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m DEPARTMENT OF BUILDING INSPECTIONS '
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(li censcrJperml tree)
with a principal place of business/residence at:
G S ail •, '1�n (phone#)5'
(strcei/city/ ap)
do hereby certify, under the pains and penalties of perjury-, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Fxpiraion 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) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnaccni ry to include information pertaining to all ooatracton)
ole proprietor and have no one working for me-
( ) T am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ perrom to do m riatcn ace e coasUuction or rrgair work on a dwelling of
not more than three units in which the homeowner resides or oo the Vvin it appurtenant thado are not generally oDandercd to be
employers under the worker's oompeasatioa Ad(GL152 m 1(5)),application by a homeowner far a Uccax cc pertnd may cvtdcaoe the
legit dahrs of an employer under the Worker's Compamation Ace.
I understand that a copy of thin statement may be forwarded to the Departmcni of Dial A mdea&Omen of Imruanoe for tba
coverage verificstioa and that failure to secure coverngo tinder section 25A of MGL 152 can lead to tho iarpositioa of criminal penalties
comisting of a fine of up to$1,500.00 andloc impraoamwd of up to one year and civil pcaal6es in the form of a Stop Work Order and a
lino o(5100.00 a day against Me.
For t=eA1 coo only
Number
—__--Lot#
., S}gnature o see/Permittee
Version 1.7 Commercial Building Permit May 15,2000
SEC?,ION 10 ,STRUCC'f.URAL PEER REVIEW.�780"CMR 110.]1)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No
SECTION 11 OWN ERA,UTHORIZATION-TO`BE COMPLETED WHEN
OWNERS°=AGENT OR CONTRATOF;;APPLFE�S.FOR BUFLDING PERMIT
I Oc 7-Y 0- (O as Owner of the subject property
li�qreb authorize e�- o ^► 2 A �Q Z to act on
ehalf in II tters relativ wo au orized by this building permit applicati n.
0 2--
Sig ure Owner Date
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 perjury.
Print Name
Signature of Owner/Agent Date
SECTION 1z, co"� IOWSERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder o�tr� 6i/t Z 0?A;'1�
/ License Num r
-3
b S�j
Addre Expiration Date
Signature Telephone
SECTION 13 WORKER5 COMPENsATFON IN UR NC
5
' AE AFFI DAVIT(M.G L c.152,°§25G(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...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTIO.N;SERVICES FOR BUILDINGS AND STRUCTORE ,SUBJECT TO
CONSTR'UC71O.N'OONTROL;PUI2SUANT TO 780°CMR 116`(CONTAI ING' MORE THAN 3' 000 C.F. OF',ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registrati Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Ar f Responsibility
Address Registration Nu r
Signature Telephone Expiration Date
Name Area of Responsibility
Addres Registration ber
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone piration Date
Name Area of Re 7ibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
-S Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addre T� r
Signature Telephone
, } a
Version 1.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L. c.40, §54) 17.1 Flood Zone Information: 17.3 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 ///k//
Frontage /v w
Setbacks Front
Side L: R: L: R:
Rear /A
Building Height
Bldg.Square Footage /o
Open Space Footage /o
(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 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
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:
' Version 1.7 Commercial Building Permit May 15,2000
SECTION-'4 CONSTRUCTION SERVICES FOft PROJECTS;l
ESS THAN 35,000
CUBIC 0�,ENCL05ED SPACE
,g 4i
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ J Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ] 1
5 GTION,S U5E GROUP AND,"CONSTRUCTION
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 ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I-astq C1 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
6M (Mercantele--)0 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:
COM;P,IETE,THIS SECTION IF°EXISTING,.BUILDING UNDERGOING RENOVATIONS,ADDITI
ON"S AND/QR CHANGEIN USE.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTIONI6 BUILDING HEIGHT AND`AREA- "
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
D3F
Floor Area per Floor(sf) 1St
nd
1st 2
.,
2nd 3 ` � c
4th 9tm ,
3rd
e
<d
4th
Total Area (sf) Total Proposed New Construction (sf) ,
Total Height(ft)
Total Height ft --------------------
Version 1.7 Commercial Building Permit May 15,2000
Gity of Northampton
Building Department
212 Main Street
02 Room 100
DEC 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-'SITEK INFORMATION "
1.1 Property Address:
� � '.'Fh�s e�`Io t' be c� m�►eted py�off'c' �`
SECTION 2 PROPERTY OWN'ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: _
LS r /C; MC
_.
name(P i ) y. `"" Current Mailing Address:
Sid aaturE`'" Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 =ESTtMA7D'CONSTRCTt
UON COSTS '
Item Estimated Cost(Dollars)to be Official Use,Only
completed by ermit applicant
1. Building (a) BUJIding Permit Fee .
2. Electrical (ki)'Estirriated Total Costof . "
Construction'from: 6
3. Plumbing Building-Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2+ 3 +4+ 5) Q heck Number
This�,Section For'Official"UseOnl
h _ •, '
tat I i Pe mlt Number "'" Date Issued
jj
3
r
;..BuildingCo pecto
mmisioiterf tnsr,of Buil dings
y •Y-
File#BP-2003-0556
APPLICANT/CONTACT PERSON ROBERT GONZALEZ
ADDRESS/PHONE 65 FRENCH KING HGWY (413)659-5324
PROPERTY LOCATION 15 WEST FARMS RD
MAP 35 PARCEL 007 001 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid �o —
Typeof Construction: REPAIR WALL CEILING&FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accesso*y Structure
Building Plans Included•
Owner/Statement or License 072482
3 sets of Plans/Plot Plan
F THE F LLOWING 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 Pen-nit from CB Architecture Committee
Permit from Elm Street Co ssion
L W-2- _
Signature of Building 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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
.' BP-2003-0556
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0556
Project# JS-2003-0915
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT GONZALEZ 072482
Lot Size(sq. ft.): 38158.56 Owner: NATARIO JOEL
Zoning:NB Applicant: ROBERT GONZALEZ
AT. 15 WEST FARMS RD
Applicant Address: Phone: Insurance:
65 FRENCH KING HGWY (413) 659-5324
MILLERS FALLSMA01349 ISSUED ON.1219102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR WALL, CEILING & FLOOR
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 Sienature•
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/9/02 0:00:00 336 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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15 WEST FARMS RD t .13-L
GIs#: COMM-ONWEALTY1 OF MASSACHUSETTS f3.�
May ". t-HAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0556
Project# JS-2003-0915
Est.Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: ROBERT GONZALEZ 072482
Lot Size(sa.ft.): 38158.56 Owner: NATARIO JOEL
Zoning:NB Applicant: ROBERT GONZALEZ
AT: 15 WEST FARMS RD
Applicant Address: Phone: Insurance:
65 FRENCH KING HGWY (413) 659-5324
MILLERS FALLSMA01349 ISSUED ON:1219102 0:00:00 0 '
TO PERFORM THE FOLLOWING WORK.-REPAIR WALL, CEILING & FLOOR
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: F7==L� Rough Frame: �-
-® .
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: 1♦'inaiQb- ,�r--
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/9/02 0:00:00 336 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo