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32C-104 (15) IP Ili : -- _ G�It,�Fe �.Za1an(Ej aLCtta •• !•'►waf DEPAR(}.TEN; oP ➢UILDO'C INSPECT iO/,S ?- _ 212 Amin Street Municipal Building Northampton, Mass- 01060 r'' Grl�i?'S CO E,NSA"1LON G1SUP. ._NCF. Ai'I ID r+.t,II' ftic��S Jpciudtr ) with a pru-icipal place of business/residencc at: �- /6 13-k (phone ) 11 do hereby certify, under the pains and penalties of perjury:; .tha: (v} I am an employer providing We iol]owine ,t,orkcr's comocassoon cover arc for Illy employees worl;:ng on this job (L�runoc co n r,•) (?clic: Nu abcr) ;-pinion -) ( ) I am a sole prooneror, general cone actor or homeowner (cc-cie one) and have hired the coon actors listed below who have the fo do 'J;.ng worker's C0 DtaS2uon pcicies: t Nonje of .).'� - N .-pi-r i -nn ) ' CG^'echo"} IR2rati� COIAD�-.Z !;4t:cr tLu.-._.' C•`-`:Jr:J�_,. DItC (,lame of C000aoor) Cuisurancc Cooaaa•,v?oUc's' Nt nccr) ("E_pir;ion Daie) • (Name of Coor`i-aciar) (Lr.s rancr mpa.cry/P ol;c)• Nnmt,cr) (Exairtion Daze) • (Name of Coarraccor) (Lnsur-atncz Conpan f/Policv Numb:.r) (ncac�:1dr.:oCJ&..c a�•, to c�c'uc�v:fvc'-.y.'i oc pc-to rt to.11 ( ) I am a sole proprietor and have no one working for me. ( ) I am.a home owner performing L the work myself NOTE:pi=oc be ew^.r.tti,,.s'. lc hct-aam.xn wbo icy pe-.aex to -r. e=-:=�x7 c r.-a, u'orz oo a th'tU:-•i of ant m«c th= tho bor oo ' o-ruiG^of ca the C-oe oc5 r r t oo=ax o lly o-A.-ai to tc c:crI t t,,,r-tho ()=2x--o s '.e(GL!52 I(S)),=.an1ir-.noo 5y a boca..aa-oe fc_bcs cc;emits oy cvid=co tho { ^y r s o o of .o o Ioyec uadcr rho W oc eoo c Coop ��Laoa Ae. [�.odcY--.aG t44s..°'Y (Pr oa or t as foe cS., my o_vetlieiioo o th.=:C_:lizt to ucuue :octioc 2S A of MC L. 152 too Ica;to the of.fix or vp ca 51_,S00.00 a eitx r'-;T' or Up to 0-CC __. c-.i1 p.c.1jo foc-a of=Stop Worrc Ord.'od rvoof5100.00a day a,7,7'IIIfx i) ?crtJi NtJn1C`G' S:I a2l-e.of Lcw "cc- ;C:c L)-17.Le -- I *a. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` 600 Washington Street 0 Boston,MA 02111 s� www.massgov/dia • :Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am 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 g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ P officers have exercised their 3.❑ I am a homeowner doing all work 11.❑Plumbing 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 employee& 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 copy 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 Signature: Date: Phone#: 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#: Versionl.7 Commercial Building Permit May 15,2000 SEC-TION710 STRUCTURAL PEERRENIE1WV(Z80 CMR 11011f - Independent Structural Engineering Structural Peer Review Required Yes Q No 0 SECTION-11=:OWNER AUTHORIZATION.=TOBE-COMPLECED-:VIIHEN` _ OWNERS.AGENT OR CONTRAC70R APPLIES•FOR BUILDING PERMIT I, 'k (iL /14-0„.J..'y as Owner of the subject property i w (yX . hereby authorize �CJ 7 to act on my behalf,in all matters relative to work authorized by this building permit application. .—. 0 7 it Signature of e.;/“ � / Date I,! J0 ON' tA/)I?)-�� i 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. Signed under thepains and_penalties of perjury. i ir' J � !UlVi Print Name l Signature of Owner/A a Date :-SECTION:'I ONISTMICTIO�1 SER CES 10.1 Licensed Construction Supervisor: Not Applicable ❑ I Name of License Holder:+ #f1 A' L-rAi a ( I f C- O l�� f / �j / License Number / l( A'° t -vrt 5+ `4j i 1 1.-ut-wr`r#` /to d/��II I I �7/J% v�L7y6 , Address I Expiration D e Signature , N j4f Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L-c.152-T§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 p No 0 • r i el Mk, Version1.7 Commercial Building Permit May 15,2000 1.. SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURES SUBJECT.TO CONSTRUCTION CONTROL;PURSUANT TO7BQCMR 116{CONTAINING -.MORE THAN_35;000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ •Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility I Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility � 3 l 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: i Responsible In Charge of Construction r- i . Address Signature Telephone ., N , Versionl.7 Commercial Building Permit May 15,2000 u8 ©R a i .QI t 'ri.. Existing Proposed Required by Zoning This column to be filled in by Building Department S ' ` Lot Size �� CO��O S C" } � �� Frontage 1 c�5 F I f ' Setbacks Front 1 324 L b Side L:'`-- "S.--&12'''R: #=1--+N L: R: 11 Rear r -Bnildmg Height L OT - , Bldg.Square Footage r % - TUC�C 1 ! Open Space Footage +�+ �{-- % i (Lot area minus bldg&paved L,L � !►-h i ping) #of Parking Spaces Fill: ' -- — — I? ?, - Ev Y t ;cr_fi(volume'8L Location) --- -- A. Has a Special Permit/Variance/Finding ev een issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regist Beds? NO 0 DONT KNOW YES 0 IF YES: enter Book ; Page: 1 and/o Document# B. Does the site contain a brook, body of water or wetlands? NO 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 , Date Issued: erC. Do any signs exist on the property? YES NO 0 IF YES, describe size, type and location: ,P'r rivret IIwir D. Are there any proposed changes to or additions of signs intended for the property? YES er NO 0 IF YES, describe size, type and location: lospon.wi4dgh( so)e pi ulmric5- E. Will the construction activity disturb(clearing,gradin xcavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 ' N IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15,2000 SECTION 4-£CONSTRUC'T1ON.SERV10ES 16J)ROJECTStESS THAN 35,000 CUBI.CFEET'OFENCLOSED:SRACE - Interior Alterations ❑ Existing Wall Signs ❑' Demolition❑ Repairs 2 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: s✓• E'K, �, 1ft'j�'�uv� rite f 'SECTION'S--USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly cia, Al- ❑ ❑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 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ,Ig1 S Storage ❑ S-1 ❑ S-2 ❑ 5B 1 ❑ U Utility ,..❑ Specify: M Mixed Use 0 Specify:f S Special Use 0 Specify COMPLEfETHIS SECTIONTF EXISTING BUILDING UNDERG011NG RENOVATIONS.AI DITIONS.AND1OR CHANGE IN USE Existing Use Group: f �� Proposed Use Group: , A'-' : Existing Hazard Index 780 CMR 34):E ` E Proposed Hazard Index 780 CMR 34):. - ! SECTION 6=6UILDINGk1EIGHTANDAREA, BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ' r Floor Area per Floor(sf) ���- ) st ; 1sti 1 „, r n° 2nd 3 t ';e%..14 " ',� ti r'1., 3rd ! 3 t , f � � 5 i 4th ; 4 i = rd c::4-'.07," �,4. }" 3„",ter 4. .fro .+ :^', Total Area(sf) t �C Z Proposed .._ � ' ' Total Pro used New Construction(sf) s x 1 I' _ ! ` °- , Total Height(ft) g „i,..,.. '-.,- ,a.)1 1 �-�� �` i Total Height ft 1 . ka '4 . " t "S0 7.Water S •ply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 1% Private ❑ Zone; I Outside Flood Zr ,eD Municipal ❑ On site disposal system 0 •-• • , Versionl.7 Commercial Buildinl Permit Ma 15,2000 City of Northampton ,-, '•-, '1, , it' . . :.„ -.-z.,_-_.-.- ---- ._,. ,44.1r,-..- ::-•-:1,....:1« ,..:,..-'1..,,I;?C•I'''' ..*:=?-■-;--"';'"'-':=- Wal '`..."'-^t.;',..,.•:'-',,,-,-,- ri1=-I-47,VA' ---..:'-4---: '" -.1;-7„7„- --_---, „--::,--ea,;i„,t,-,,,m,:,,A _Building Department ' ,e,..iln 41■,,,,..140 j:A/,,,I..,4..r...a,'UT,., .-.,,,,c,:, -3!..,.,_A:,.',--A7--,1-=,—...:47...-i*,:-.4.1y,:o re.::::--7-'_.',.?„.:A.,,-_,-,..--•.--7,1,-;":;1,-kr ....4.,":,'"7.1Z:s1.-,:-., l'.2-71-.7, A'-..7.4..T-:-.4.-1.-Zj.---.,' 212 Main Street .a:-:w.,,:cc.:10-,-.&04tati5A„\--,--3,--f....,E,..t.d.,:-,•-=.4.-----;-...,,,,t,,,,,,::„....a-Am .,'4=,-1,:_;,,,,''--:.,,c,.,,,,,f,..7'';'.--Zt-,._,,---Zr-gr—ci'l.r.: -:-. ..:::::t's-'.14•-z.--- .,..„,,,..;.4, 11,1-4:::,,,i-V i ,Room 100 44,1..7.,„0,4:„.:,,e,„:44,,,-2 0,,,,,t,,Tig-,011P...z,;,',,,,,^,^...,,-.4-,,,...'.,...::!..,....,.,,,,,,,,,,,....."4-..-....,-,".t, •,.....,-.zo .V1 - " 2.001 ,. ,-,.i.,,,,..:_ t.„,.-*_,q-.,-L,'-;;.L,•'-' :-k--'...o.,..'_ r-4,;'=---T.,:. 4'4--1,t1:-'F.-.tti..z, ' Northampton, MA 01060 :41.4--T!,- --!!'.44, 45A phone 4137587-1240 Fax 413-587-1272 .77,7-7.4 ,-...,,,,c..F.,"-d7,1,;0."-ittrii.144.11. - ..-6i ,W,V-4-r:',"2,- * z,-fi-,,, ,,,.., --..,151E.*:.-..e*,,,,Q APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING •' • ATECTIONT;,BITEINFORM&ION r-..- - _--- ,,,.14y,(9..,J... .-4 ,tiLtts.-et-tio.11,-,tolje'seo.rniiWdby'Offiae____'-',2:--4--'4,Lnfr..-5-1:' ----ATI-Property-Atli:fres : • ..,...-,FIC-7,P,,,*...:!..L-.,,I,..--a,J,„,,,.;;;;.,.;,-,;..:="q-,,4.,:,,,i,1-7-','.. P...1,,5;=----- 1 •2:ic") (C)4,1 ilARZ. I 0--e-1,...1:t77-,,, 1---7,, ,mreasti.,-,-.11!=tt---:•-f .:-----1-1;.--,1 f i ftori - rlo'ttrt'cii--:----dd i 1 'r.'-...-,...,`.'-,,,,,,r„,, ,w.,. .„ -,fiejA:1,,-r4 .4:4, I•x-r--3,,, , -.,,,,,-----,,,,,,,ii'- ,a-c, I .,,, .,,,,,,,,..4 ,F4014.1&,:dag—,,,,,,,v,tV: 4--I*1:611764- -SEC-tit:1N 2-,-.PROPERtY-61/1403snii7*!-1140R12-07AdENT'::! :'''.:----'- 2.1 Owner of Record: /*K17 (a it, „ pre 4,,4- 4,4s-cz 0 17 i 'f 3 P o5pec 1 5 , 1 Name(Print) ' . Current Mailing Address: .2,422;4...... Signature r // its,--6-- / Telephone 2.2 Authoriz Agent: ' A up izy i 1 /e y ,j, Name(Print) Current Mailing Address: I Signature / ' )611 , Telephone -- ,. - - SECTION3-ESTI ATED-CONSTR CTION COSTS Item Estimated Cost(Dollars)to be Official UseOnl• completed by permit applicant ,-. --. --.. - -• - _ - 1. Building I rue; - 1 ,(a)Building"Parmit Fee 2. Electrical i _ .... . I (b)Estimated-Total Cost-of I el, oa() i 0 ---Cohatruction froni(6) i-----) . . 1 I ,, ning.PiiiiiifFee 3. Plumbing 1 0 1 Bu41. - ¶ co.400 A.A..1..A.,.... 1 0 , 4. Mechanical(HVAC) I , o0 i q..5"-e)1 , 0 - 5. Fire Protection 1 1 6. Total=(1 +2+3+4+5) Vedd -Check Number 4 -7 ci 2., .. . . Only Building-,Perriiit:NOMUti' -Date-- • ...... „_ --liked . . Signature: . Building Commissioner/Inspector of Buildings - , Date e0 i( e cj e(owt 5 File#BP-2007-1050 APPLICANT/CONTACT PERSON JOHN LANDRY ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413)204-9880 PROPERTY LOCATION 50 CONZ ST MAP 32C PARCEL 104 001 ZONE NB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Wo7 0 G'� Fee Paid V v Typeof Construction:_MOVE VESTIBULE FROM RIGHT SIDE TO LEFT SIDE(36 SQ FT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 093450 fr {il7 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Co - fe.sion Signature o 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. 50 CONZ ST BP-2007-1050 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:32C- 104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-1050 Project# JS-2007-001687 Est. Cost: $4000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 25047.00 Owner: WORLD WAR II VETERANS ASSOC Zoning:NB Applicant: JOHN LANDRY AT: 50 CONZ ST Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204-9880 WC NORTHAMPTONMA01060 ISSUED ON:5/8/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:MOVE VESTIBULE FROM RIGHT SIDE TO LEFT SIDE (36 SQ FT) POST THIS CARD SO IT IS VISIBLE FROM THE STREET r 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: (j t THIS PERMIT MAY BE REVOKED BY THE .ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS; Certificate of Occusanc L Signature: FeeType: Date Paid: Amount: Building 5/8/2007 0:00:00 $50.00742 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo