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32C-165 (36) 0 0 o la e Gift, d xvirt aillptov � � �lYSaarhasetta' DEPARTMENT OF BUILDIT(G INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT (licensec/permittee} with a principal place of businessfresidence at: `(phone#) S�o'9t l (str=Ucity/ ap) do hereby certify, under the pains and penalties of perjury, that: I am an employer providing the following workers compensation coverage for my employees working on this job: (Lnsura ce Company) (Policy Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired µ the contractors listed below who have the following worker's compensation policies: l (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compatry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (assach additioml shed if neocnx,y to include infotzmri on pertaining to an ma rae o ) O I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whilo homeowu=who employ pcuom to do maintenance,o=siructionor repair work on a dwelling of not more than throe units in which the homeowner raids or on the grounds appurienanithereto arc not g ocrally oomidered to be employers under the warktt's o nion Ad(GL152,ss 1(5)),application by a homeowner far a license or permit may evidence the legal oa- of an employer under the Workees Compematioa Aei I understand that a copy of this ttatrment maybe forwarded to the Depertn e A of Industrial Accidea&Of m of Irnuranoe for the ooverxgc verification and that failure to accure coverage under sec uoa 25A of MOL 152 can lead to the imposition of criminal Ka&Wes consisting of a fine of up to 51,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop WorkOrdei and a fine of 5100.00 a day against tnc For dgratwe erne oa1Y Permit Number gyp#{ Lot# of Viocrisecipermittee Versionl.7 Commercial Building Permit May 15,2000 SEC'�ION#�Q�S'�F2�C A�r�PEEF�RE�%IE 3� �78Q C R�110�11) �"� Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SEC TiON�11 OWN ERAUTHORIZATION 70tBE COMPETED WHEN WI�fERS AG E NTAOR CONT,RA�CTOR APPLIES' pR BUILDINGhP£RMIT;3 a f V ,., 1, ,r3 as Owner of the subject property hereby authorize ���.�^ / o.,� to act on my behalf, in all matter relative to work authorized by this building permit application. Signature of Owner Date 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 the pains and penalties of perjury. Print Name Signature of Owner/Agent. Date SECTION 12 3C8NSTRUCTION:SERVICES, �,. . 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Urv�e i en� I I G P2�i Address Expiration Date Sign ture Telephone SECTION 13 WORKgp$'COMPENSATION INSURANCE AFFIDAVIT(MA L,c.152,,§250'(6)) k:. 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 9f the building permit. Signed Affidavit Attached Yes....... No...... ❑ . ' Version 1.7 Commercial Building Permit May 15,2000 SECTION 9'PROF1 5� 11II 1 �ESiG1 !AN ONS7"RUGTION SERVICES ,'FO,R BUIL"DINGS 1A D STRUCr 1RE UBJECT 0 ©NSTRUCTION CONTROL F'(7RSUANT,,T0;7$0 Cz116;(CONTAINING'IGIORETHAN 35;000 C E <©F„ft LLCJ�IS;ED 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 ,J,7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: ublic o 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 "..� MAO'; ` akx' GE11G )* fiONSN �5 "IC ICES FOR�P � EG � ' 1� 500Q l'x 9ra" 2C�"���.a�4��'"� '� �iHS? ,7,,�,`t' tc .m,t5i?n t9ti� FF, wcb-.�• a.,� a�+ �s::�r{" sun,lu:�a✓, 5.'3...e?..6, �� ra 3am 12 .�3�'e:,a. Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ 1 X—. Exterior Alterations Demolition[] New Signs [ ] Change of Use [ ] Other [ ] Accessory Building[ ] Repairs [ ] Scr� n� sEROU AnD coNSraUCTI USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 10 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 High Hazard ❑ 3A Cl 1 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: W - - M Mixed Use ❑ Specify: S Special Use ❑ Specify: GOMI?LETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS DE ,ADDITIONS'ANQ/OR CHANGE IN"1J o SE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): f SE%lON 6 B ILDtNG HE1GHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION " Err il��V �pYi f i Floor Area per Floor(sf) 15t 2nd uses '" I st � i' 3rd 2nd a 4th �4 3rd E: 4th Total Area(sf) Total Proposed New Construction (sf) ----------------------------------- Total Height(ft) Total Height ft -------------------- 3 Version 1.7 Commercial Building Permit May 15,2000 City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587.1240 Fax 413-587-1272 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 INfORMATIFON' T. 1.1 Property Address: 3 Eimtbist��ct,., SECTION 2=;pROPER7Y dWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print }'- Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Prin Current Mailing Address: • Signature Telephone SECTION 3'=SST-IVIATED`CONS`TI2EGT�ON-COSTS Item Estimated Cost(Dollars)to beftc� l; Jnly completed by ermit applicant 1. Building (a) Bu'iiclir g Permit f0i 2. Electrical (b)Estit ted T`o" i �t ofi Cans#ruc i.`on frorri 6 3. Plumbing uild�i rig,t.erm t F � 4. Mechanical (HVAC) 5. Fire Protection ' 3 � 3 £ 6 Total (1 + 2 + 3 +4+ 5) C610'"mber a3�"�� A 3 yy.�j yt� iyr j A,y��, �+�•b�y;, }•� a 'i� .��r 3 £ rr ��y v s >p�� "Jig r g; Vic'3t4 '.; 3�� � A�� G 4 l��Al ii/"Olr`�`f�YrQ .Ti-ia } ➢ a}� ,� J ;; rhf dI '"3 S3 ? i $u�I�It �g 3i�'rr►tt mi ? �' ' x 1371ka2 � 'Y'# ,Y U3 a 9 lruj�` v f '.3 33 ?•pa» 3 3 5 ri;n� � � far�i'^�aia�" � � F�5} 1) 3' c .m+ �-. 1 .�N1I�' �� � � . a - n f Lg Ik, u bra Building 0 11%slan•rlgsp�ar of Bull!?,gs C'au. S EASA ,4 r s BP-2001-0857 GIs CiJ�10NWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2001-0857 Project# JS-2001-0884 Est.Cost:$1500.00 Fee:$50.0 0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grown: Pioneer Contractors 017890 Lot Size(sq.ft.): 105415.20 Owner., MATTHEW PITNOIAK Zoning:CB Applicant: Matthew Pitionak AT.• 125 PLEASANT ST (UNION STATION) Applicant Address: Phone: Insurance. 125 PLEASANT STREET, #125A Workers Compensation NORTHAMPTONMA01060 ISSUED ON:5121010:00.00 TO PERFORM THE FOLLOWING WORK.-REPAIR AND RESHINGLE BAR ROOF AND PATIO DECK POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 VIOLA N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy SiLynat ure: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 5/2/010:00:00 6595 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo