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11C-004 (3) • 1A .11�-0• p�. _ \ 1`ie C�ri� t7f iorf )tlp foll Q:f1E �lasanchn�rtta _ • c� DEPARTMENT OP BUILDING INSPECTIONS •�^ 212 Main Strcct Municipal Building Northampton, Mass. 01060 WOPJG R'S CON PENSATION INSURANCE AFFIDAVIT L, 0M/51S_J.�Q �_• (li cccscclpermi ttcc) with a principal place of businesslresidence at: 17(3.,D/mofr Prnv_D ('f/e's,r6 Y j7i (phone') 4,j - ?Q6 41S-1/4y (sQc Jcity/Sta zip) do hereby certify, under the pains and penalties of perjury, :hat ( ) I am an employer providing the following worker's compensation coverage for my employees worng on this job: (Cnsur_n Company) (Policy Nur bcr) (r';-piraon Data) f , I am z general contractor or homeowner (c -de one) and have hired the conn-ac of 'Listed below who have the following worker's coone.nsaron policies: (Name of Co r c-,or) (Insur-ncc CornDa1yI?oUc- Num c ) (E pir dt:on Datc) (Name of Contractor) (Ins-w-an Company Poilcy Number) (LxTir lion Date) (Name of Conzraeto;) (T_nsura.ne Compan}•/Pol:q- Nnmbcs) (Exoirrioo Dalc) • (Name of Contractor) (Insurance Company/Policy Numb..r) (Expitatio° Date). (atucb Ai;;oca!t5eu ncoc,Ary to rdu&inform-a-ioa pertaining to all oom-s.Cora) - (k) I am a sole proprietor and have no one worl,-ing for me. ( ) I am.a home owner performing all the work myself. NOTE:paesc be ew-m't t c w j C b•CDGOWIDCn wbo Craploy pezoat w Jo .,,, C=%.14100 c rtpair wvoric oa a dwralizz of not mort then L rco tmtr in uoaiciz the bocnoowvcr resdo or oo the pourath zppurtca:r1 t c-ao crc cot&-eh—nity oocridmi to be aizployc- uo c the wckkeel oact*c+c-,'co.Act(GL152ss1(5))•appiitypoo by a botacoo.-o=fax t lice__or permit troy c-vidcocc t c legal R-.,a of an o=ploy.r under ciao Workoec Comp.omatioa Ad I uodcst.nd th..r a copy of thi,catcm.caa may 1>.a focw..rded to tbo • troaoa of lort•aTritl Aoodaal Of5oo of 4uuzooa for th. eovcr1.6-c vq-ificzaioa,md th_t L-iltrc to LCCLUT'CO verttso u idcr soetion 25A of MOL 152 can tad to the impoai[ieo of criminal penahira our oacnizios of a Gm of up to S 1.00-00 andlor ixoprisoca7ocat of up to one year end civil peaahio io tb<form of Stop Wort Orda and rrm o(5100.00 a ray ag inet me For dep rtaa�->l ux only ,,y Pcrmit>�n� Si ,�• ua�e-.a `�/� Map::_ Lot n s` -. Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-•STRUCTURAL PEER REVIEW(78Q CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 11 OWNER AUTHORIZATION`- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT � � , �. 7 , as Owner of the subject property hereby authorize Y1,4--> <-w 3 - l � - to act on my behalf, in all matters relative to work authorized by this building permit application. ) 7 , 1 3/6/0 Signature of Owner Date XI, ,z,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. Signed under the pains and penalties of perjury. C . / y2 J Print Name ? / Signature of Owner/Agent Date SECTION:12 CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ::,0--r,A,, l C 1(0 9 7 q �/ License Number L(3 Din. PJ riPiz o !a. G -ao,aoe 7 Address Expiration Date fbe /a 3-09 -zecs"z7,J./ 'ature / Telephone SECTION 13 WORXERS''CO.MPENISA710N 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 ❑ Version1.7 Commercial Building Permit May 15,2000 •SECTION 9 PROFESSIONAL DESIGN AND OD,NSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION':CONTROL PURSUANT T011010 F(136 XPONTAI NING MOP ETHAA13S OOO cs.,OF.ENCLOS;ED.°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 1 7.Water Supply(M.G.L.c.40,§ 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: f Public ❑ Private ❑ J 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 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT 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 .-► . n ES ' 46 ELON 4-ON ON C O rROICT#-I.ESS A1 ,3 �k �CUBICF EEN fiF�Cf� AI-4,:f.',#� . - ' i �‘7Z-V Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] Pt nAccessory Building [ ] Repairs [ ] BRIEF DESCRIPTION '7,ry J U (,� ,L — --i� _ � � ' SECTIONS USE=GROUP`AND; NSTRUCTIONTYPE' i LA....„ i�r USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly I A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 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: COMPLETE1 SSECTION EXlS3ING:,_y 'rv.1NG JNDDtGOING RhNOV''.72-.,.`-'2.:ONS,J�A�Tf1ONS'ANDJORCHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6BUILDNG HEIGHTAN D AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION '4.'"..,1';'',,%-''''.0.4'',71'i i r, r - a PP SE�NI,Y i a ' 01x, iM ,,. Floor Area per Floor(sf) 1 yk4 �* �. , ' 0 .,g ;`t. 1st 22nd '0 ta,,N .,� a A� a `" 1 -z 4^�'t' - i n a v% hql .. $ 4s}±d'¢C 2nd '� a� � x�x 3rd . ,y, a d �� 4 th 4th , io'" tt"w, re3sIa�M6 Total Area (sf) Total Proposed New Construction (sf) 14,0 P ----__-- --- ---- �, 14 te %44 * t"Total Height(ft) „' .. r .; .: Total Height ft---------___"'_ *� ; ° " �'r" a *,, Version1.7 Coal Building Permit May 15,2000 . o-'' ," � a t -r e", City of Northampton ,eF s 4 -' Building Department 212 Main Street fi Room 100 , , , Y 1 �G t _� - rn '-L�° Northampton, MA 01060 F k; r �' fi'''r' phone 413-587-1240 Fax 413-587-1272 r r. i APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION .SIT f OBMAT3'ON • a. :. x� t° $'° ,a a i•-., of a e o "c ® ,W 0 e e ® , V ,1.1 Property Address: P :i i s� x�A k � PE* # i . a i � - "' ECI'IO.N 2 P.ROPERTY' 3WNERSHIPIAUTIiORIZED AGENT �' k 2.1 Owner of Record: 14(74 Y i)c/1/P S d': -- ,1 `-' / e -- -. (:_,, ›dl• , 4. „/„..,i)i, . 0,,. _73 c Current Mailing Address:(Print) e z-- fY) e , C 4--tom s , L e. f i 3 Li — / Telephone 2.2 Authorized Agent: y3 PaJ �� -- --1;;;-,,, a H -•I p /O /Current Mailing Address:(Print) q/3 '—)9 - S' iI ' Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION EOSTS Item Estimated Cost(Dollars)to be Offic�a1Use Only completed by permit applicant 1. Building 4,A3 q,,,. Gs— (a)Budding Permit it/4.w— Wlirtsr4 2. Electrical Conslrgctiof .' 6) 3. Plumbing uildingercrlfifee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1+ 2+ 3+4+ 5) Claeck Niirnber- - 0 This SSection°For'Official Use Only Buildin Perna t,Number• t x 9 . . ti :,�ate~Issued Signature: Building'Commissi©ner%inspector of Buildings Date 122 FLORENCE ST BP-2006-0862 GIS#: COMMONWEALTH OF MASSACHUSETTS moms*:"i + CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0862 Project# JS-2006-1329 Est. Cost: $2345.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Tom Boyle 111700 Lot Size(sq. ft.): 8407.08 Owner: ELLIOTT RAYMOND S&CLAIRE M Zoning:URA Applicant: Tom Boyle AT: 122 FLORENCE ST Applicant Address: Phone: Insurance: 43 DAMON POND RD (413) 296-4544 CHESTERFIELDMA01012 ISSUED ON:3/6/2006 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 3/6/2006 0:00:00 $25.006231 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo