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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
(phone#}
(strcet/city/statrlap)
do hereby certify, under the pains and penalties of perJury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
v
(Insuranec 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Comp my/Policy Number) (Expiration Date)
(attach additional shed ifnecesssry to include inforwafion peataiaing to all oxdmct is)
( ) 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 while homowm=s who employ p=ons to do maiatcnance,oonstution or repair work on a dwelling of
not more than throe units is which the homeowner raider oc oo the grounds apputtenarrt thereto an not gully considered to be
employers under the vmd Ices oompeasation Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal staatu of as employe under the Workees Compemation Act
I underzt=d dma a copy of this uatemeat may be forwarded to the Depwtn rn of Lsdru al Attaca&Offioc of Insrusooe for the
coverage verification and that failure to aoaue coverage under section 25A of MGL 152 can lmd to the i oa of aimi wl penalties
000sisting of a fine of up to 11,500.00 and/or impr 6oamerd of up to one year and civil penalties in the form of at Stop Work Or dui and a
firm of 3100.00 a day against me
For dgmt nwW—only
Permit Number
Map# Lot#
JSipnatura of Licensee/Permittee
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 0MR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTI4IN 11-OWNER AUTHORIZATION .TO BE'COMPLETED WHEN
OWNERS AGENT`OR CONTRACTOR APPLIES'I:OR BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 Na e
gnature of Owner gent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ou�7" v
License Number
Addre s Expiration Date
ignature Telephone
SECTION 1:3 i WORKERS'COMPENSATION INSURANCE Af FIDAVIT(M G:L. 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...... ❑ F3
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESICN,ANb CONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTICN'CONTROL PURSUANT TO 780 CMR 116(CONTAINING" MORE THA V 35,000 C.F.OF EIVCLOSEC)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
3 General Contractor
Not Applicable ❑
Company NameK
4-44Kt
Responsible An Charge of Construction
36
Addr
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 i� 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 1-'� DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained i Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are ere 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 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC,,FEET'OF ENCLOSEC"SPACE
Interior Alterations j/ Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
SECTIONS» USE GROUP AND CONSTRU ION TYPE
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 Hi Rh 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: U �'
Existing Hazard Index 780 MR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
fl Ed N ..
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) St
2nd
Jift
1st �.
i
3rd
2nd % y
th
3rd ' .
4th f z � y
WT
mw
Total Area (sf) Total Proposed New Construction (sf)
do y
_
Total Height(ft) � r
Total Height ft --------------------
-- Versionl.7 Commercial Building Permit May 15,2000
2 6 City of Northampton
�E Building Department
i
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.I-SITE INFORMATION
1.1 Property Address: Isis se I
Ilk
3 /
SECTION 2>PROPERTY OWNERSHIP/AUTHORIZED AGENT
G.�
2.1 Owner of Record:
A,
Na eRrint) Current Mailing Address:
/I Q W." j k 6 - 5-
Signature ! Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3,- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / (a) Building Permit Fee
2. Electrical (b).Estimated Total'Cost"of
Construction;from 5
3. Plumbing + 0 dd Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2+ 3 +4+5) Check Number Q -
Thls Se+c#ion or Official Use Only
;Building Permit Number: Po Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0588
APPLICANT/CONTACT PERSON CHARLES PAQUETTE
ADDRESS/PHONE 36 FAIRVIEW AVE (413)586-5431
PROPERTY LOCATION 274 PLEASANT ST
MAP 32C PARCEL 174 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
TTypeof Construction: CONSTRUCT INTERIOR PARTITIONS FOR NEW TENANT
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License 007900
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co ission Permit from CB Architecture Committee
/2 Sao
Signature of 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.
�� t5
274'PLEASANT ST SP-2001-0588
Gls COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 174 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0588
Project# JS-2001-1056
Est.Cost: $13000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: CHARLES PAQUETTE 007900
Lot Size(sq. ft.): 5706.36 Owner: PAQUETTE CHARLES&ELIZABETH
Zoning:GB Applicant: CHARLES PAQUETTE
AT. 274 PLEASANT ST
Applicant Address: Phone: Insurance:
36 FAIRVIEW AVE (413) 586-5431
NORTHAMPTONMA01060 ISSUED ON.•12127100 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT INTERIOR PARTITIONS FOR
NEW TENANT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
�N Footings:
Rough: ' ��; %f,� Rough: y�1610 House# Foundation:
Ue'
Final:.�!11�$,/00 Ae Final: 31407-16�'7r/.I d,,/^
Rough Frame:G�
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation.
Final: Smoke: Final: eK 3-/y-D/✓�""' "!
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA�f6N OF
ANY OF ITS RULES AND REGULATIONS. '
Certificate of Occu anc si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/27/00 0:00:00 4090 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo