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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 T y
WORTER'S COMPENSATTON INSURANCE AVIT
I,
(iicenseelpermittec)
with a principal place of business/residence at:
(phone#)
(st met/ci ty/5�air/-rip)
do hereby certify, under the pains and penalties of pegury, that:
I am an employer providing the following worker's compensation coverage for in),
employees wort:rig on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
( ) 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) (Insi=ctce Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Inszuance Company/Policy Number) (Expiration Date)
(ariach additioml sleet if n6cxa to io,} iafora on pertaining to all coatrad )
( ) 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 homeo%n who cinploy pczzow to do maimm%ace,wwtr=oaor repair wort;on a dwelling of
not more than throe units is v Erich the homeowner reside or on the pounds apptutemani thwcto ace not gcocmlly coasidercd to be
employers under the%vorktr's compensation Act(GLI52—zs 1(5)},application by a homeowner for a lice cc permit may evidence the
legal stanto of an employer under the Woricodc C.ompemation Act
I understand that a copy of this rtatcmcnt may be forwarded to the Depa m eoi of Dial Aeadeat&Offioc of lm= noo for the
oovaigc verification and that failure to segue coverage under scctioa 25A of MGL 152 can lead to the imposition of crimm"penalties
oomisting of a fine of up to s 1,5oo.00 ancVoe imprison of up to one year and civil pen<ics in the form of a stop Work Order and a
fino o(5100.00 a day against me.
For dq=tn=iW uao only
Permit Number
6L �/j_/p3 P# Lot#
r
igia tnre of Li cr tee e
Versionl.7 Commercial Building Permit May 15,2000
SECTION 107.STRUCTURAL PEEWREVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION11 -OWNER AUTHORIZATION.-TO BE COMPLETED WHEN
OWNERS AGENT;OR CONTRACTOR APPLIES''FOR BUILDING PERMIT
I, 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
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.
C "P,L & S S FAQ
Print Na"
f � ' b �
Sig ure of Owner/Agent V Date
SECTION 12 -CONSTRUC'T'ION SERVICES
10.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
SECTION 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...... ❑
r
Versionl.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 CM'R 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
r
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
CU'BIC'FEET"OF'ENCLOSED SPACE
Interior Alterations X Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ )
SECTI'ON'5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A �- ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business K 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ _ 3A ❑
Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
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 CONSTRUCTION OFFICE USA ONLY
wa _ 7''
Floor Area per Floor(sf) g"
St
2nd
1st
3rd
2"d
r
4th
3rd
I r
4th
a ..
Total Area (sf) Total Proposed New Construction (sf)
_- ----. - ---------------
'
Total Height(ft)
Total Height ft --------------------
Versionl.7 Commercial Building Permit May 15,2000
Gity of Northampton
Building Department
212 Main Streetr a io ar
MAY 2 7 2C;G3 Room 100 Y
Northampton, MA 01060
phone 411587-1240 Fax 413-587.1272 /Sited? ns� u
�a
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
This section to'be completed by office
1.1 Property Address: y
Map Lot,:-- -Unit
C91 4 ,3
�K.
Zone Overlay District"
Elm.st.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) r Current Mailing Address:
Signature Telephone
2 2 Authorized Agent:
(o 4APLE �=
Name(Print) Current Mailing Address:
`/3
Telephone
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 0 � „ (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection OC 00.
6. Total =(1 + 2 + 3 + 4 + 5) Check Numberv.�
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1067
APPLICANT/CONTACT PERSON CHARLES PAQUETTE
ADDRESS/PHONE 36 FAIRVIEW AVE (413)586-5431
PROPERTY LOCATION 274 PLEASANT ST
MAP 32C PARCEL 174 001 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 NON-BEARING DIVIDER WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 007900
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF�MATION 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 Commission
e Z.",
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
s
'x'14 ST BP-2003-1067
GIs#: COMMONWEALTH OF MASSACHUSETTS
`:W�-1114# CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1067
Project# JS-2003-1695
Est. Cost: $850.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHARLES PAQUETTE 007900
Lot Size(sg. 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
NORTHAMPTON MAO 1060 ISSUED ON.613103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT NON-BEARING DIVIDER WALL
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:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 6/3/03 0:00:00 4943 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo