23B-046 (82) 1
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1 SEC f-ION 10-STRUCTURAL PEER REVIEW(78Q
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endent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
S E. 'ION 11-OWNER AUTHORIZATION -TO BE COMPLETED:WHEN
OY. .ERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT w
as Owner of the subject property
Ik - -
he: y authorize to act on
m. ' 3half, in all matters relative to work authorized by this building permit application.
Sig :ure of Owner Date
QT as Owner/Authorized Agent
he ; declare that the statements and information on the foregoing application are true and accurate,to the best of my
kr.: edge and belief.
Si. d under the pains and penalties of perjury.
Pri
I
SiF r:: of Owner/Agent Date
SE 'ION 12 -CONSTRUCTION SERVICES ;r
10. :_icensed Construe ion S ervisor/: Not Applicable ❑
as cf License Holder: �° / / 06
License Number
,,2 /Yoo
Ac' ss .-- _ \ -1 Expiration Date
Telephone
S,
SE. -,ON 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G..
W ors Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
wi :s: 't in the denial of the issuance of the building permit.
S;� ,ffidavit Attached Yes ❑ No —
7. Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
jbi c ❑ Private ❑ 1 Zone: Outside Flood Zone ❑ Municipal ❑On site disposal system [3 8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be rifled in by
Building Department
Lot Size
Frontage
Setbacks Front ! CJ i
Side L: R: ��� L: R: C )_�
Rear /
Building Height
Bldg. Square Footage C'
/3 /`i
Open Space Footage % ,,**
(Lot area minus parking) bld &paved
B p ri �J 7
of Parking Spaces C l 2..
Fill: AVA(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: a C
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES _
IF YES: enter Book G` f Page and/or Document #
B. Doe the site contain a brook body of water or wetlands? NO DON'T KNOW
. YES ` Ir'YI
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 NO
IF YES, describe size, type and location: -k-i
D. Ar there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
lECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35000
)BIC FEET OF ENCLOSED SPACE w `
Interior Alteratio Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
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 ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A
E Educational ❑ 2B ❑
F Fa--tory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Ins: tutional 3L 1.1 ❑ 1.2 1.3 ❑ 3B ❑
M M=rcantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Ut lity ❑ Specify:
N! xed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN-USE `
Exis`. : g Use Group: Proposed Use Group:
Exis' Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING'HEIGHT AND AREA
k `, OF,FICEUSE�O I '
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION P .. � .: ..,.. ' .. .
Floe n.rea per Floor(sf) 15t !' IA-1 y
Y
2nd igi,yix"t
gnu—
a
3,d 4th sk
4th
Total Area (sf) 42 .a 00 Total Proposed New Construction(sf)
Tota' Height(ft) d'
Total Height ft ------------------•-
Versionl.7 Commercial Building Permit May 1),luuu
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVWTE--C AN H $R 99�CCkfRANCY OF, OR DEMOLISH ANY BUILDING
OTHER TF4AN A OE .� Q,FVilll DWfIING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This 5 Won to be eolttt leted by"Off;"Ce:'
PM
W.
T
-t -�f
Mk ��/(� Zooe� Oreraysfrf . - -
1 'Ir�1
El m St.District CB Dist;ict ,,
SECTION 2 . PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
On lr�� � L I�/7 .s° �°7 /�601 Ay Z-'Oc u
'lame(Print), Current Mailing Address:
Signature Telephone
2.2 Authorized�Agent: 10i,
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION;COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building — ' ) o (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
0 00 r 0 ® Construction from 6
3. Pumbing Building Permit Fee
4. Mechanical(HVAC) I U 0U
5. Fire Protection 1 0 00 a Z'
6. Total =(1 +2+ 3+4+ 5) Check NumberCVL�
t is Section For Official Use Onl
g Number D
building ate Issued: ".
Permit
z �
Signature. ;
Building Commissioner/lnspeclor 6f Bulldings Date
File#BP-2005-0412
APPLICANT/CONTACT PERSON COOLEY DICKINSON HOSPITAL THE
ADDRESS/PHONE 30 LOCUST ST NORTHAMPTON (413)582-2312 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: EMERGENCY DEPT-REMOVE WALL&DOOR&CONSTRUCT NEW OFFICE
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
INF,QeWATION 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 on 16//P/ZCc.
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-2005-0412
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock:23B-046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0412
Project# JS-2005-0553
Est. Cost: $50.00
Fee: $50.00 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 THE
AT. 30 LOCUST ST
Applicant Address: Phone: Insurance:
30 LOCUST ST (413) 582-2312 () Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.10120104 0:00:00
TO PERFORM THE FOLLOWING WORK.-EMERGENCY DEPT - REMOVE WALL & DOOR &
CONSTRUCT NEW OFFICE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
% ��Y Footings:
Rough: Rough' . " 44 r 41?65- House# Foundation:
Driveway Final:
Final: Final:
/�a yl�y / Rough Frame: JDt��s� iG
Gas: Fire Department - Fireplace/Chimney:
Rough: `Oi s Insulation:
�4; 4 Final:Final: Smoke: (3
THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/20/04 0:00:00 34876 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo