'-- --,_,__ wmm_...m ./o.u_S
License Number
PO i l�! 5 /IAA- ' _ ✓5 `
_ _____ ___. __ _. M _ __ _.__._______ __.
Address Expiration Date
/ 3 TO
`•nature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MMG.L.c.152,§25C(6))
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil • permit.
Signed Affidavit Attached Yes No
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'EIJLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
I
Name Area of Responsibility
Address Registration Number
r
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
_ I
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable 0
Company Na e:
_ /065 15
Responsible I arge of Construction
•
Address
_
re Telephone
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON-ZONING
Existing Proposed Required by Zoning .
This column tote filled in by
Building Department
Lot Size s _ ; . .._._._._. —..a....
Frontage ___._.._..._.___ __ ._
Setbacks Front
Side L:: l R: 1 L:1 J R:7-1
Rear Elij .J
Building Height ,__.__._:
, i _ l
Bldg. Square Footage —1 _ .. % F-1,
Open Space Footage %
£
- (Lot area minus bldg&paved i i i 3 �i ?
parking)
#of Parking Spaces i i
Fill: ;)
(volume&Location) ' _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
_ NO 0 DON'T KNOW 0 YES 0
1
IF,YES, date issued: ? i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 mm
IF YES: enter Book ' Page; ! and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (,) DONT KNOW (3 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: 1-
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 Q NO Q
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.
•
e
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 a
CUBIC FEET OF ENCLOSED SPACE '--
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ ditions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other❑
Brief Description ,Ent r ay brief escri tion here. •�- ca ra ���'`"' i3:-.4.---4---
a C&�M.Pr,aww'S eel ■�-st,1 b D 4rL �r4� O r`-S
Of Proposed Work: 1 par,
__.2
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 1 B I ❑
B Business ❑ 2A I} ❑
E Educational ❑ 2B - r ❑
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 L ❑
__
U Utility C3 Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:' E
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)
s
___._______. _ - 1st r'
1st ' i
2nd
2 ___-__-__..._.. __._ _______
3rd _
3rd 3`d
4th 4 ' _.___. _. _ __ '
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
X .6
ti _ Versionl.7 Commercial Buildin_Permit May 15,20000 C
-.. City of Northampton . ,i r4 ;
►I i'6 Building Department .i
JUL 2 2013 212 Main Street t,
_, i Room 100
Northampton,;MA 01060
'1-p non 413-587-1240 Fax 413-587-1272 •• "-►• '�
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
b3 (fl A J\ -F ID Map Lot Unit
Zone Overlay District
w._ ._ - EIm St District CB District...
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address
Signature 11J' Telephone
2.2 Authorized Agent:
NamePnsi+Lk. __.._._. .__ _._ __......_..._._...._ _ -
(Print) Current Mailin Address:
3
3 _.._-___._._____,
Signature Telephone
SECTION 3-I ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building jw° '``--D (a)Building Permit Fee
;_ ....,7_, —______—________ ,______________
2. Electrical i (b)Estimated Total Cost of
s Construction from(6)
3. Plumbing i Building Permit Fee
4. Mechanical(HVAC) _ __
_._..
5. Fire Protection _.___
. .
6. Total=(1 +2+3+4+5) / I Check Number / C.
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0060
APPLICANT/CONTACT PERSON TIMOTHY J LUCE
ADDRESS/PHONE P 0 BOX 14 LEEDS (413)387-9800
PROPERTY LOCATION 63 MAIN ST
MAP 17C PARCEL 205 001 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 ��
Fee Paid
Typeof Construction: REPLACE RUBBER MEMBRANE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100515
3 sets of Plans/Plot Plan
THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 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 Commission _ Permit DPW Storm Water Management
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.
63 MAIN ST BP-2014-0060
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-205 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-2014-0060
Project# JS-2014-000137
Est. Cost: $7800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 14157.00 Owner: FINCK RICHARD W TRUSTEE
Zoning: GB(100)/ Applicant: TIMOTHY J LUCE
AT: 63 MAIN ST
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON:7/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE RUBBER MEMBRANE ROOF
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 7/26/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner