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GZt� of 'Nart1ju111p full
�r(SaACh ttS[11a'
w m DEPARTMENT OF BUILDING INSPECTIONS E'
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE + t AVIT
F, si no 2'o C_
(licensecJpermittec)
with a principal place of business/residence ay.
_ 4-;2 // '0,e-144,4 r'a .) /hj (phone#) SW-$eke 7
cit /state/zi
do hereby certify, under the pains and penalties of perJury, that:
(d�I ari an employer providing the following workcr s 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:
(Name of Contractor) (Insurance CompanylPoiicy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) insurance Coml�auy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shcct ifneccssary to irY l- iaformarioa perUining to all..afracwrs)
( ) I am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who emplay persons to do nta inim a not o=studioo or repair work oa a dwelling of
not more tban throo unite in which dje homeowner resides or oa tbo grvan s appurtenant tbacto an not gco=lly 000siducd to be
employaa under the vvotkuAs oompcnsaticn Act(GLIS S 1(5)),application by a homoowncr for a lioawe cc Pamd may evidence the
legal ctatua of an employer under the Workeet Compensation Art
I understand that a copy of this ctatcmcat may ba forwarded to trio Dcpertm,�d of Indudrial Att=dca&Offioc of 1nxAtooa for the
ooverage verification and that failure to senor:cov=W under soctioa 25A of MGL 152 can lead to tba ikon of Criminal Pcnaltirs
ooasisting of a fine of up to S1,500.00 and/or imlttiso�of tip to one year and civil pmaltics in d)c form of a Stop Work Order and a
frm o(5100.00 a day against mo
For dgmt>ird> use GY
j' Permit Number
d— U�} Maps Lot#
Signature of Liccnsce/permi e
Versionl.7 Commercial Building Permit May 15,2000
SECTION,10=STRUCTURAL PEER REVIEW Q86CIVIR110.11)'
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 -OWNER AUTHORIZATION.-TO B.E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t7,, l- as Owner of the subject property
hereby a ize to act or
my behalf, in all matters elative to work authorized by this quilding permit application.
i nature o ner Date
I, 4 io,+J L Jup as ems„/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.
z�e31 P,) L
Print Name
Signature of Owner/Agent D
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder L
License Number
Address Expiration Date
5'6 ` ell
Signature Telephone 0l✓
SECTION 13 -WORKERS' COMPENSATION INSURANCEAFFIDAVIT(M.G.L. c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavi!
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION,.9;P,ROFfSSION,AL,DESIGN:AND CONSTRUCTION.SERVICES - FOR BUILDINGSAND STRUCTUR£S35U,BJECTTO 11,CONSTRUCTION�CONTROL'�PURSUANT TO'780�CMR 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
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
Version 1.7 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:
Version 1.7 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 Existing Ground Signs Additions ❑ Flo ing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [kl
❑ Accessory Building[ ] Repairs [ ] >
WSce 47-P 7Z- ,3
SECTION,5 - USE GROUP AND CONSTRUCTION-TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 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:
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):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTIONfFIC USE OhfLY
Floor Area per Floor(sf) 1Std f
1st
2nd s� �rx
a .
rd
2nd 3 sv
rd 4 � E
4th PfN,
Total Area (sf) Total Proposed New Construction (sf)
.: .
Total Height(ft)
Total Height ft -------------------- f ,
- - Versionl.7 Commercial Building Permit May 15,2000
V
City i rthampton as,vf i'er p
J�.'�1 - 2Ct uil� epartment
2 i n StreetewerlSep► i .;
Roo 100 VterllNeliaz c y
4 �x(1¢ tampt n, MA 01060
phone 0 Fax 413-587-1272 PlotfSitet�ns
Other Spec �£g ,y
ua" z
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 I ted
to be c, mp by office
AJ d Map Lot . Unit
ZoneOverlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print) Current Mailing Address:
Lf
Signa Telephone
2.2 Authorized A ent:
1 �► � �
Name t) � Current Mailing Address:
M n J q-,
Signatur Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ib C" (a) Building Permit Fee
1i
2. Electrical (b)Estimated Total Cost of.
Construction from! 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) a Check Number,
This Section For Official Use Only
Building'Permit Number: Fate Issued:
Signature: ;
Building Commissioner/Inspector of Buildings Date
ASAN't`ST BP-2002-0626
GIS#: COMMONWEALTH OF MASSACHUSETTS
k.3i '141, CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2002-0626
Project# JS-2002-0985
Est.Cost: $3375.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sg. ft.): 12327.48 Owner: PAQUIN GERARD A
Zoning: GB -pplicant: B & R Siding
AT. 317 PLEASANT ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:118102 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/8/02 0:00:00 18036 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
ow