23B-046 (114) O��KMf p�O
Crit� oaf wart[Jaillpfatl M
8 B j3�aiascllnsctta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(zy v- S(-WV\At Q l � /'-�(_
(iiermitt=)
with a principal place of business/residence at:
(�r�_C—G-�, (phone#)
(st=Ucity/stald2ip)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following worker's compensation coverage for my
employees worming on this job:
(2(to�V'� -7)3 r 03
(Insurance Company) (Policy Number) (Expiradi n Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insuranc c Company/Policy Number) (Expirttion Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if neocnixy to ine}tsdo infvrmatioa pertaining to all ooatn d )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persous to do mxird�coastrucdoa or repair work w a dwelling of
not more than throe units in which the homoocvnar asides or oa the grourr4s appurtenmi th+seto arc oo(geaeraky ao=kkrcd w be
employers under the wock,et's oompeasatioa Act(OL152,ss 1(5)),application by a homoowacr for a license or permit may evidence the
]cgal stanza of an employer under the Worker's Compeoution AcL
I understand that a copy of this statement may be faewardsd to the Deparoam2 of Industrial Aoddaa&Offioo of la wanoa for the
eovertge wnficstion and that failure to toeure coverage under stejon 25A of MOL 152 can lead to tba impos¢ion of criminal penalties
consisting of a fine'of up to$1,500.00 and/or i mpisom nerd of up to one year and ci%,U pcoxNes in the form of a Stop Work order and a
find of S 100.00 a day apinA tvc
For dq,attmertal arse aaty
Permit Number
D MP Lot#
S of Licensce/Permittx
Version 1.7 Commercial Building Permit May 15,2000
HG` S WA4 4 J '. 5lt
SECTION X10 STR C kf PEAR RE1lIEW(7I LIUf 116�1}
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTION-,, -1AUT ORIZATtON TO BE COMPLETEI?'� F�EN�
O)NNEISAG , O�� CT01PPLtE�S0 no I A–'�Wlcx�d„
t�, as Owner of the subject property
hereby authori `v� to act on
my alf, in I atter relat" to hlk authorized by this building permi applic tion.
� 2
ig ture of 0 ner 6ate
��J N S, Z GO J T as Own r Authorized Agent
hereby declare that the statements a d information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signatu of ner/Ag ate
SECTIO, 2-=CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: `` Not Applicable ❑
Name of License Holder: �w v C 5 (:)-
License Number
�e �3ax — 9
- 3
A s Expiration Date
Signs re Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE,AFFI DAVIT.(M;G L c 152;§25C(
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...... ❑
' r Version 1.7 Commercial Building Permit May 15,2000
9.1 Registered Architect:
1 Not Applicable ❑
Name(Registrant): V O
egistration Numbe r 2
Addre / ;J
E f",Si Telephone
92 Registered Profe sional ngi eer(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
T( I tK� C Not Applicable ❑
Comp, )Name:
y �j 5
Res po sible In Charge of Construction
"0o go X �3S �N yvi
Addre
Lo
Signature Telephone
r
Version 1.7 Commercial Building Permit May 15,2000
17.Water.Supply(M.G.L.c. 40, §54) 17.1 Flood Zone Information: 17.3 Sewage Disposal System: I
Public Private ❑ Zone: Outside Flood Zone ❑ Municipal Ur On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
L� Building Department
Lot Size -1 �pq y�o� s 9 01 '4 2-
Frontage 2 6 S g 2 VS 119
Setbacks Front 10Z [O Z
G
Side L: 9 R: 1 Z L: $ R: 2-
Rear i 9 [ S
Building Height &q. L c
Bldg. Square Footage qo z v, ( . Vo yCjZ 1Z G,I
Open Space Footage _ 0
(Lot area minus bldg&paved t)(v(�cj G 7 5 B.y
parking)
#of Parking Spaces
Fill: 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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES X
IF YES: enter Book 9 Page y / and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES X ` i✓t_vV\ 5T- 3ROQ r-
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: QJ YIy Sf(,Q OA-)D R)C 0( PC--<,rl(`
D. Are there any proposed changes to or additions of signs intended for the property ?YES—
No X
IF YES, describe size, type and location:
' Versionl.7 Commercial Building Permit May 15,2000
ZAA,MA
SECTION 4 NCO k£ ICES FOR QRGAdir..S LESS THAN 35,00
CVBIC:F
',. b`ri�»
•. :: c�?.,,.. :,s,s. rn;�e*. ..'�iF'Y.. .; m>:x3u•' '�'-a. .L mJf..sr• xF°v-. kv,� .
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
•X ❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
UES('2�P'rr : �001 T lu'N O F PeMT►T`w jV fj ti o � Q F P C— si P.
SECTION'S USE GREgUP ANC?NCONSTRUGTIaN'>iYPE 3 `
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional JQ 1-1 ❑ 1.2 1.3 ❑ 36 ❑
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 hF EXIST ING;;BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN'USE
Existing Use Group: -Z- Proposed Use Group: -t- Z-
Existing Hazard Index 780 CMR 34): Li Proposed Hazard Index 780 CMR 34):
SECTION 61 BUILDING HEIGHT,AND.AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION `
Floor Area per Floor(sf) St
2nd
IN IN
1st } v
3
2nd rd
4th
3rd
4th
Total Area (sf) r Total P oposed�lew Construction (sf)
Total Height(ft) (O 1
Total Height ft �� �
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
g Department
2112 Main Street
1110orn 100
A 2 9 �rQ�Jor pton, MA 01060
phone 413- -..240 Fax 413-587-1272
A PLICA:ffQk*6�66NiTjW REP R, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1=,SITE INFORMATION
ri his-sectio tafa"com�ilef° "b`.o
1.1 Property Address:
3o Loc v S i 5T
o Y �v1 j V �3 �1 G Iy b Q
IZ � � ► � %Zone.
i
ME
SECTION;-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
06o FACty�jscj�Ao54 t T'+rt
Name(Print) Current Mailing Address:
LA
ign ure Telephone
2.2 Authorized Agent:
3a wc:�ST 'ST
Name(Print) Current Mailing Address:
`t12> 23y
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. Electrical 11 — (b)Estimated Total Cost of
U Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) i& (o — CheckNumber 71
This`Section For,.Official use Onl
��, mr#Number Date Issued
z
A
BSI °�49"ai � !. *per Rya
Biitdin admissione"rllnspE�rotBu(d�gs,. y , Dafe
File#BP-2003-0214
APPLICANT/CONTACT PERSON MOWRY&SCHMIDT INC
ADDRESS/PHONE P O BOX 135 (413)773-3176
PROPERTY LOCATION COFFEE SHOP-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
Ty_peof Construction: RENOVATE INTERIOR-COFFEE SHOP
New Construction
Non Structural interior renovations
Addition to Existing
Accesses Structure
Building Plans Included:
Owner/Statement or License 075360
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commission
Signature of Buildi Official 7 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.
COFFEE SHOP-30 LOCUST ST BP-2003-0214
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV:Block: 23B-046 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildiniz
Category: BUILDING PERMIT
Permit# BP-2003-0214
Project# JS-2003.0389
Est.Cost:$8680.00
Fee: $50.00 PERMISSIO FS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MOWRY & SCHM!DT INC 075360
Lot Size(sq.ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL 1NC
Zoning:M Applicant: MOWRY & SCHMIDT INC
AT: COFFEE SHOP - 30 LOCUST ST
Applicant Address: Phone: wance:
P O BOX 135 (413) 773-3176 Workers
Compensation
GREENFIELDMA01302 ISSUED'ON:8130102 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE INTERIOR (TOFFEE SHOP
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: �MI—House# Foundation:
veway Final:
Final:// �'�'�'�J Final:
Rough Fra e:
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 anc Occu
N Si l!nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/30/02 0:00:00 5195 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo