32C-177 (14) t
e
s�$ i Y 4f)B% rzt4 xxf Nariliamptn
asaacI tsctls' _=
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0, :7co DEPARTMENT OP BUILDING INSPECTIONS 4 iZeill
Wi.it
212 Main Street •' Municipal Building __
Northampton, Mass. 01060 r''
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, Y�, 1/- K 407, censeeJ see
(li perms )
with a principal place of business/residence at:
() 5)c 16uO-C o1-yek.e 6(° I (pbonet#) Li l. S3(Q -257S- Se-
(street/city/slate/zip)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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:
A.
,, (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
if
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed ifnecantary to include information pertaining to all ooraraeion)
)(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 pawn to do mainTrnxnre,construction or repair work on a dwelling of
not more than three units in which the homeowner resides or oo the grounds appurtenant thereto are not generally coaridered to be
employers under the worker's ration Act(GL152,ee 1(5)),application by a homeowner fore license or permit may evidence the
legal status of an employer under the Worker's Compensation Act.
I understand that a copy of this stag may be forwarded to the Departn>ecd.of Industrial Ac ideat'Offioe of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fins of 5100.00 a day againet me..
For departmental use only
r 1 Number
iii all bo r ma Lot ti .
— jt y` Signature of i i c e nsee/Pcrmittee
t
" Versionl.7 Commercial Building Permit May 15,2000
SECTION 10 'STRUCTURAL PEERREVIEW(780CkIR .1011
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION y11-,OW AU
NER THORIZATION TO BECOMPLETED =WHEN
OWNERS AGENT OR'CONTRACTORAPPLIES FOR BUILDING 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
ak1 1 13)20-0‘ i
Signature of Owner/A:-^ �'b Date
SECTION 12-CONST• ION SERVICES
10.1 Licensed Construction Supervisor: ,1 /
_� Not Applicable ❑
Name of License Holder : l2. ,`°-
License Number
\c - 40 Li ,1z-k? f k i C S (O c7 I b f
Address C)10i4 1 Expiration Date
g%1
Signature Telepione
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
SECTION 9 RROFIESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS,AND STRUCTURES SUBJECT;TO
CONSTRUE;TIONC,ONTROL PURSUANT TO'780'CMR 116'.(CONTAINING; MORE-THAN 35,000 C F,OFE1NCLOSED 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
Versionl.7 Commercial Building Permit May 15,2000
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 ❑
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
(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 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 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:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FORP tOJECTS LESS THAN 35,000
CUBIC.FEET OF ENCLOSED'SPACE .' v0 ' *
Ti's .. ,a &,,.p,;;; lj„ S fl Rt M
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ) Change of Use [ ] Other [ ]
❑ ,/i p, y, Accessory Building[ ] Repairs [ ]
haw : 4 Lvm 1L l
;SECTION 5-USE GROUP,AND CONSTRUCTION TYPE.
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly I A-1 ❑ A-2 ❑ A-3 ❑ lA I El
A-4 ❑ A-5 ❑ 1B ❑
B Business El 2A ❑
E Educational ❑ 2B I ❑
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 El 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 IN'USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTIONS BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION -',7
Floor Area per Floor(sf) ist y
�.
2
nd �r
1st
k $
2nd vi € ' t s %
c k
3rd 4th .'t- 4 ''' F
4th '''' .sue :4• 4.-•g;,•.4•.,.,
,, Y ? , z c'i ' . fn ' f y fir✓^-Total Area (sf) Total Proposed New Construction (sf) ; 4 _
x
Total Height(ft)
Total Height ft ry ,, A ,,f% ` 4
1.
Versionl.7 Commercial Building Permit May 15,2000
C E U V E C - Northampton -
:uil i ng Department 3 t , � f a
Main Street
2001 �
{
SEP 1 4 w
P.00m 100 i ,-
k .�thampton, MA 01060 et �
DEPT OF BUII E z,,
�1N�'d �� 587 1240 Fax 413 587-1272 ? �i, ■ � , , �
NORTN{tM oN, 01 � � '��
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
This section to be completed by office
1.1 Property Address: ,, 1
1 Map Lpt `� 4 UknitP
‘ Zone Overlayfstrtct4
Elm;St. District CB.Di ict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED,AGENT
2.1 Owner of Record:
c1 :I'CA .' ectk fi T.O. , F 3l.b x I OLI 7 S qOLYa14. e
Name(Print) Current Mailing Address: 0 1 CD q I
Signature ‘1r Telephone
2.2 Authorized Agent:
64,, .(Z.. -. c\c .,c-- S -Inn si=
Name(Print) Current Mailing Address:..........e:ilv
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item ,Estimated completed Cost(Dollarsermit )applicant to be Official Use Only
by p
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
(6)
3. Plumbing Building Construc Permit tion Fee from
4. Mechanical (HVAC) , f�
5. Fire Protection t5"
_6. Total = (1 + 2 + 3 +4 + 5) i D I Check Number
This Section For Official use only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
00 PLEASANT ST BP-2002-0300
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mitp13100k:32C- 177 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofmg BUILDING PERMIT
Permit# BP-2002-0300
Project# JS-2002-0450
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK NAIDORF 001083
Lot Size(sq.ft.): 18338.76 Owner: CHERRY REALTY INC
Zoning: GB Applicant: MARK NAIDORF
AT: 300 PLEASANT ST
Applicant Address: Phone: Insurance:
P 0 BOX 10475 (413) 536-8888
H O L Y O K E M A 010 41 ISSUED O N:9/17/010:00:00
TO PERFORM THE FOLLOWING WORK:4 X 12 ALUM PITCH ROOF TO ASPHALT
ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 9/17/01 0:00:00 6104/6114 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo