29-001 (7) 10/042000 05:20 8028934577 PLAYGROUND BOB PAGE 02
-
p. t
OCT 5 2000
(ryik of Natfflamrrtalt
DGPARTMEW OF BUt1DrXC iNSPECTICNS l
2212 MuiA Strwt • MultiCi?01 Buihling
Northampton, Maea. 01060
WOR(ER'S COMPENSATION INSURANCE A.FMAVIT
(lioa>5aJperrnina)
with a prinrpal place of bt,sines-slresideoce at:
_D 1q Pholacii) `l
(strxt/atylstauJap}
du tc:eby certify, under Che pairs and penalties of pequr<t, that:
( ) i am an empluyer providing the MOWiug wuskel's cutr►pausauo;a covecago Cc' sr►y
employees wo2inng on this job'.
_ 't10rJwl�Dti -- _ I vj 1191 - 002 La I
(Iw�rusce Con ►ar) (policy Nuolbcr) (F pir=o D }
( ) I am a soie proprietor,general cams=-Cor or homeowner(circle one) aad have hired
tht contractors listed below wbo have the following workees compeasanon policies:
~W(Name of Coamtctor) (tasursncc C:omparry/Policy Number) Mn imtoe Catel
Ma=a:Contrac tes)Y (las m"m Compauy/Poticy Nuintx:) (Zvpirauou DuC4
(Name of Coauactor) (taster(--Coapuly/Poucy 1luu tl) (EXPLaauo Datc)
(Nasue of Conaactor} (Exuraace Coospassy/Fancy Nunn xs) (E41raaout Date)
(tly[b'-�—�:drd irn..>�7r b iWIW1s inilema0eo potriui:sa 4 alt:rq.dpf.)
( ) X am a sole proprietor and have no one working for Lae-
( ) 1 am a home owner performing ail the work myseif.
NO 11.`:plow be-MVMM Mal while MWOMoers.40 molar poww a d9 maimmonc%wmtvwaror npak-ark.e a e..eUiat of
lift ewouaamwu%ua1vMMtb&boa martwidaeorccOwVmoftVp,atnwtleimartoa`eousWeoaeaaedto be
140AMaortlMi4QIWWfw motor**W4 WAatcCAVV9MMOM AaOPtlaneal ry.We�eowmrrarabarareorpenotsmsrawdwa.ib►
2—rwttard"^owy aum oweema ow. bo 1,vwwdrd to eh&mrm." r—,atmi AM W Omar or mW.oa.fw ow
otv W%aiAoetion aad ttua Wlurs to overt WKtgo under r etina 45A of 210E 112 c.0 lad is mo imroodid d areairrml peaaltin
nom s*ore 50e of ur to 12.300.00 MWW ingrinavaca ofup W trot ym ead dvo roahits m ibe ibe n of a"Wat OWw and a '
run of St e0.00 n ear■ems M
n For ode Nam n..mtr
�
Permit Ntsmbes
MW _Eat W
.... 9i rmirlac
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......0
SECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS NEIRS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-TC111 V�Apa-. o.- 6-kaLt al, Ht is kvl�jjaL—likTaivwner of the subject property
1, 1 �J
hereby authorize *ICA V�C& to act on
my behalf, tters relative to work authorized by this building permit application.
= !9bE100
Signature of 0 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.
Print Name
Signature o(Vner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder 1 1 1-7 7
License Number
Address Expiration Date
L/0-:1-C)
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION 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....... ❑ No...... ❑
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9!7 PROFESSIONAL DESIGN ANDCONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION NSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
9A Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(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 Ig
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
r
Versionl.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 ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
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
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO X 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? YES NO X
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Versionl.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 ❑
Exterior Alterations Demolition❑ New Signs Change of Use Other bo
❑ Accessory Building Repairs
—rjc'p'.
SECTION 6- USE GROUP AND CONSTRUCTION, TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Io 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 Hi Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential 19 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
g
y� 01 FIDE�1SE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
F.
Q
Floor Area per Floor(sf) f,
ist
nuk":
nd
2
1st
3 rd
2nd k'
4 th
3 rd
&A
4
4th
Total Area (sf) Total Proposed New Construction (sf)
...................................
77 107'
Total Height(ft)
Total Height ft --------------------
i
;- M► Z Versionl.7 Commercial Building Permit May 15,2000
Cj y of Northampton =`
B1 ld ng Department
' 12 Main Street > '"
3
OCT 5 f Room 100
prttampton, MA 01060
M 1`
phgge,,I b-5 7.1240 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- SITE INFORMATION
Th' section to romplfed bY�off
1.1 Property Address: e
Map �hf� t
> t
r
AA, ttn any Ostrl� , zfl
,�
EIm St.District" +CB PiOfi'#"�'
SECTION 2- PROPERTY!OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(PripO I � Current Mailing Address:
s y-y0-3
Sign ur Telephone
2.2 Authorized Agent:
s� \A,, t-
Name(Print) Current Mailing Address:
s�-`r-I-/o::s0
Signature' Telephone
SECTION'S ESTIMATED,CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �` ® (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4+5) Check Number J d
This Section For Official Use Only
Building Permit Number: Q Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2001-0377
APPLICANT/CONTACT PERSON NORTHAMPTON HOUSING AUTHORITY
ADDRESS/PHONE 49 OLD SOUTH ST J yq —q0 3 0
PROPERTY LOCATION 178 FLORENCE RD(FLORENCE HEIGHTS)
MAP 29 PARCEL 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: CONSTRUCT PLAY STRUCTURES
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessojy Structure
Buildina Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: §_ _w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co 'on Permit from CB Architecture Committee
p �000
Signature uilding 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.
178 FLORENCE RD(FLORENCE HEIGHTS) BP-2001-0377
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-001 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:PLAY STRUCTURE BUILDING PERMIT
Permit# BP-2001-0377
Project# JS-2001-0610
Est.Cost: $14000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin
Lot Size(sq.1): 255697.20 Owner: NORTHAMPTON CITY OF
Zoning.URA Applicant.• NORTHAMPTON HOUSING AUTHORITY
AT: 178 FLORENCE RD (FLORENCE HEIGHTS)
Applicant Address: Phone: Insurance:
49 OLD SOUTH ST (413) 584-4030 O
NORTHAMPTONMA01060 ISSUED ON:10 118100 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT PLAY STRUCTURES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 10/18/00 0:00:00 2856 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo