32C-149 (28) A E (rii�3 of �,3crtljalliptnll
A E g�casRchncclla' _
0EPAR TIM EIJT OP DUILDNG INSPECTIO?,'S
212 Main Strcct ' Municipal BuildinG ,
Northampton, Mass. 01060
WOM<aR'S CO)UENSATZON LNSURA_NCTE A VIT
EL
{li�.Jlxrnli flee)
V"Ith a pli,-icipal place of business residence at:
S o v✓E�T H A M p T O U hone ')
(Sn-C- 6ty/staa-12ip)
do hereby certify, under Lhe puns and penalties o;perjury., hat
( } I am an employer providing the following worker's compcnsr: cove�ge For my
eroployecs working on Ons job:
(La=t O= Conr=y) (Folic: (r:-pirauon DaL.)
(4 am a sole proprietor, general contractor or homeowner (ci cie one) and bcVe hired
the cones actors listed below who have the follo%vi p, worker's cocoensadon policies:
(game of Cont^ctor) (Inn rant: Coinoan)v?obcc; NIIUmYcr) CF-xpinuuon Datc)
(Name of Contractor) (Inssranc-- Camoa.ayi?oUn, Num^_r) (Lx-oir,[ion Date)
(Name of Coaaacio,) (Lnsurancc Compao)•/PoUcy Number) ():xpim6on Datc)
(Na.me of Contractor) (Iasura.n= Comcz>zyfpoLcy Numbs) (E%-pi-,&n Date)
(ntucb ad9,ZOCaj r3cC ifn�, ca c�VvC, nf"-cuioa pertaiains to a 00=--Z.on)
(✓ I am a sole proprietor and have no one wor4dog for me.
( ) I am.a home owner performing all the work myself.
NOTE:ply be na llt lb.c:.LiJetbemco�v�m Sabo c�ploy pezons to do r -• c��coo c rr air work=a d..clL^�of
OfX—111:. � O:--Iro to%,-bcb tb.uviDw�+'uci r.&.or 00(bC Ouo,A 27XiflCII1L"lI1CC'.D LT Do( oc<=.dd_=-cd to tC
cmploy=uoG the—k-m oc!�cn Act(GLr52=1(5)�.t;V ia6oc by 4 b0moo0.'oc far c lip__oc prnna=y c idcocc tl:c
IcgsJ m-=of a c=ployx under duo Work; e,Co�p,,L;=AcL
[undcrst,cad that a ooyy of tbij ml�my t e for-+wrd.ed to the Dopercmc:oa or Lo&,e icJ ncodrr&Offioo or lrc�ror t'-
cov0n-&'t waif atioc&rd UL-A Uum to scout)cvctase trod=iDe oa 23A of),(GL 157 can lob to tba L-P=e;Cc of o imiwl pcaallicc
oomi5:ins of a rtne of up to S 1,500.00 for=Iper; of up to ooc y=Lod a%iJ pcacliia iD the form of n Stop W orY Order and.
rim of.11 DO,00 a day cpua4 mmr-
For dcputai-�u.c only
permil Numb=
Si tum of t-ic=-15 fPCr7TUticc C2 ..1
t
/ Version 1.7 Commercial Building Permit May 15,2000
SECTION.10-'STRUCTURAL;PEER'REVIEW(780 R110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No.....
.❑
"SECTION 11-OWNER AUTHORIZATION -TO`BE!COMP:LETED' WHEN
OWNERS-AGENT:OR'CONTRACTOR APPLIES FOR BUILDING PERMIT'
C �--� [ ,..�>—C� as Owner of the subject property
hereby authorized el r'" , to act on
my behalf, in a'll T�tters relative to work authoriz d by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
her y de tare t the'jt&ements and i fo ma on on t e for going#lication are true and accurate, to the best of my
knowledge and be ief.
9 Si ned under the pains and penalties of perjury.
n e
O (j
Signa ure of Owner/Agent ate
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ,/
Name of License Holder : �A r I4E yv' !v `�j O � —1
i� I 14-
� S o � WE ST l� A � p r o N License Number
1� 5 6
Address Expiration Date
Signature Telephone
SECTION 13 -WORKERS COMP ENS ATION,INSURANCEAFFI DAVIT(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...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS`AND.STRUCTURES SUBJECT TO
CONS fRUC,TION.CONTROL PURSUANT TO'780 CMR 116(CONTAINING MORE THAN 3S'U00,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 / , /
P� S E C � C �1 5 MA . L14 04971L/ Not Applicable ❑
Company Name: y' G d I 406-710
StN 1 /
Responsible In Charge of Construction
SO L/ wF5-rHAMP7o,J RD . fL09 A
Address
Signature Telephone
1 Versionl.7 Commercial Building Permit May 15,2000
7.Water Supply(M.G.L.c.40,§54) 17.1 Flood Zone Information: 17.3 Sewage Disposal System:
Public V Private ❑ Zone: Outside Flood Zone ❑ Municipal Ef 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
arldn )
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO y 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 V/
IF YES, describe size, type and location: /
D. Are there any proposed changes to or additions of signs intended for the property ?YES V
No (�
IF YES, describe size, type and location: 1-erg n c� C J� LOk,-'� �L 0%
l
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSYtUCIION SERVICES FOR PR07EgC LESS THAN'35,000 ,
CUBIC FEET°OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs F/( Change of Use [ ] Other [ ]
Accessory Building [ ] Repairs [ )
BRIEF DESCRIPTION:
R u i d� a r, �3 a�'�c� .. `�
SECTION'5 USE GROUP AND CONSTRUCTION"TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A 0
A-4 ❑ A-5 ❑ 1B ❑
B Business id 2A ❑
E Educational ❑ 2B I ❑
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: e-, Lop
S Special Use ❑ Specify:
COMPLETETHIS'SECUON IF EXISTING•BUILDING UNDERGOING RENOVATIONS,'A'DDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION fi°BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
�MC&;L7SEONLlf
Floor Area per Floor(sf) in
2nd
ist
f
ndH��
rd —
4d' 4�'
Total Area (sf) Total Proposed New Construction (sf)
_------—------------—-----------
Total Height(ft)
Total Height ft-----—----------- eif `.
K
k s.
Versionl.7 Commercial Building Permit May 15,2000
City of Northampton
_ �► Department M v
ain Street
I 1 om 100
t
No ton, MA 01060 A
.r
"
OCT Oft&Ah- 1 40 Fax 413-587-1272
APPLICA �JN;TMCON!f � ,"*EPAI RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
N Fir�=-M HER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooerty Address: ro Th�ssection tome completed by of=6 .
3 ; s
1 a —,
1 Map M 1Lot
/A��
l
SECTION 2--PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print))/ /� Current Mailing Address:
Signature Telephone
2.2 Authorized Aaent:
nt) Current Mailing Address: o o
Sig re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building o00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost Of
Construction from 6,
3. Plumbing Qoo Buiilding`Permit'Fee
i
4. Mechanical (HVAC) — c-D —
5. Fire Protection
6. Total = (1 +2 + 3 +4+ 5) 1711 b CSC? Check Number
This Section For Official Use Only
Building;Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0439
APPLICANT/CONTACT PERSON DANIEL HEWINS
ADDRESS/PHONE 1504 WESTHAMPTON RD (413)582-9929
PROPERTY LOCATION 269 PLEASANT ST
MAP 32C PARCEL 149 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid '-
Typeof Construction: CONSTRUCT BAR FOR SEATING&2 HALF WALLS FOR COFFEE SHOP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049714
3 sets of Plans/Plot Plan
THE FOL LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 s' n
Z L
Signature of Building Of icial 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.