23B-046 (83) i �Gas *&
•
� r
�Y . . +✓..N" 4:c�'w � ;` i s r'� tC� sb�'lery`:.
I SEC PION 10-STRUCTURAL PEER REVIEW
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,BUILDII4G 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.
Sid .ure 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
kr edge and belief.
Si. �d :r the pains and penaltie of perjury.
7 '
Pri a
Sic of Owner/Agent Date
SE `ION 12 -CONSTRUCTION SERVICES
10. '_irensed Construction Supervisor: c Not Applicable ❑
Na ci License Holder: laJ c d / ��ncS6� n 72 3
License Number
Ac' ss---� Expiration Date
Sic Telephone
i
i
SE: , ON 13 -WORK RS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L 6:,152, §25C(6))
W ors Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
wi in the denial of the issuance of the building permit.
Sid :,ffidavit Attached Yes....... ❑ No......
♦.......... vv..u..V.V.Y\L\.l\M\..b v.....\
7. Water Supply(M.G.L. C.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
jblic+❑ Private ❑ 1 Zone: Outside Flood Zone ❑ Municipal ❑On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
C]' �j / Building Department
Lot Size / ' / ' (a ��
Frontage �o ! C'� �r, /
Setbacks Front 102 /D
Side L: R: L: R:�2
Rear A
Building Height / 7/1 1�
Bldg. Square Footage %
Open Space Footage / %
(Lot area minus bldg&paved / 0 612—
rj
arkin b /
#of Parking Spaces
Fill: A
(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: AUS
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book % Page _ and/or Document #
B. Do, 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? YEAS NO
IF YES, describe size, type and location: /lj5-rA 1/7
D. Ar there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
-:�N. :+i.
SECTION 4 CONSTRUCTION SERVICES FOR PRhOJECTS LESS THAN 35,000
1BIC FEET OF ENCLOSED SPACE
.:;
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
FA# L4111 Aqll� PC
SECTION 5 . USE GROUP AND CONSTRUCTION TYPE /�Q �'
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A A13-1.
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F•2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Ins-itutional 1.1 ❑ 1.2 1.3 ❑ 3B ❑
M M-rcantile ❑ 1 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U U' City ❑ Specify:
V iced Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF,EXI STING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN-USE-
Exis' Use Group: Proposed Use Group:
Exis' Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION `FOFF�ICE'USEO_ LYY � s
Floc, Area per Floor(sf) 1st /
3
� I
1st 2nd 'a .
_ �-.• c�R:r i;,,p� �*:. i.
3rd
4th :
3 d
Total Area (so [ v� U Total Proposed New Construction(sf)
' fl/U
Tota' Height(ft)�•
Total Height ft • T�
vGISIVUI., L7u1RL1IgrCrMILcvtay ,d,�Vvv
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, RENOTEFF,,CANGE'T�iE tJSO UPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A-0 H OR TAI dIA tL SWELLING
SECTION 1 -SITE INFORMATION
- " - s section to be c6gvieted by'office- „
1.1 Property Address:
LOW
1VI8p r.. .' -�
�r`�f /� �//,/�//
/v o A, d i' A- 01060
-'?.�L 1 ;;�'t' �•�.a y '`fie �¢ •,''fi d � �'1..,.1�a .... -i
r r -_a c s i .�� ,� 4 Ilr'• t a. tea-,
Elm St.District
.:.:. :..:.
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reco d:
C6 , a -3D 0GUsj Sr
lame(Print)/. Current Mailing Address:
1 �—LN- -23
Signature Telephone
2.2 Authorized Agent: COG
S�qr—i q "S60
Name(P 'nt) Current Mail' g Address:
A- 2--
Signature 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 0 U, 00
2. Electrical (b) Estimated Total Cost of
60 , 00 Construction from 6
3. P umbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection -
6. Total =(1 + 2 + 3 +4+ 5)
S O 0. V Check Number
'This Section For Official Use Onl
Building Permit Numbe* ` J Date Issued:
Signature: y `;, { � ''�'ao��.,y ha:c b t � ,,�
..... Date -
". ' Building CommissionePllnspecto�:6f Buildings �.`.;,,..
v R� Jc% "v-
File#BP-2005-0411
APPLICANT/CONTACT PERSON COOLEY DICKINSON HOSPITAL THE
ADDRESS/PHONE 30 LOCUST ST NORTHAMPTON (413)582-2312
PROPERTY LOCATION 30 LOCUST ST-OUT-PATIENT DEPT
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: INSTALL WALL&DOORWAY IN EXISTING LOCKER ROOM TO SURGICAL DAY
CARE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinn Plans Included:
Owner/Statement or License 082324
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF.9,RMATION 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 sion
Loa
Signature of Building Official Date rof
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-OUT-PATIENT DEPT BP-2005-0411
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2005-0411
Proiect# JS-2005-0514
Est. Cost:$3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: COOLEY DICKINSON HOSPITAL 082324
Lot Size(sg.ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoni _Pf r ? !_rY.IMCKINSON ' !iISPTTAI. ?l-;�
A3: 30 LOCUST ST-OUT-PATIENT DEPT
Applicant Address: Phone: Insurance:
30 LOCUST ST (413) 582-2312 O Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.10114104 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL & DOORWAY IN EXISTING
LOCKER ROOM TO SURGICAL DAY CARE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
1 a. Footings:
Rough: Rough:/d h� �/-'House# Foundation:
Driveway Final:
Final: Final: ! Q / �E//��--'"
y! " ' Rough Frame:
Gas: Fire Department Fireplace/Chimney:
I I 1
r
Rough: Oil: Insulation:
Final: Smoke: Final: Oj-c
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
01�ze�'�
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/14/04 0:00:00 34875 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo