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DEPART ME11T OP DUILDFNIG INSPECTION'S
212 Train Street ' Munieipnl Building
1"tarthampton, Afass. 01060
vy()I cElI ,S COMTENSA` TON, GNSURANCF AFFMAV17' .'
-
(li Jperm�itcc)
7 5�
(stria/ci t}/staic�a p)
do hereby certify, under tic pzin5 and penalties of pcgufy, :hat
( ) I am an employer providing the following «,orkel's coinoens-lion coverage for Illy
eluployces worling on tills job`
OmgLLr-: =Com=ma ,) (Polio: Nu--ab--r)
( ) I am a sole proprietor, general contractor or homeovemer (ci:cie oee) and hive hired
the coon actors listed below wbo hive the following worker's compe Lt2don paicies
Oliamc Ofcontmccor) On--u ancc. Colnoan)•fi'ci.icc; NurnCC:) (F.:xoirdt_ec Date)`
(N.-,me of ConlTaaor) _ (Instranc Comoan`/Po!ie; Ntu�c^_r} (-B-Dir.:iion Dale)
(Name of Con1_iaelor) (Laser e:-- Compan3•/PoUq- Numbu) (Ex-pimtJon Dale) I
(Name of Contractor) (Instuanc-c Comcauy/Pobcy Numb-z.0 (Expirdoon Daic)
(at1�.Cti ad�i�oc�l r`icci ifa ��•to i,> u6z infonn.aoo pcIaiaing to.1J
((/S I am a sole propfietor and have no one woridDg for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=c be ee{,the .•t Jc tso es;)toy pcu m to w r. -, �;c� c,cr trcLir-ori:m of
ant mote th a L'.ro-_•imkf in which the boma� cr raicSo oc oo the p c> hr zp�is e-. ,-e Ce-e Y oc- ;dcrt to be
eixployca tttk e tx..txi r1a sien Act(GL1 S2-=1(S)} a�plrntioa by n batneow oQ ry c lie _oc p rmit rz_y c��dcnoc the
Icp1 rt-.uz of.a e=:Ployor under dzo Worj el,coaspoavt Act
I and-rn�d dtc>oon orthi.—1—a y bo rorv.nrded to tbo Depertm w or ln�.itri c!Modmt�'Off o0 of i�uc•oro ra the
oovcrx&,:vCnECtioo n.•td that L-11%=c t4 sazuc tovernbt tn>dcz lzc6oa 2 S A of MOL 152 c�o Iced to the i.,•-pOlkiM or cimiatr pe °
cooaismg of►rMc of up to 51 500.00.zW-i= isoc rut or up to ooc year tod civil prn.ltia in L,forth or n Stop Wort Ord=and.
rim of 5100.00.day tpiny ttx
For dcp.rtxz'=�u.c only
permjt Numb=
Sipintum of L,,3te
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Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 1 011)
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION-11-'OW..,NER AUTHORIZATION�TO-BE-COMPLETE UWHEN
OWNERS.AGENT OR CONTRACTOR APPLIES FOR BUILDING-PERMIT
,as Owner of the subject property
I ,
hereby authorize Y ✓ y �L73f 'to
act on m e alf,in all afters rela' e to work authorized by this building permit application.
w ,
I ? 0
Si re 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 pedury.
.1 X11h
Print Name
Signature of Owned a Date
SEC..TIONA2 GON OV,SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /-'R ZZA Y '7
License Number
Address Expiration ate
Signature v-✓ Telephone
SECTION 1'3-WORKERS'COMPENSATION INSURANCFAFFIDAYIT(W.'G.L.:c:152;,g;25C{6})
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this afndavit wiii result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
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Versionl.7 Commercial Building Permit May 15,2000
SECTION .9 PROFESSIONAL DES ION,AND CONSTRUCTION SERVICES-FOR'BUILDINGS-AND STRUCTURES=5U63ECTT0:
CONSTRUCTION CONTROL PURSUANT'TO 780- ON
CMR 114-(CTAINING MORE THAN,35,00Q C.F.OF"ENCLOSED-SPACE)
9.1 Registered Architect:
Not Applicable ❑
i
Name(Registrant):
Registrati on Number
{
Address
F Expiration Date
i
Signature Telephone
9.2 Registered Professional Engineer(s):
t
Name Area of Responsibility
1
Address Registration Number
L '
Signature Telephone Expiration Date
s
Name Area of Responsibility
f i
Address 4Registration Number
Signature Telephone Expiration Date
t I
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
1 i
f
Name Area of Responsibility
i
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable❑
Company Name:
t 2
E
Responsible In Charge of Construction
f t'
i
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L R: -, ' R:'--
Z S
Rear
Building eta ( �-4
Bldg.Square Footage % I �—
Open Space Footage %
(Lot area minus bldg&paved 1 I
parking)
1 i i
#of Parking Spaces
Fill:(volume"&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON7 KNOW ® YES 0
IF YES, date issued: E
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW 0 YES 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO !� DON7 KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ` NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION'4=CONSTRUCTION SER1/ICES FORPROJECTS LESS THAN 35.000
CUBIC"FEET OF:ENCLOSED SPACES
Interior Alterations Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description !Enter a brief description here.
