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DEPARTMENT OF BUILDING INSPECTIONS _=t�-
212 Main Street • Municipal Building '
Northampton, Mass. 01060 ' utr'
WORKER'S COMPENSATION INSURANCE: AFFIDAVIT
I, CvtyS1-R14 cI. Se *. C,
(licenseeJpermittee)
with a principal place of business/residence at:
•
3oc) Pt,£.AS4..aT 53 AlactrnkdaHP-tab. Nv*b1s4‘phone#) '5$U 74./y'
(streeticity/stairh ip)
do hereby certify, under the pains and penalties of perjury, that:
(4 I am an employer providing the following worker's compensation coverage for my
employees working on this job:
TRgott.Pa S Wgea-ue'TVgvJ 404 - 3- 9I
(Insurance Company) (Policy Number) (Expiration Date)
`g 3103102
( ) I am a sole proprietor, general coati actor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
4
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compa.ny/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet if necessary to include infocmaiioa 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:please be aware that while homeowners who employ persons to do nraintrnxtW,construction or repair work on a dwdling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto art not generally 000sidcrcd to be
employers under tbo worker's compensation Act(GL152,sa 1(5)),application by a homeowner for a license a permit may evidence the
legal statue of an employer under the Wocirac'a Cocnpeasaiion Act
I underhand that a copy of this rtatemeai may be forwarded to the Department of Industrial Aid a Offioo of Irssunnce for the
coverage verification and that failure to secure coverage under marina 25A of MOL 152 can lead to tba inapositioa of criminal penalties
consisting of a fine of up to S 1,500.00 and/or imprisonment of up to coo year and civil peachier in the form of a Stop Work Order and a
firm of 5100.00 a day against tux.
For dgnrtmraal uao only
- Permit Number
• ..* . - ` —'11,1•- _ i 02 MaP11 Lot#
Signature of LiccnseelPermitce �:
•
,r•-••• Versionl.7 Commercial Building Permit May 15,2000
•
SSE TION•2 T'RUCi'U�2AL REERgREVI£WsIIiI,liSONtMk1�.�
Independent Structural Structural Engineering Structural Peer Review Required Yes ❑ No ❑
•
lSECTION 1 pWNEFyt�AUTHORIZATION 7O BE:COMPL'ETED WHEN' '
OWNE2S AGtT''OR tiONTRACTOR APPLIES 'OR BUILD(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
, 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
SEGT10012 CONSTRUCTION SERVICES •
• 10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ,4/d Lu CI K llee.
License Number
3� /&"4 C 0#1 ff, PYo"e`t c e f 'i4 la (o C s 01)t)I�3
Address Expiration Date
a ) -sir 9 cf 3 �' ` Li
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 building permit.
Signed Affidavit Attached Yes ❑ No ❑
Versionl.7 Commercial Building Permit May 15,2000
SE(iTION 9"' _ OF SSIONAL DESIGN AND3CONSTRUOTION�SERVICES FOR BUILQIN,GSANp, 3'UCTURES SUBJ�CTTO4,,, ;
CO NTRUCTJO(+��ONTROL'.;PURSUAt∎i d 780'CMR 1]:6:(CONTAINING''MO�RE THAN it't000t �jf rENGLOSEA SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration 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
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
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
P7.Water Supply(M.G.L. C. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
ublic I Private ❑ Zone: Outside Flood Zone ❑ Municipal A 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 vo
(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 X 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 X 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
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:
A
Version1.7 Commercial Building Permit May 15,2000
.
SECTION 4 C STRICT ON,SERVICES FOR PROJECIT$ LESS THAN 35 00bi
C>,C C4:pi 1O'EN2 OS•D PAC k 0 N
on
nterior Alteration ) Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
EerW ITCSC'.(Z, -7roo3: T:1i 7o-z (/ 00,-i . iC ftc4,., Clio,/4 y
°SECTI OV 5 USE GROU�?ANI)CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I.1 ❑ I.2 ❑ 1.3 ❑ 3B ❑
M Mercantile X 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
',COMPLETE THIS SECTION IF EXISTING'BUILDING UNDERGOING RENOVATIONS,ADDITIONS,AND/OR CHANGE INUSE '
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION „ 4%
Floor Area per Floor(sf) �k A'
1Str
t
1st ,�(7L' 2 � ` r, y cif �_
2nd e`1 SC 0 3 #' -'
4th 4
3rd a yf 4 ne to _
4IYE, ltd, r? -
4th ,,, A.
Total Area(sf) Total Proposed New Construction (sf) 4 :-
Total Height(ft) i . a ° `4•
Total Height ft ; '! .-
Version1.7 Commercial Building Permit May 15,2000
( orthampton•
�i.� 2r— 1'u fi‘,,li
: Department � � �� , �„,....
I = Main Street r,
JAN 3 1 200 �.om 100
if
o ton MA 01060 �w :
fvrrT4J.. 587. 240 Fax 413-587.1272 _ ''f �
G ••Yawm,i..®...w�s.,,�4xmwes »aa...r.. .., ur„xa >..«.....i,2h
APPLICATION TO CONSTRUC • -AIR, 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: s ; This sect ott to a pmpl fed by ®#fce k
N done �� bOverla 9 1. t t �f�
� / / : � : k t
Elm SttDlsgIrict CB D3str ct / � `.- �.
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED°AGENT`
V'e_0 Record:
1%/14 z tc N A 2(tots 2 G (� • C'?ty ( b -Ci fol yal4 (►��1-
Name(Print) Current Mailing Address: Q ►Q��t
4l1Mill 5'''Ste- VggQ
Signature
ir�j Telephone
2.2 Authoelzfd Aeettt:
C'S 5P(.LLP4tr jZ N C C It SU►t.1 C L SpRp a 30b Q(.QI�'S-A ref Si t4 �WNP
Name(Print) Current Mailing Address:
Signature ... Telephone _
SEC TI®N 3 . E TIM T D.C• '.'TR 1•N'' 1®.
Item Estimated Cost(Dollars)to be Of ftetai Use(;iil ,.;
completed by permit applicant '
1. Building c (a) Building Permit:Fee
2. Electrical 3'oO, c (b) Estimated Total Costof .•Construction.trorn(6)_,
3. Plumbing I ‘,./1 0p . 'cc” Building Permit Fee-
4. Mechanical (HVAC)
5. Fire Protection
, '-‘' /-., :-, - - -,', ,-,_ , , , _
6. Total =(1 + 2 + 3 +4+ 5) + Od, v` Check'Number3 7 15-'''
T is'Section.Foir Official Use Only v"
Buddin Per �t Number. i _Date issued
Signature. P
Burldii g Cu iss oneri✓Insp or of Buildings D e,�',
File#BP-2002-0691
APPLICANT/CONTACT PERSON NAIDORF MARK C""/?7'4-e 5Pl1"/
ADDRESS/PHONE (413)536-8888 0
51-11—()1744/C)
PROPERTY LOCATION 300 PLEASANT ST
MAP 32C PARCEL 177 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ce5a
Fee Paid
Typeof Construction: INSTALL WORKING KITCHEN DISPLAY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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 Commissi
z 2 0C �°--
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.
'300 PLEASANT ST BP-2002-0691
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 177 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0691
Project# JS-2002-1100
Est.Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALAN LAVALLEE 077198
Lot Size(sq.ft.): 18338.76 Owner: NAIDORF MARK
Zoning: GB Applicant: NAIDORF MAR K
AT: 300 PLEASANT ST
Applicant Address: Phone: Insurance:
(413) 536-8888 () Workers Compensation
H O L Y O K E M A 01040 ISSUED O N:2/6/0 2 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WORKING KITCHEN DISPLAY
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/6/02 0:00:00 3910 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo