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23B-046 (112)
0 0TttA)l PTO laf NartIja111pfoil B 6 �ressrtchnsrtta' m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORTCER'S COMPENSATION INSURANCE AY t AVTT (lic,_s permittee) with a principal place of busi iess/residence at'. Pei 36-, 13.x— �i fie (phone#) `1B 773 .-31.1 10 (strut/city/staiclrip) o t3v 1 do hereby certify, under the pains and penalties of perjury, that: ( 1 am an employer providing the following worker's compensation coverage for my employees working on this job- (Insurance Company) (Policy Number) (Expiration Date) (}�7 am a sole proprietors general contractor..Qr homeowner (circle one) and have hired the contractors listed below who hav°ewe following worker's compensation policies: aryl Nlt,�'Z�u� �55o�1 R wM2 �9otJ 2I._,3zbi zit ka 31 G 3 (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) CA w(y6 g 6 6 ,-)14 z (N of Contractor) (Laurance CompaayTolicy Number) (Expiration Date) ' (Name of Contractor) (In-SI=B arnpany/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (anach a kh-60a 1 slx ifnc c—uY to include mformirion pe U=ng to e.11 oo�ndor3) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please lx aware[h3i while homeowvcn who employ paront to do mainirnsace atucrioa at repair work on a dwelling of not maro than tlxno unitt in which the homeowner resides or oc the VvAadt apputtenhnl thaeto arc not generally oo=dcrrd to be employ=under the wocka's oo¢pcus4on Act application by a homoowna for a liccax or permit may evidmoe the legal ctahu of an employer under the Woriccet Compomalion AcL I uadrnt� dirt a copy of thin rtatcmeat may be forwarded to the Dcpaeta of Indru4ial Aocidmt>'Offioo of Iasruwoe for the ooverx verification and that failure to seatre ooverago trader socdoa 25A of MGL 152 can lead to tho imposition of criminal Penalties comisting of a fine of up to S1,500.00 and/or imptisonmrn of up to one year and civil pendtia in the form of a Stop Work Ordc and a firm of S 100.00 a day against mc. ��- For dgmt="we only t (� Permit Numbes Map{{ Lot# Si i of Liccnsce/Pcrmittee e Version 1.7 Commercial Building Permit May 15,2000 SECTION 16-STRUCTURAL-'PEER'REYIEW' 80 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION 11-OWNER AUTHORIZATION -;TO BE COMPLETED,WHEN OWNERS`AGENT OR CONTRACTOR APPLII S FOR'BUILDING'PERMIT - I, Ccw L,C-'y 0 1 C I<�,1 A)SO as Owner of the subject property hereby authorize c T I -�-A Q to act on my behalf, in all matters relative to ork authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare 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. b P Prin e I Z: , 2 a--2 Signatu e of 0 ner Agen Date 1' SECTION 2-'CONSTRUCTION"SERVICES 10.1 Licensed Construction Supervisor: I` Not Applicable ❑ Name of License Holder : Ro') <f:) ?cU � CS 6-75 //b� _ License Number Address Expiration Date Signat e V Telephone SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(0) `. Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ l'CL I?�511DOc� Version 1.7 Commercial Building Permit May 15,2000 SECTION"! 9 PROFESSIONALdESIGN AND"CONSTRUCTION SERVICES -"FOR"BUILDINGS AND STRUCTURES SUBJECT TO CONSTR.UC710N:CONTROL„PURSUANT TO 780"CMR 116`(CONTAINING ,MORE THAN,"'3`S,000.0 F,dF"ENCLOSED SPACE) 9.1 Registered Architect: I<1 Not Applicable ❑ Name(Registrant): 4117 6¢ Registration Number Exjiiratio Date S' nature Telephone 92 Registered Pr essio I i er(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 Not Applicable ❑ Compan Name: + o3y ►J S. �Ro�J Responsible In Charge of Construction o Addr Signatu e Telephone Version 1.7 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 0 Private ❑ Zone: Outside Flood Zone ❑ Municipal &7 On site disposal system ❑ 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Z (O Z7 $ Frontage 2'(O `7 Z 2 (,:, 5 Setbacks Front )v Z, o Z Side L: R: Lt L: ` R: 1 Z Rear I C ) E Building Height <�- L y . Is Bldg.Square Footage Ho Zj�GI L % 96 Z b LI I , L Open Space Footage _ _ % (Lot area minus bldg&paved parking) #of Parking Spaces (d Fill: JU !J 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: M ta IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES X IF YES: . enter Book 9CI 'Z I Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES X ELwv S �32o6, - 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 X NO IF YES, describe size, type and location: C--Aj "~ EM C-a(,C-Aj D. re there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: 'r Version 1.7 Commercial Building Permit May 15,2000 SECTION-4-CONSTRUCTION SERVICES FOR'PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE _ Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ k ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other ❑ Accessory Building[ ] Repairs [ ) ev-61 may ; /Vv .i'NT-1Q r *fN kj Ceti CC �ZUoM . SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ lA A-4 ❑ A-5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1.3 ❑ 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: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE.IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USEONLY, Floor Area per Floor(sf) 15t EAJ ri fJ 2nd �s Ist _ rd 2nd 3 3rd 4th �3 anal '` `» 4th i � Total Area sf '--I 00 ( )_ f �I � Total Proposed New Construction (sf) Total Height (ft) a T Total Height ft -- !� � Versionl.7 Commercial Building Permit May 15,2000 e P141�`„ City of Northampton o o. Building Department . . . 212 Main Street , 2003 Room 100 n.. . Northampton, MA 01060 e phone 413-587-1t240 Fax 413-587-1272 Y 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: This section to be completed by office Map Lot Unit 1 19 �� G, (' Zone ' Overlay D'istrict Elm St. District "CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ 12100�.(Ey 01 kki 50 Q I�s� �-�� _ 3o (—o C0 ST 7!5T . Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: e©c;> ,( O I C�t'v 5 b eJ (tos P(j� Name(Print) Current Mailing Address: X13 .. ? Z - 23 ( 3 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building C�1 (a) Building Permit Fee 2. Electrical / _ (b) Estimated Total Cost of ZO, �� Cst Construction from 6 3. Plumbing _ G Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 61 00V 6. Total =(I + 2 + 3 +4 + 5) q ooc) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-0604, APPLICANT/CONTACT PERSON MOWRY&SCHMIDT INC ADDRESS/PHONE P O BOX 135 (413)773-3176 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 PC_r_m_it Filled out Fee Paid s�- Typeof Construction: RENOVATE DAKIN CONFERENCE RM(2ND FLR) New Construction Non Structural interior renovations Addition to Existing Acccssory Structure Building Plains Included: Owr r Statement or License 075360 3 sets of Plans/Plot Plan iFOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON O ''TION PRESENTED: pprc d Additional permits required(see below) PLA N KING BOARD PERMIT REQUIRED UNDER:§ Intel_wdiate Project: Site Plan AND/OR Special Permit With Site Plan ;Major Project: Site Plan AND/OR Special Permit With Site Plan ZO? \G BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* _Received&Recorded at Registry of Deeds Proof Enclosed Othcr 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 le - Z O Signature c wilding Official Date Note: Isswi,wo of a Zoning permit does not relieve a applicant's burden to comply with all zoning requireme:i t and obtain all required permits from Board of Health,Conservation Commission,Department of public�),i ri<s and other applicable permit granting authorities. *Variance t,e granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning�. _,velopment for more information. BP-2003-0604 GIs#: COMMONWEALTH OF MASSACHUSETTS . CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0604 Project# JS-2003.1001 Est. Cost: $119000.00 Fee: $495.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: 1A Contractor: License: Use Group: B MOWRY & SCHMIDT INC 075360 Lot Size(sq. £t.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC Zoning: M Applicant: MOWRY & SCHMIDT INC AT. 30 LOCUST ST Applicant Address: Phone: Insurance: P O BOX 135 (413) 773-3176 Workers Compensation GREENFIELDMA01302 ISSUED ON:1127103 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE DAKI N CONFERENCE RM (2ND FLR) 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: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 1/27/03 0:00:00 5698 $495.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo