32C-029 (8) GS Builders
Gerry Shattuck
25 South Main St.
Haydenville, MA 01039
413.237.9820
To Whom It May Concern,
I request that you grant a modification to waive the requirement for
control construction for the project (demolition only permit) at 11
Brewster Court in Northampton 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,
I Gerry Shattuck
Gerry Shattuck
GS Builders
;_.. The Commonwealth of Massachusetts
..... Department of Industrial Accidents .
k— v ,—''" Office of Investigations
1=r �R. 600 Washington Street
,*
..,., -.BBoston, MA 02111
.. <.. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information ( X (C '(/ Please Print Legibly
Name(Business/Organization/Individual): � _
Address: � ' , ` / '
City/State/Zip: k. Phone#: 1 S 1:57 '`rz,,
Are you an employer?Che k the appropriate box: Type of project(required):
1.❑ I a a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
g Y P tY• 9. ci Building addition
[No workers' comp.insurance comp.insurance.$.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑
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.❑ 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 c• ' under the pain ' • • . ' l' of perjury that the information provided abov is t ue and correct.
Signature: Date: it
4111P
Phone#: r L( ( 3 7 _. z-g-2{
Official use only. Do not write in this area, to be completed by city or town official
-- —City 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'CIVIR 110.11) : --- .-: .. - '.
/
Independent Structural Engineering Structural Peer Review Required . Yes 0 No N&
SECTION 11 -OWNER.AUTHORIZATION-TO PE:COMPLETED. WHEN.'. . -' i
OWNERS AGENT OR CONTRACTOR APPLIES FORBUILDING'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.
-------7
Signature of Owner . Date
- -— r - -- -- r —
I, --- -- --,„——,,--- ,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.
Print Name
I
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Su rvisor:
--- ik1/4--lk- Not Applicable 0
Name of License Holder C-...
License Number
(c___ ecor ____1
Address -- Expiration Date
Signatu
Address
______
..„ F-Fr --z-s-,---w-0-7
.„......,_ _ __
Telephone
SECTION 13 WORKERS COMPENSATION INSURANCE AFFIPAVITIP/I:G.L.::c:.152i.§2.5C(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 buil • g-Permit.
Signed Affidavit Attached Yes No 0
.......mmummotk
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 EILOSED SPACE)
9.1 Registered Architect:
,.. .... — _ Not Applicable ❑
I
Name(Registrant): t _,.
Registration Number
Address ` ._,. :. .,. ___._ _._._„_.:.. .:.......:_.._..,....,.......
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address �� Registration Number
Signature Telephone Expiration Date
p. .«..., .� .,..,«_. �..._ ._, ,..,_ ......__,.._,.. ......_._ .
/ . t i i■
,
Name .
Area of Responsibility
Address ` R istration Number, _ _ H
Signature 'N ' Telephone w w, 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
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_Address
Signature Telephone
•
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON,ZONING • ,
Existing Proposed Required by zoning .
This column tore filled in by
Building Department
._ . — .
Lot Size i . _._ I __. w _._I
'
Frontage __w._.. _ ._ _ ` > -.. = i
Setbacks Front _ _ ....
Side L:.. _�.� LI___ _ R:1.. I I ;_
s 1 :i
Rear -- --
Building Height _ .
Bldg. Square Footage . 1 . % i I l
Open Space Footage �.,. 1 % . ......,
(Lot area minus bldg&paved
parking) __....._1
#of Parking Spaces 1 c
Fill:
(volume&Location)
A`
A. Has a Special Permit/Variance/Finding ever been issued for/on the s'te f F,
- ` NO 0 DONT KNOW 0 YES 0 I 1
r. 1 1 /
IF YES, date issued: { ; /
IF YES: Was the permit recorded at the Registry of Deeds? ,
NO 0 DONT KNOW 0 YES 0 f
IF YES. enter Book 1, I Page, and/or Doc ent#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued: F
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location . .__. .__. .__._H._.
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:
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.
,
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION:SERVICES FOR PROJECTS LESS THAN 35,.000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs X Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description !Enter a brief description here. ~—— ____.__.___..___,.
Of Proposed Work:€ 0/P n u WALL g.Qvvvt r�. �� • u,t 0174--
,,_A vv ("�-
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) I CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - r ❑
F Factory ❑ F-1 ❑ . F-2 ❑ 2C ❑
H-High Hazard ❑ -, 3A ❑
I Institutional ❑ I-1 17 1-2 ❑ I-3 ❑ 3B ❑
M Mercantile ❑ `\ 4 ❑
R Residential ❑ R-1 R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑,, S-1 S-2 ❑ 5B I ❑
U Utility
/ 1 �' kc,, _.__.. _ _..__ _M Mixed Use j i
1
V
S Special Use ❑ �' ��_�./ Pecify: . , ___ r._.._..,...........___.,,-.,e,__.._._........ .�_ _._..,... ,
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _,___.,_ ___,.._w, . _____ __.: Proposed Use Group: '
Existing Hazard Index 780 CMR 34): ,,.__ M__~__,___ Proposed Hazard Index 780 CMR 34): .____ m ___._m._ w_,___,___1
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
sc
1 sr ....._. 1
i �.
_.. .....__ _...
2nd
2nd' 1
3rd €3rd ' __ ...__...._ n
4in ____—_ ...._ _._._.... 4m f '
1
Total Area s
( 1) 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 0 Zone' ,___ .,_j Outside Flood Zone Municipal ❑ On site disposal system
.. _
Version1.7 Commercial Building Permit May 15,2000
- - '-' ''-- 'Departmeht us nily-r'----;,;',
L.___._.__j.City of Northampton
:
'--,,ti.e,"N, „,4,-,wal.014,,..110ft..,11:ilkt.014.s.,„'
Building Department 'CuIV,QiitiQriit.4W a
a'Y'-', rmtf....,,,..,,,,-.1A...oz.,4,,,,*--..,,,,,,,,, ,,,,,,,,,,,,,,,,.;.0,4,,
....
6 tiu,o, , 212 Main Street
1 " ,..",-!:::,,,,w.-:4„.4-i,.. .itA.:,,,;',,,,,,l.::v.,..,1,',44::::,,,,..;k:.,,:a,,i,
Room 100 'VV,,ataj'hyalli:*Vatfabifjtyk:'A;..tkq'vt.tumtwitq..rm,w4':i,;n.x, ,.;
,
L---------- --- -- ---3 N rthampton, MA 01060 IVi61:Seg:76'fiii:rdilkerPkii&,V*-41irWV,IV :,,gd. 4,1.:,,v,'. .:;;.::-,,,
Electric, Fi3mIng 6,-Gas iripections 4, .A:,:.-,. .:,4,:,,,,.',,;,,*:-.:.::,,,,,,.:,,,,:;,,,,,,.;:,,,,:i...,„.:;,:::::,,,,,i,:::_
Ncrthairiptcn, 10 AP110E132 413 587-1240 Fax 413-587-1272 'PIOu$ite;,P.ratf ,e,":'4qh:.E:,::,;: ;:':',,g...::74::,,,.::!;*:,;-,zt:-.i.k,iz,,W'z':i,-:::dff:4_PO::,.,.'
,,,,,,,,,,iv.,...;14„,,,,„.,,,,..,,,i,,,..::;,,...„:„.„.„,,..-.„..,,,,N,FoyA4vagr4towv.rlw.,f,:itri,
bther:spiclisi:vd,,,,y!,(7 -,,,,,,,,k,,,,,,,,n,An31,:m.,;,,,-,v.y..,3,,,,,,:,,,,..,o:
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
:
_.. :.„.. ..._. _ :
Map Lot Unit
i r c
1--
/1 gritia 4— c ----f o-v- 1 Zone Overlay District
.CB District
...
SECTION 2-:PROPERTY OWNERSHIP/AUTHORIZED:AGENT'.. '::::'.•-.::
.
2.1 Owner of Record:
,
Name(Print) Current Mailing Address:
Signature , Telephone
2.2 Authorized A
_ _ _ . . ...,....
Name(Print) , Current Mailing Address:
„____ 3 —_ _ - ,
Signature ----
. ..........
--_—...------ _.— -- —
! Z77 y_T-Lo
Telephone
. . . :
SECTION 3-.ESTIMATED.CONSTRUCTION COSTS:.. .' •:.•.:
Item Estimated Cost(Dollars)to be .,-., . :. :. ',:- OffiCia1:UseOnly
completed by permit applicant
1. Building I 2-----,47€D-------------1 ,(6)"'Buildirig Permit Fee ..17---7-.---.-- •,',.
2. Electrical ,:. .., , (b);:EstimatecITOtal Cost of
..
ConstrUctibn.from(6)
3. Plumbing 1 ....,...-- i 'Building-PeFmit.Fee
4. Mechanical(HVAC) ...„._,...33. „_ . ..,
, di 0
:_ ..„.. ....,....„,,_........,...........,._ .....,
5. Fire Protection
',....... ...„.„ .
.. .... _ _ _...J
6. Total=(1 +2+3+4+5) kk X,-,4251-‘2,3 Check Number tidi
This Section For Official Use Only
Building Permit Number . Date
Issued
Signature.._
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0661
APPLICANT/CONTACT PERSON GERRY SHATTUCK
ADDRESS/PHONE 25 S MAN ST HAYDENVILLE (413)237-9820 Q
PROPERTY LOCATION 11 BREWSTER CT
MAP 32C PARCEL 029 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid `
Building Permit Filled out /1a .!
Fee Paid
Typeof Construction: OPEN WALL TO REMOVE LARGE EQUIPMENT c
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 058422
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
t/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
Demolition Delay
`i t3
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.
r
11 BREWSTER CT BP-2014-0661
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-029 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0661
Project# JS-2014-001138
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERRY SHATTUCK 058422
Lot Size(sq. ft.): 4268.88 Owner: L 0 R T INVESTMENTS C/O NORTHAMPTON BREWERY
Zoning: CB(100)/ Applicant: GERRY SHATTUCK
AT: 11 BREWSTER CT
Applicant Address: Phone: Insurance:
25 S MAIN ST (413) 237-9820 0
HAYDENVI LLEMA01039 ISSUED ON:12/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:OPEN WALL TO REMOVE LARGE EQUIPMENT
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 12/4/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner