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DEP/tiRTMEWT OP OU[LOFNC [NSpECT1o1:S —
212 Mc'U] Strcct ' Municipal Iluildin�
Northampton, Mass. 01060
�-YOR CER'S CO1I CTENSArn0N GNSURANCE A FITSAVIT
ctl R,_Yov le- Go 19,5
�>,�ith G principal place of business residence zt.
5 t. L vW/ow ?16756 (,hone.) SX7 2SoO
P)
do do hereby eerily, under tlt.c pairs and penalties o'penury, Al
( ) C
am ?1 employer providing [1le followine cOmocns-�10n cove Zsc For Illy
etuplovices worming on'ti115
uAwe 6dios� �z- -o6
(L2s raw Conr�.) (Pclic- ? L rr) (�:pir cior DaLr_)
a sole proprietor, general conlTactor or homeowner (circle one) and have hired
the cony actors t sty 'below who hive the follovvine worker's cocD:)e,Ts2oon policies:
(Nero-, o. ccn�nc-'orl (ln�ran Colnoin}'/t'cuer ?dim cs) (t>:PirdGOn f��tc)
-_ (Name of ConQZCior) (11lSLtZDC: COIIlDa��•/POJ�' Ntu�crr) ���ir.:tion Doc)
(Name of Conzracto,) ([asuranc:. Com7=y PoUc�' Numbu) (E�a rcioa Dntc)
(1\'ame of Contractor), (Lasuran Gomczoy/Po�ey Num�J) (E��itation Da1') .
(an�c, �i::ocJ bcc if occc.� � c�c'u�iafo-c»oc pcuin:ns to.Ll axrr-_co-�) .
O I am a sole proprietor and have no one worhang for me.
( ) I am a home owner perfor-niing all she work myself.
NOTE:plc be ca-irc Lr thjc be..0-�wtio caploy P—,=Lo w -s oo r m p_or x .d..1L or
not more lb-n err_=r,,is =ido,cc Lb-.D-ouo,�,z,-,yu,•tcn:.�ebe-e�Tax C-a--zny Ln tr
c,?loy--�unG the aim Act(GL152r.1(S)�=4 pU=Lz=by fc «pc7w�r n-+dcoco rite
cp!cu u oleo cr?toyer unCef d o Woke r Coomom+L�Act
-pry or min—y ba ro. a dod L.L- all-or U-. —r-�.
co'c x vc-LL=310o e.:-'�t1h1 L-.;j=w ccmirc'wrcr�.;_u�l«xion 15 A of Mol-151 an led w the ti" roc or cimiasl pco'l i�
�or.Si ocup to S I}Oo.00 mr yr ca{tt; orup t-0 ooc yc- end r,=,l,io be roan ore sioP Wort Ord.-,.ad .
r�or 5100.00,d7y e tzx
F,ds
Permit Nu-bcr
Lot
sl; c�nscxlPcrmucc -ate J ,::
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL'',PEER REVIEW,{780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......0 No......❑
SECTION 11;--OWNER,AUTHORIZATION--.TO BE'COMPLETED WHEN
OWNERS AGENT�OR 'Cd RACTOR APPLIES F.OR.BUfLDING PERMIT
I,
Cooley 6;ckih s/ol? �/OS�iTccL as Owner of the subject property
hereby authorize Gf /C AloU E? C D/ 5 r OCo 't O G . _to act on
ny Zb?e ,, in all matters rel ork authorized by this building permit application.
-/8-06
Signature of Owner Date
I, 96t v/ne! h y/e COhS 7l'UCT/O/:7 -Zh 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.
Tire o.y`h i S �e//e fii e r
Print Name
Signature of Ow en Date
SECTION 12 -:CONSTRUCTI.bt4SERVICESi
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ///17J�/1% S �e/% Jai e`' _ 066227
License Number
//e r S T. v a//a G�/. /�i9 e;7/O'5-6 07-07-07
Address. � Expiration Date
7 3- sy7 0
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION]INSURANCE, FFIDAVIT
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....... W No...... ❑
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 9 PROFESShONQL DESIGN AND:CONSTRUCTION SERVICES -;FOR BUILDINGS AND STRUCTURES SUBJECT TO`
CONSTRUCTION CONTROL P,llRSUANT TO 780 CMR 116{CONTAINING MORE THAN.35;000 C F OF�ENGLOSED'SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
I
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 nn // Co V/��Ad M. �`7�261 G' 1. �1 S I/PUC 110/2 1 l Not Applicable ❑
Cornpany Name:
Tiino��y S t2e//e-tie r
Responsible In harge of Construction
511V,'//e r 6 T' � vc1/out/1l O/O
Address
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 X 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, 5'27 8 96 9, 5/27.8
Frontage 2,6 se ' 2 6 5 8 1
Setbacks Front 102 / 02
Side L: 98' R: 52 L: 8g R:
Rear /8' /9"
Building Height y 5 ' 16'y 5
Bldg. Square Footage y02 1 %
86 yp2,86 _
Open Space Footage %
(Lot area minus bldg&paved 6
azldn ) !t�
#of Parking Spaces 761 761
Fill: N/A YIA
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES X
IF YES, date issued: Der- 13. ZOO/
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book 6 60y 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 l� NO
IF YES, describe size, type and location: VQrlO!!s
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
Versioal.7 Commercial Building Permit May 15,2000
=SECTION 4 CONSTRIiCTION�RVI -ES�OR�P.ROJECTS LESS THAN 35,000
CUBIC.FEET OF NCL SED SPACE-
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ [Roofing ❑
_9r ❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building [ ] Repairs
BRIEF DESCRIPTION: ealu e7' --Iw i tGS ra T�p,o41t ,���4 A�iwlAisTRATid/J 1�'Ld 3 l'`'�li`
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:
COMPLETETt1IS SECTION.IFDZU. NG-.B. NG UNDERGOING--REN0yA IONS,ADDITIONS ANDJOR_CHANGE IN 1JSE
Existing Use Group: I-2 Proposed Use Group: Z-2
Existing Hazard Index 780 CMR 34): y Proposed Hazard Index 780 CMR 34): y
SECTION;6 BUILDING,HEIGHTAND REA t
__
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION E �,aOFCUSI` NLY4
Floor Area per Floor(sf) 1 "� ' S '
2nd
2nd irk °
3 "nn
3rd —
r r L �` i
4t a vZ r.
4e
Total Area (sf) Total Proposed New Construction (sf) L Y
Total Height(ft) E 5
S �
Total Height ft
Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton
Building Department :qua y
212 Main Street
Room 100 11 a ,t
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 Y SITEZNFORMATION
1.1 Property Address: ������ ? ° �ssecfion�to�e�omplete�bar office � �"k
� rt`. .� ���' ��
;c in So// //OSoI f-Q� C> f sYa ;sue i fl , ipw
` .gc
30 4 Ocus r 57' INo�e�
` �^s'
fi, srY'c
SECTION 2 _PROPERTY OWNERSHIPJAUTHORIZEDACENT
2.1 Owner of Record:
Cooley Dichihsoh llosai7'al _30Zoc4lst 5 r Po. I3ox Oo/
Name(P' t) Current Mailing Address:
y 13- 582 - z3i
Signature Telephone
2.2 Authorized Agent:
T,xothv S. Pe Ile tier 5/f'I,'//eh 57 . LUQJAV41, /y1B 0/056
Name(Print) Current Mailing Address:
y23 by7 2 500
Signature Telephone
SECTION-3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official-use Only
completed by ermit applicant
1. Building (a)Building iPemiit Fee
2. Electrical ed b Estimat Total Cost of
9'G 7. c )
Construction from Q-
3. Plumbing --,;jAui1dincf.lPdrmit fee. .
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) y y Check Number —
Thissec ion For'Offidal Use.Onl
Building Permit Number Date Issued-
Signature:
Building Comm issioner%Inspectorof:Buildings Date
I r
File#BP-2006-0730
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 187 East St SOUTH HADLEY (413) 532-9243
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: CONVERT 3RD FLR ADMIN OFFICES TO THERAPY AREA
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License 066227
3 sets of Plans/Plot Plan
iF LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Pen-nit 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 C ssion
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.
:50 LOCUST ST BP-2006-0730
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B-046 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
CatejZory: BUILDING PERMIT
Permit# BP-2006-0730
Project# JS-2006-1117
Est. Cost: $6194.00
Fee: $50.00 PERMISSION.IS HERF.BY GRANTED TO.
Const. Class: Contractor: License:
Use Group: Raymond R. Houle Construction Inc 066227
Lot Size(sq.ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning: M. Applicant: Raymond R. Houle Construction Inc
-`iV JS 1 V i
Applicant Address: Phone: Insurance:
187 East St _ (413) 532-9243 Workers Compensation
SOUTH HADLEYMA01075 ISSUED ON:112012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 3RD FLR ADMIN OFFICES TO
THERAPY AREA
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-x/f(� House# Foundation:
Driveway Final:
Final: 1 Final: -
� Rough Frame: � �� � `'� �
Gas: Fire Department Fireplace/Chimney:
Ro,`,;�. ;�;?• Insulation:
Final: Smoke: Final:o)( 5.
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU TIO g
Certificate of Occupancy Signature: _v
FeeType• Date Paid: Amount:
Building 1/20/2006 0:00:00 $50.00
212 Main Sheet,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo