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m DEPARTMENT OF BUILDINIG INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060
WORICE,R'S COMPENSATION INSURANCE AF MAVIT
(Iic�nserJpermittee}
with a principal place of business/residencce at:
/�IA • 6210Lr (Phone') 5 - G t
(str city%stair/ziP)
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:
C_ tee-, �A A�,L,\ W C, 'S Ltcj�F, -(201 I2pto3
(Insurance Corap3ny) (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:
A
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
�r
(Name of Contractor) (Insurance Company/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insuranct✓Compaay/Pobcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additioml shod ifnooc—ry to include information perad ing to all coaraaors)
( ) 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 vihile homeown=who employ pa-.row to do makacaance,=strum or repair worts ou a dwelling of
not more tban throe units in which the homoowncr resides or on the grounds appuetenarsi iberdo an not Sexually coondcmd to be
employtn under the svorkcez o=pcm4on Act(GL152,ss 1(5)),apptication by a homcowncr for a Gccnsc or pamit may cvidcaoo the
legal status of an employer under the Workeez Compamaiion Act.
I understand that a oopy of this ttafemml may be forwarded to the Departnoui of Industrial Accidc&Offioe of lavA aoce for the
coverage verification and that failure to secure coverage under section 25 A of MOL 152 can lead to the imposition of criminal pcnakies
omiLvdag of a fine of up to S 1,500.00 ancVor imprisoomestt of up to one year and evil penalties in the form of a Stop Work Ord--and a
fine of s100.00 a may against me_
n
For depart mr —only
i ;/ Permit Number
Al �ti 2 D - Map# Lot#
c� S gnature of Liccnsee/Pe ttee e
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, S�C�r �t ��yw► 'to� 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.
- r
Signature of Owner Date
a as Owner/Authorized Agent
hereby declare that the statements and i formation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
� 'VtiL
Print Name
Signat 'e-o Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: t Not Applicable ❑
Name of License Holder : ��� uk 017
License Number
Address Expiration Date
Sigry6ture/ Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG..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....... L`/ 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)
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
Versionl.7 Commercial Building Permit May 15,2000
f 7. Water S9pply(M.G.L. c. 40, § 54) 17.1 Flood Zone Information: 17.3 Sewage D)sposal System:
f Public �
Private ❑ Zone: Outside Flood Zone Municipal VOn 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
arkin
#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 V YES
IF YES: enter Book Page and/or Document#
11 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 t 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 I/
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 ENCLOSED SPACE
Interior Alter ions Existing Wall Signs Existing Ground Signs Additions ❑ Roofing E)
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
SECTION 5- USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 4 ❑
R Residential ❑ R-1 11K 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 LCE SE G �
F
�� ,� .> . elf�l&,�..� ��- ��_.Y. ... ,•a u
Floor Area per Floor(sf) St
6
r a
2nd
y ��
1st_ 'q i s.` 'a�.,"'^''' aa ;.
2nd 3rd y
00
4tn k �
3rd T
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft -------------------- ;�
Version 1.7 Commercial Building Permit May 15,2000
�' k� �€ DeparttUSe
r� City ,Northampton Status of Perm►t r
I
�'ngDepartmentt1rb�Cutl3Dnewayl'eimlt ��
212 Main Street Sewer/Septic A ail ab ty �
3 Y
3 2003 IR�bm 100 WaterlU+lell Avatlabii ty z
V Ea
Northarnptcan, MA 01060 Two Se#s of Struetur�l'Plar� r t
p are.- 14' 58 1240 Fax 413.587-1272 PlWSitePJan{s 0 "f.
Other Specify
.}
APPLICATI v ONSTRUCT, REPAIR, 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: This section to be completed by office
Map �3 Lot l Unit
441 Zone Overlay District"
! L _ Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curren'. Mailing dress:
Signature Telephone
2.2_Authorized Aizent:
Name(Prir).t'' Current Mailing Address:
Sign ure' 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
0,07,v ' Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total — (1 + 2 + 3 + 4 + 5) 1 Check Number a S
This Section For Official Use Only
Building Permit Number:�1"a Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0693
APPLICANT/CONTACT PERSON Pioneer Contractors
ADDRESS/PHONE PO Box 1145 (413)586-5491
PROPERTY LOCATION 36 KING ST
MAP 32A PARCEL 255 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
Typeof Construction: REPLACE PLUMBING IN BATHROOMS(200,201,300,301,302,400,401,402)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 017890
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 mmission
�0 L
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.
BP-2003.0693
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0693
Project# JS-2003-1127
Est.Cost: $41000.00
Fee:$205.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Pioneer Contractors 017890
Lot Size(sa.£t.): 72614.52 Owner: STAR NORTHAMPTON INC
Zoning: CB Applicant: Pioneer Contractors
AT. 36 KING ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers
Compensation
NORTHAMPTONMA01061 ISSUED ON:2120103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PLUMBING IN BATHROOMS (200,
201, 300,301,302, 400, 401, 402)
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/20/03 0:00:00 8032 $205.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo