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32C-156 (4) ��ttAMp�, goo It Crzf� x1f &Nartilailiptoll 8 d �lasaecflasrtte' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT I, IR �CAA,1,,,rt` (licenseelperrnittec) with a principal place of business/residence at: CQM , —cu (phone#) L0 (stTret/ci ty/stalrl�p) do hereby certify, under the pains and penalties of pcgury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (E-xpim do a Date) ( ) I am a sole proprietor, eneral contractor r homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: �/0 3 (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) ., (Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date) (Name of Contractor) (Insura ace Comparry/PoLicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioail shcct ifntarssry to irx_lude informarioa pertaining to all ooatractors) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:pl ease be aware that while homeowners who employ persons to do.n ntc a zi�cr.coust,"on or repair work on a dwelling of not more than three units is which the homeowner resides or on the grounds appurtenant thereto arc not gcowally coasidcrcd to be employers under the worker's oonVc:ns ioa Act(GL152,ss 1(5)),application by a homeowner for a liccose or permit may evidcnoe the legal sum of an employer under the Workcet Compomaiion Ad I undexstand that a oopy of this statement may bo forwiudad t.o the Departmcos of Industrial A ocidenti Of roc of Insurance for the coverage verification and that failure to seatre covenrge under section 25A of MOL 152 can lead to the imposition of criminal pcnaitics coatking of a fine of up to S1,500.00 and/or impsuomn of up to one yew and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day tgaimt me-- For dgisrtmrrtal—oY Permit Number "_._ / � hiap# Lot# Signature of Liccnsce-Re Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 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 i I rl :f— n s as Owner of the subject property hereby authorize Ke( Ty� 4 �tl �� to act on my behalf, in all matters relative tow k authorized by this building permit application. Sign ure of Owner Date I, & 14 as Owner/Authorized Agent hereb eclare that the statements bnd info mation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print ame !2�_ _7[f o�- Signature of Owner/ gent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ w Name of License Holder : hle u, i't�A/y�l 0 /' �� U `7 License Number 3 Address Expirati n Date 517 67 Si nature Telephone SECT!, N:13-WORKERS'-COMPENSATION 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...... ❑ ' Version 1.7 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 ENCLOSED SPACE)I 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 e � Not Applicable ❑ Company Name: Ke— ( AL'Ii Responsible In Ch arg of Construction t Address A113 Signature Telephone Version 1.7 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 ❑ 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: Versionl.7 Commercial Building Permit May 15,2000 SECTION.A-CONSTRUCTION SERVICES FOR PROJECTS,LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE -- Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] "v�,sc.2�P�s erg e xi ->rI rz bczt . t�c,rlc��rbcxzX-�„ 1�I(e, ,h'1 R�h� SECTION'S - USE GROUP AND;CONSTOUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H Hi Rh Hazard ❑ 3A ❑ Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 a(— 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 CHANGEIN 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 CONSTRUCTION § , gait �i st„,: �y Floor Area per Floor(sf) r St lst Q� SY 2nda�' 3rd 3k 2nd z � xo 3 shy rd th 4th RR, Fir Total Area (sf) (Do. Total Proposed New Construction (sf) xa i s ................................... �,^,�n Total Height(ft) Total Height ft ------------------- a v Versionl.7 Commercial Building Permit May 15,2000 f Northampton rh ing Department ! l 2 Main Street Room 100 I i. JUL - 9 2002 N pton, MA 01060 ' phone 41 -58 -1240 Fax 413.587-1272 _.r . nF^T nr��llt G;`�t;iNSP£CTIOhS A`PION`TOI-C`ONSTR AIR, 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: , ° �s Y � B Mal A � >R[m St,'DistricfwCB'Dlsrc SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f�rrc_ < e Name(Print Current Mailliinng ddres`s: Q/ Signature Telephone 2.2 Authorized A ent: KP gneut AAA, Name(Pri Current Mailing Address: 4-/'/ 3 ,5-J 2- '"7 6 -T ignature Telephone 5ECTf03N $-ESTIMATED CONSTRUCTI0N'COSTS Item Estimated Cost(Dollars)to be Official Use Only; completed by ermit applicant 1. Building fyn d (a) Building Permit Fee 2. Electrical (� a (b) Estimated Total Cost of d a Construction from 6), 3. Plumbing ©® a� Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) 1�1 v Check Number This Section For Official Use Only BuildmgPermit°Number: Date Issued: 3 Signature: Date Building Commissioner/lns pector of Buildings File#BP-2003-0035 APPLICANT/CONTACT PERSON KEITH HAMILTON ADDRESS/PHONE 3 LORD ST (413) 527-7767 Q PROPERTY LOCATION 31 KINGSLEY AVE MAP 32C PARCEL 156 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid T}peof Construction: DEMO EXISTING BATH WONDERBOARD,TILE,&SHEETROCK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 074129 3 sets of Plans/Plot Plan THE FO 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 C ssion Signature of Building Officia 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. BP-2003-0035 AVE GIS#: COMMONWEALTH OF MASSACHUSETTS yy�1�4yy�ryM wR7+��[ CITY OF NORTHAMPTON k' �A.1 aL�✓°'.A4 ' Lot: -001 Permit: Building CategoryL BUILDING PERMIT Permit# BP-2003-0035 Project# JS-2003-0099 Est.Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITH HAMILTON 074129 Lot Size(sg. ft.): 6011.28 Owner: JOHNSON ERIC Zoning:URC Applicant: KEITH HAMILTON AT. 31 KINGSLEY AVE Applicant Address: Phone: Insurance: 3 LORD ST (413) 527-7767 () EASTHAMPTONMA01027 ISSUED ON:7115102 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO EXISTING BATH, WONDERBOARD, TILE, & SHEETROCK 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 Sienature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/15/02 0:00:00 3126 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo