32C-287 (7) ,� .`E (riff rsf ��r�:fll�ltl}�folr _
�' E }�azancflacrlra'
o DEPARTMENT OF DUIL.DrNG INSPECTIONS
212 Main Strect ' Municipal Building
Northampton, Mass. 01060
�VORICCR'S CO'NOENSATION AF , AZ,IT
(Ii ccnsccJpermi tt�)
wlLb a principal placc of bus1ness/res1dence at:
(phone'}
(SO-muci ty/sZ21c_12�P)
do hereby certifj-, under th.c pains and penalties of perjw-y, hi
O I m an employer providing the followine worker's comocnsadon covemgc for Iny
eroplovecs worlang on:Liiis jots:
(lnsur��Conn ) (POUC- ?:i-�ir_t) -- (T pinion, D21.°.)
( ) I,am a sole proprietor, general contractor or homeowner(ci:c?e one) and have hired
the coati aclors listed below c-fbo hive the folio%wing worker's cocoen-sa�on po-kies_
(Nam: Of CDn"_nCiDr) (Insrura c-- Cornpan)-/POUc-i NiumI --C7) (r':St1JL•^? Daic)
(Name of Contracior) Rn-7w-alc-- COMpa,7v/?O6M' NtL06rr) Date)
(Name of Co=mo,) (InJrurancc C.ompan)'ROUC)- Nam— CEvpiratioa Dam)
(Name of Contractor) (Insurance Comrzffy/Pobcy Numb r) (Ezpirz6on Daft) .
(L—h ad`i i oc5,r 64=-it mooc .ry to infortya o(i P<staia%as to a_Il
O I am a sole proprietor and have no Oct wor4 ng for me.
I am..a-Dome OwDer perforrn-img all the work myself.
`NOTE:Plcsc be ecrzre fvl e.t�Jc bcmaolmcra w'oo employ pew=w dj ;=r•,r. cc==.t..,oc r rcp=-ir work on.d--LL=_,;of
rant mote tb-L'-roc tmi•J in%dads tb c bomoa reeds oc oa the aeuad:t zqp-%vca thew cc oct Do-:Uy oecr:d_=cd to Ce
eitploye�-)"— Lhc--S cis rte,r-..:m Aa(GLI SZ=I(5).1 aPDLieapoo by a bomooax f<a:Grp or permit rncy c%idrxc LL:
lepl rtsnu of ao craloyec wader dso workr-'C-CV a.Uioa Ad-
I uadast and tha>copy of thi,mtcmmi m.y be f.,,,,ied to ti.Dopertaxrs of lo&=.rW Acridcary Office or In vr.00e for th.
c0w-6'o hsiCc'ioa&:d tiu L-ih=to LD u bovc o%='&r Samoa 25 A or MCL 152 c=ra.d to tba i-apo cm of==im-U pcna.lti=
ooaiix-i of a Emc of«p to S 1,500.00 andror or UP to o,X yrsr tnd t=t1J Peutio in 6-room of a Slap Wor'c Ordcr and a
fi=0(5100.00 a day api=tnc
For -=-'t u, only ---•--7
Pcrmit Number I r
Lot 1
ignacun of Li c U=cc
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER'REVIEW;(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize' — !to
act on my behalf,in all matters relative to work authorized by this building permit application._
Signature of Owner Date
i
I,? 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 Deriurv. e
Print Name
I
Signature of Owner/Agent Date
SECTION.12-CONSTRUCTION,SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ------ -- - --i -
License Number
i
Address Expiration Date
i
Signature Telephone
SECTION 13-WORKERS , INSURANCE AFFIDAVIT;(M.G.L.c.152,§25C(6))
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 Q No 0
OL
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED!SPACE)
9.1 Registered Architect:
-- Not Applicable ❑
Name(Registrant):
Registration Number
Address
i Expiration Date
Signature telephone
9.2 Registered Professional Engineer(s):
i
Name Area of Responsibility
i
Address Registration Number
I
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
t
Signature Telephone Expiration Date
Name Area of Responsibility
i
Address Registration Number
s '
Signature Telephone Expiration Date
� k
I
Name Area of Responsibility
E
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
f
Responsible In Charge of Construction
Address
Signature Telephone
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 ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTIONTYPE
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 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 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 ED Specify:
M Mixed Use ❑ Specify:
S Special Use F-1 Specify:
COMPLETE THIS:SECTION IF'EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: I Proposed Use Group: !
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING-HE1GHT-AND AREA
OF'CE USE C*w
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION s
�ti t ,t
Floor Area per Floor(so a
is
1st
2nd '
2nd.—......-_.r..._,_ ez..W �
rd
3rd 3 �r r
a ,
m .
4th 4
Total Area(so Total Proposed New C� onstruction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone' Outside Flood Zone❑ Municipal ❑ On site disposal system E]
Version 1.7 Commercial Building Permit May 15,2000
"l; THAMPTON Z0N1N
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L R:�---Y L:' R:
F
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
' 1
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page! and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
r1
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued: ? j
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 1 NO 0
IF YES, describe size, type and location:
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Buildin Permit May 15,2000 -
'08 AQ
1 � � tuselo[al
City of Northampton �#
Rp
Building Department ; .;
212 Main Street we Wes ,
Room 100 k � ` W
r
_may +1 Northampton, MA 01060 .:
phone 413-587-1240 Fax 413-587-1272
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'-SITEINFORMATION
1.1 Property Address 1 TWts s�d Wit to be completed b affice
y.. / i 2°or,e �Ker"aj�blstcict a
J
���Elm"�St.DlStrlct' �"� ` CB-L11stGic� '*
SECTION 2.-PROPER TY,OWNERSHIP/AUTHORIZED AGENT. .
2.1 Owner of Record:
e/y%AAM jibe
Name(Print) Current Mailing Address:
01 tv
Signature Telephone �3
2.2 AutKorized A ent:
Name(Print) Current Mailinq Address:
-= - 0
Signature Telephone S'
SECTION 3 ESTIM ED�CON RUCTION COSTS
Item Estimated Cost(Dollars)to be ;Official Use.Only
completed by ermit applicant
1. Building i +1 .(a):Building."PermitFee —
cif 0 0-t4 r
2. Electrical (b)Estimated'Total=Cost of 1
Construction from 6
3, Plumbing Building.Pemilt Fee
4. Mechanical(HVAC) —,
5. Fire Protection ' ~-
6. Total=0 +2+3+4+5) ;Check Number
This Sectiomil7 wOfficiat'Use Onl
Building Permit Number PDate"
Issued
Signature:
Building Commissionerlinspector of Buildings Date
121WILLIAMS ST BP-2007-0464
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-287 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-2007-0464
Project# JS-2007-000683
Est.Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10497.96 Owner: JENKINS BENJAMIN J&KATHERINE
Zoning.URC Applicant: JENKINS BENJAMIN J & KATHERINE
AT. 12%WILLIAMS ST
Applicant Address: CK Phone: Insurance:
149 FEDERAL ST (41) 358-6839 (7)
FLORENCEMA01062 ISSUED ON.1012312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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:
FeeType: Date Paid: Amount:
Building 10/23/2006 0:00:00 $50.001052
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
122 WILLIAMS ST BP-2007-0464
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-287 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-2007-0464
Project# JS-2007-000683
Est. Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10497.96 Owner: JENKINS BENJAMIN J&KATHERINE
Zoning.URC Applicant: JENKINS BENJAMIN J & KATHERINE
AT: 122 WILLIAMS ST
Applicant Address: Phone: Insurance:
149 FEDERAL ST (41) 358-6839 (7)
FLORENCEMA01062 ISSUED ON.1012312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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: Q i< 0Z—/3.07
THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATIDN OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc Si nature:
FeeType: Date Paid: Amount:
Building 10/23/2006 0:00:00 $50.001052
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo