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Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN ANDCONSTRUCTIO�t SERN�CES 'FORBUILDING8 AN D,STi2UClJRESSUBJECTTO
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CONSTRUCTION CQNTROL.PURSUANT TO 780 CMR-**d'rCONTAINING -MORE THAN 35,1109 C.F..OF ENCLQSED;SPACE
9.1 Registered Architect
I
Not Applicable ❑
Name(Registrant):
Registration Number
Address I
I
Expiration Date
i
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
i
Address Registration Number
f
Signature Telephone Expiration Date
Name Area of Responsibility
i
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
! I f
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
1
i I
Responsible In Charge of Construction
r i
! i '
Address
Signature Telephone
I SECEION 10-STRUCTURAL PEER REVIEW(780 o CMR
y
L endent Structural Engineering Structural Peer Review Required Yes......0 No....b.
S E :'ION 11-OWNER AUTHORIZATION -TO BE COMPLETED.WHEN.
OY. .ERS AGENT OR CONTRACTOR APPLIES FOR,BUI0ft PERMIT
as Owner of the subject property
he: : 'y authorize to act on
m., ' half, in all matters relative to work authorized by this building permit application.
Sib lure of Owner Date
as Owner/Authorized Agent
he : declare that the statements and information on the foregoing application are true and accurate, to the best of my
kn.- edge and belief.
Si. :d :!,ider the pains and penalties of perjury.
Pri
SiF �� of Owner/Agent Oate
SE "ION 12 .CONSTRUCTION SERVICES A.
10. '_i-ensed Construction Supervisor: Not Applicable ❑
Na ::f License Holder : Cl)I J U <"? .`) o n– U �2 l --c)
License Number
r
Z-Lo, -2- 3 0 C,
Ac' is Expiration Date
sic
Telep hone
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x=
SE TON 13 -WORKERS' lOMPENSATION INSURANCE AFFIDAVIT(M.G L c-.152, §254*
W ors Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
wi ;s.i't in the denial of the issuance of the building permit.
Sig ffidavit Attached Yes....... ❑ No......4q-
I
Version 1.7 Commercial Building Permit May 15,2000
MR
'.¢ 4 '•7 _ ...
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:= R:3 L:' I R:!
'
Rear i
�utCding t�el I i
Bldg. Square Footage 5 — % i —
Open Space Footage %
(Lot area minus bldg&paved i �— /L�1_ .l
arlan ) L'j'��
#of Parking Spaces
Fill:
(volume&Location) {
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON- KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON- KNOW 0 YES
IF YES: enter Book I ( ; Page L and/or Document#,
B. Does the site,,-contain a brook, body of Water or wetlands? NO 0 DON- KNOW 0 YES
IF YES, has a permit been or nee�to 6e obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: }
C. Do any signs exist on the property? YES N NO
IF YES, describe size, type and location: i Gay.
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location: i
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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
i
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S;EC�T10N���zG;Qd�S7.Rl7GT,lON�SERI�GES�f®Ft,PROJ,EC'fS£ESS THAN 35;OQ0
CUBi.C"FEE,T`OFaENCL05ED`SP.AGE"
Interior Alterations',154.Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other[3
Brief Description iEnter a brief description here. R cl-kvve- /vc,1v dc�7 rid As CC
Of Pro osed Work: ` pp
SECTION 5. USE GROUP DL TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 0 A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business --._ ❑ 2A
E Educational ❑ 2B El
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional 1-1 ❑ 1-2 �. 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential El R-1 El R-2 E] R-3 El 5A ❑
S Storage ❑ S-1 El S-2 El 5B El
U Utility Specify:
M Mixed Use Specify:i
S Special Use 0 Specify:E
C`OMPLEfE TI IS SECS l td TF EXI$TJNG BUlLDI1JG UNDERGOING R£NOUATIONS,ApD, IONS-q, 1,OR CI IANGE IN USE
Existing Use Group: I Proposed Use Group: i
Existing Hazard Index 780 CMR 34): i Proposed Hazard Index 780 CMR 34):
SEGTION''6�8UILDING.HEIG1-IT AND*AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
� u
Floor Area per Floor(sf) rx
St
............
ist
2nd
2nd
rd
3.d i ! 3
4th = 4th i
Total Area(sf) C.' DU s Total Proposed New Con ction s � frt -ti y s
Total Height ft L _ I -
-� 7
-Total Height ft I f
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private E] Zone! ' Outside Flood Zon2Q MunicipaLj On site disposal system[]
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
Building Department
212 Main:Street
Room 100
_ v (,,,Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,REPAIR,I RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
-_---OTHER THAN A ONE OR TWO FAMILY DWELLING'
SEC�IOM�'SITE'itiFORMATION>' _ _-
x, sTh�secfrontobe corrt�fetedtsyoffce r
-1:t-Property Addres x Y . r
L..�G'V✓ J � I r��C �s'� S e s�' xV s u�by �'��,,.,, 'di�,s,�' ss Y, %
SECTIONZ ,PROPEF�TYQWNERSH1PlAGTHORI2ED AGENT -�,�
2.1 Owner of Recor :
Name(Print) }} cc / Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Maitinq Address:`
Signature
4 1 Telephone L '
SECTION:3. ESTIMATED,':CONSTRUCTION COSTS".
Item Estimated Cost(Dollars)to be Official Case Only
completed by ermit a plitant
1. Buildin 13000 .0 (a Budding Permit Fee
g I
I
2. Electrical _ (b)Estimated Total Cost of S
r ConstiucbAnrom;
3. Plumbing I Surld�ng Pemiit Fee
4. Mechanical(HVAC) I i
5. Fire Protection ' u U c`
6. Total=0 +2+3+4+5) -2- 1-Check,Number ' d`
Tt,. ..Section'`.For.O'fficalllse<Oinl
Bnilcit�g'Permlt°M,'p' er
- :Issued:
r . .
Signature:
Building,Canimissioher/Inspector of;Bu tdings Date
d7 JUex�lhj
/-/C" G'f- Tien
File#BP-2006-0783
APPLICANT/CONTACT PERSON COOLEY DICKINSON HOSPITAL
ADDRESS/PHONE 30 LOCUST ST NORTHAMPTON (413)582-2313
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 \ D
Typeof Construction: RENOVATE LOCKER ROOM 2ND FLR ADMIN BLDG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 082324
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91MIATION 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 Co ssion
2/,2.7
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.
30 LOCUST ST BP-2006-0783
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B-046 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0783
Project# JS-2006-1193
Est. Cost: $20000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: COOLEY DICKINSON HOSPITAL 082324
Lot Size(sq. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning: M Applicant: COOLEY DICKINSON HOSPITAL
AT: 30 LOCUST ST
Applicant Address: i Phone: Insurance:
30 LOCUST ST (413) 582-2313 Workers
Compensation
NORTHAMPTONMA011060 ISSUED ON:21712006 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE LOCKER ROOM 2ND FLR ADMIN
BLDG
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:r— Ob Rough:' ���/ �� �(t A1----House# Foundation:
`�
Driveway Final:
Final: S'� ��p hF inal:
Rough Frame W
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: V� , 5.�2 �Y Final:[7lC _��✓ " OG^/�%
THIS PERMIT MAY BE REVOKED BY THE �ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
/ /ice '' -
Certificate of Occupancy- Signature:
FeeType: Date Paid: Amount:
Building 2/7/2006 0:00:00 $100.0059642
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Comnussioner-Anthony Patillo