23B-046 (40) iri t
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DEP/\RTMEt7 OP BU[LDD1 C (NSPEC 101:5 —
212 Maio Strcct ' Municipal Duildinc
Northampton, Mass. 01060
W O RIQ:R'S C O)IT E N S r1 n(D N INS URA Ci✓
_I'l;,>e r Ar, W671.7d R,_h!ov/e C 17-5 1-176 .
(lsccnsctJpern�tt�)
���th a pr�,napal place of business/residence 21.
s_t. L v W/ow (hone-)
do hereby ccrti_f)', under Lhc pains and penalties of perjury, that
( I aru an employer providing d1e ioflowing work-cr's colnocrnsL:jon cove^gc for Illy
eluplovices «or�n� an Li1is job'.
Ivor GPr ed-Z"g ea _CCA(/(/c ���t�s� vZ 3 1-06
(L2s nc Coax sy) (Pclic; ? L r) (r;pir tior Dzw)
( ) I_am a sole proon'tior, general con actor or hOmtowDer (c cie oee) and have hired
the coo-o actors Lsted below who have the fok%V1nQ worker's comoeji�don pckies:
('Name o.Co:,..l:ae-,Or) (In2r�ne Company/�ci e,' ?'utn cr) (r>:�ira oe f�nle)
-- (Nzme of CooTaelor) _ (Csurancc Comoazv/Poticy \uric^r) (-LNpL uon Dale)
(Name 0(coca-aclo,) Inc: CompaDyi?o>ic�- N;mbar) (C D rcioa Datc)
(Namc of Conaaclor) Comcz fFQLcy Numb,:--r) (S>pration Dal-,)
(-a,-c]:AZDcal[ScC tr accc-y to c,c p�In.11
O I am a sole proprietor and have no oat worhdog for ¢me.
( ) I am a home Owner performing all Lhe work myself.
NOTE:plcx b:canrc the 4 tjc bcmr vcn wt>o cxxploy pczoaa caw —.r.�oo c-rc-, •�orz oo .d..c11L—z of
aac moe=ti;:;t'JV=,ru-a«�ncb the bomcawDC rcid�or oc Lb. p-ound4 Lo be
JI°Y�u Lh-wuia7O -- ccAa GL15L.1 5
( )�:pglir_iboo try .ho-,ncoarc fa:�c _a pc-mn r`-7�-idcDc�tiv
I p l rL y c o f ca—2P o y x un d:e W o tick Coal on Act
l undo-ry�d des>Dopy y ba fora-a.rded to t.bo Dcpa�cmc.�t of I� �J .cod f Oft oo or I,--ror tlb
roc Q-LG=c oe°-,d 11Lt tv sea r='co ruo�u r sc_ ca 25 A of MGL t 52 an lad o he im c!=o�Qc mina,peailt s
coa i= of i Gi of up to S I.500.00 .rbyor cy r� 0 up w ox yc�r cad aail p�,lio is'mac focm o(.Stop Wort OH--�d .
ru of St00.00 c d_y ip rs¢x
. F a d p..rtu�=z1 u,c on7 y
_ 0�0 PCtID,I Nt1ID t)CS
Lot n �'
S
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL'PE£R REVIEW(780.CMR 110.11) -
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 -:OWNER"AUTHORIZATION-TO B&COMPLETED WHEN
OWNERS AGENT'OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
I, Coo/e Y b;skin s/ /C onn /-los',Q; as Owner of the subject property
hereby authorize Q U You e. C o/ 5 r oc, t D G . _to act on
my be , in all matters rel �authorized by t his building permit application.
2 -06
Signature of Owner Date
I, �L//3'ID/`)d R, 1/DVle Cohs T/�ucTio/� �h c as Owne uthorized A en
hereby dec are 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.
7Zwo1`'hi S- Pe,/% fiie-r
Print Name
Signature of Ow en Date
SECTION 12 -CONSTRUCTION SERVICES= ...
10.1 Licensed Construction S'upervisor: Q Not Applicable ❑
Name of License Holder : //i!'Jd7, t, S, 0 e//e f-i e r� _ 066227
License Number
/y, //er ST yc�/ate/_ /�i9 d/Ou�6 07-07-07
Address Expiration Date
4// - 6 517 Sec
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG t c 152,""§25C(5))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida- `.
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... R No...... 13
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS ANDSTRUCTURES'SUBJECT TO
CONSTRUCTION CONTROL PURSUANT T0780 CM,R 1. 6 CONTAINING MORE THAN 3S':66 �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
194? In 4161611 n O R)5 /)UC 7-/0,19
Not Applicable ❑
Company Name:
vino t/i S. 12e-//e-7-ier
Resporsible In harge of Construction
Address
�i3-.�y725oo
Signature Telephone
Versionl.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 ;4 On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 96 9, L127. 8 96 9, y27.8
Frontage 2'6 5 8 2 6 5 8
Setbacks Front 102 ' / 02
Side L: 50 R: y2' L: 88 R: y2
Rear
Building Height y r 6 y
Bldg. Square Footage y02'8 6 1 J % V02,96/J
Open Space Footage %
(Lot area minus bldg&paved 7 , 6 7 V- 6
arkin )
rf Par=Spaces 761 7
: N/A 111A
ume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES X
IF YES, date issued: eC 13-, 200/
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book 6 $Oy Page 2-39 and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES >r NO
IF YES, describe size, type and location: VA r l o vs
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No—VfJ
IF YES, describe size, type and location:
Versionl.7 Commercial Building Permit May 15, 2000
SECTION•4 CC0NSTRUCTI,0 S.ERNICES FOR ROJECTS LESS THAN 35,Ooo y t
PU$IC:FEET O,F'.£NCLO$ED�P,�1Cf -
w... -
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
Accessory Building [ ] Repairs [ ]
BRIEF DESCRIPTION• l¢>�����^ da }/a� rGdt���' ' �4�'l�f /j/1rSC /.�Tt'�"pcaJ G� � e//`lt/D%J / /lisf�v,�'1
ui ivy! S
SECTION 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 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ I-2 ❑ I-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:
COMPLET#lISECiIONIFDQSl3NGUILOING UNDERGOINGRENOUATIONS,ADDTfIONSANDJOF2 CHANGE IN-.USE:. _
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 66 BUIL`pING,HEIGHT ANDREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION a� NLY rl{r r'
���.:,„€ e+�:���i`�aj'a„-�rid ��r i_,r r.� t Y._•ii y ,.;..
Floor Area (
Floor er
P n 'E s� s , y
n
2nd u y x7 s v
lst
nd
3 �,
3rd u ey y a *i zF 3 a�y3i �s
4m
4m Y
�y75,+' 7,`x 1 ': ,•.-yam. x _
Total Area (sf) Total Proposed New Construction (sf) ry t
Total Height (ft) ter« y ry
Total Height ft—------------— --
5
v cisiunl.i Lo=erczat nuu.cung re=t May 15, 2000
City of Northampton u
Building Department
212 Main Street
r Room 100 � � .
Northampton MA 01060 3i
r ;la ��
phone 413-587-1240 Fax 413-587-1272 aas s
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
1.1 Property Address: �'y ` ;Thissec�on�o�eo,Fmpletedboffice
_ nt+ �' s'hi v \`
gt
/f-�� ,
Co � F-i Q � � Q
_
4 � Zone � t' VeT�a ��IStIICt" .� ---r S5 e
�" .-V 5 ,c'u a +�`. `-` v-,.a, Y. c. 's '�i.' is
sSw-.1� '.ss.4
SECTION;2 PROPERTY!'OWNERSHIP%AUTi10RIZED AGENT
2.1 Owner of Record:
Coole y Dickinsoh //oS Q/7i5(l 30�Or6lsf S r. /eo. /go Soo/
Name (_�'E�� Current Mailing Address:
S'/-3- 582 - z3/
Signature Telephone
2.2 Authorized Agent:
Tom„o th y S. /'e//e/'-i e,-
Name(Print) Current Mailing Address:
5'i3- by7 2 500
Signature Telephore
SECTIONS ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building {a} Building Permit-Fee
6 2-, ,3
2. Electrical Total Cost of ;
r -;Eonstruction from'. 6 - _ _
3. Plumbing ) ��� cO Bwld�ng Permit Fee:
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5 ��.Z' '/Z Check Number_
This-, ection`:For'Official Use.Onl
Building Permit Number Date Issued:
Signature:
Building CornmissionerjInspectorcf.Buildings Date
File#BP-2007-0683
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 Q
PROPERTY LOCATION 30 LOCUST ST
MAP 23B PARCEL 046 001 ZONE M
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: DENNISTON PLACE(LITTLE HOUSE)-ADD HANDICAP RAMP&MISC INTERIOR
RENOVATIONS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066227
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan /w "o? /-0
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 Commis 'on
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.
lLf� �i i
. City of Northampton
BUILDING INSPECTION LABEL
Inspector
Date— 1-7
30 LOCUST ST BP-2007-0683
GIS#: COMMONW1 ALTH OF MASSACHUSETTS
Map:Block: 23B-046 CIT'Y OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pennit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
CategoL)L- BUILDING PERMIT
Permit# BP-2007-0683
Protect# JS-2007-001033
Est. Cost: $77892.00
Fee: $330.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Raymond R. Houle Construction Inc 066227
Lot Size(sy. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zonin : M Applicant: Raymond R. Houle Construction Inc
A r: 30 LOCUST ST
Applicant Address: _. .._�.
5 MILLER ST (413) 547-2500 Workers
Compensation
LUDLOWMA01056 ISSUED ON.1/2/2007 0:00:00
TO PERFORM THE FOLLOWING WORIf:DENNISTON PLACE (LITTLE HOUSE) - ADD
HANDICAP RAMP & MISC INTERIOR RENOVATIONS ( COMPLY W/521 CMR BEGS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P."". Build„ng Inspector
Uiulcraround: Servfce: ,� ?Meter: 7 ) -
ti f'-r<I{ )C_ j?�� Footings: 11 � ��
Rough: ��} /',/ Rough: �I i House# Foundation:hcf 4�S tc g-7-0 7,�
Driveway Final: ,
TA
Final: Final: !
Rough Frame: �c'oo/+�• c -
Gas: Fire Department Fireplace/Chimney:
r
Rough:+
Final: '' � Smoke: Final:
THIS PERMIT MAY BE R-EVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy /�1z� Signature:--.__
FeeType: Date Paid: Amount:
Building 1/2/2007 0:00:00 $330.5013330
212 Main Street,Phone(413)587-1240,I`ax:(413) 587-1272
Building Commissioner-Anthony Patillo