Of Proposed Work: jam/°�v'
SECTION'S USE GE30UP=A11000NSTRU9TION 'PE -_
. .
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ B ❑
❑
A-4 ❑ A-5 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High 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:
I
M Mixed Use ❑ Specify:
;
S Special Use Specify:i
:COMPLETE TH1S SEGlOf�1 TF EXISTING BUILDING UNDEE�GOtiG F2ENC��fATFONS.ADDIT#ONS ANDORxCHANGE 1N USE
Proposed Existing Use Group: Pro� � Use Group:
Existing Hazard Index 780 CMR 34):' Proposed Hazard Index 780 CMR 34): 1
BECTION<6 BUILDING HEIGCiT AND AREA,:
O
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION 4
�.a
Floor Area per Floor(sf) ,
St j
2nd 2 z
.3rd 1 � 3 rd
..
4m ( -
4"'
Total Area(sf) I Total Proposed New Construction(sf) a � �
R x'.
..�
Total Height(ft)
Total Height ft ,k �
x # k
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone i ' Outside Flood Zone[-] Municipal ❑ On site disposal system[-]
� R
Versionl.7 Commercial Building Permit May 15,2000
of Northampton S#a
u i "ng Department �zevva '
Main Street
° Room;100
LQN No mpton, MA 01060
phone 413- 87-1 40 Fax 413-587-1272 P
APPUC r,(Wf q 4 AIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
tar�K'� OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTIOM _SITEiNFORMATlON -
hes section to be completed byroffice_
-l:1-Property-Addfes -
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SECTION Z: Pf""OPERTYOWNERSHIP/ACITHORIZEDAGENT s
2.1 Owner of Record:
{"`3:��G- / v�'���T~ � !7`l'L c���L� •� 5%�'�'��,�';/_�,2�1.z1,y7i,��'�„J
Name(Print) Current Mailing Address: hit
Signature ; % y Telephone
2.2 Author,//fed Agent:
Name(Print) Current Mailing Address:
Signature 'A�C J L U �z L�F Telephone
SECTION 3-=ESTIMATED CONSTRUCT(ON'COSTS
Item Estimated Cost(Dollars)to be Ofciat Uset3iafy
completed by ermit applicant
1. Building � I fa)`Building7Permit Fee
2. Electrical o {b)Estimated Total•'' -ost'bf` t..
2 e- nstr"uctidn firorri 6�
3. Plumbing ! Bu lding, ennitiFee
i
4. Mechanical(HVAG) I_
5. Fire Protection j G7 U Z7 f
6. Total=(1+2+3+4+5) Check Number
This Sec#ion"ForAfFiciaillse-Onl
Building Peni#Number - D"a#e
r
Signature:
Building Commissionedlnspector.of-Buildings Date
File#BP-2006-1019
APPLICANT/CONTACT PERSON Larry Yentsch
ADDRESS/PHONE P O BOX 120 LEEDS (413) 584-4750
PROPERTY LOCATION 102 HAWLEY ST
MAP 32C PARCEL 240 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out —14 19
Fee Paid
Typeof Construction: UNIT R-2-SHEETROCK&REWIRE&INSULATE KIITCHEN BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 048666
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9A64ATION 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
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., ,
fl s
CG,L CbAa c &► 0 (v s 16 d -r,) dA4C y ,J , (0- n' E
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
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02 HAWLEY ST BP-2006-1419
Comm _ A8SACHUSETTS
Moo:_Rj%L 32C 246 CITY OF AMPTON
Builtlir
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i t# &2006 4jg
C Cron 'ari License: ,
pit.ra n! Larry Yen*h
lot lize(so.R.): 9841<{? OWner.: HkAFAT, PAUL iR
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