18D-058 (9) Skyc�n Dq
Commcrdat•-koiden tial
construction • Renovation
209 Locust street "Fames
Box 142, Florrnee 413 586-8491
Mass. 01060-142 Fax 582-M75
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
���� WORI{LR'S COMPENSATION INSURANCE + + AVTT
L _1-� � g �((",4' e- li' - S ir.
(licenserlpermittec}
with a principal place of business/residence at:
ICO
(phone4) C9
(strc°t/city/staielap)
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following worker's compmsation coverage for my
e ployees working on this job: 0
'713 D
(Insurance Company) (Polite Number) ( iration DT-)
( ) 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) (Expiratioa Date)
(Name of Contractor) (Laurance Company/Policy Number) (Expiration Date)
(Name of Contra(nor) ansuranc.� Compauy/Policy Number) (Exxpimbou Date)
(Name of Contractor) (Ll��uance Contpany/Policy Number) (Expiration Date)
(attach additiomt slices ifnccenAry v,include infbrMation pertaining to all ooatradors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing aU the work myself.
NOTE:please be awue that while homco-tvera who employ perzoaa to do raaiatcaanc'cocsuvction or repair work on a dwelling of
not mote than throe units in wbich the hotnoowncr resides or oc the Vvar, s apputtcnaai tbtrez arc not generally 000suicrai to be
employers under the wotkct's oDmpam4ca Act(GL152,ss 1(5)),application by a homoow=fora l o=c or permit may cvidcooc the
legal ctst w of an earployer undar d2,o Worka?s Con2ponsation Act
I undcxstand that a copy of this ctatcmcnt may be forwarded to tho Dcpartm a of lo&ui d Aoridl-&Orrioe of bmrvice for the
covmge verification and that failure to accure cova-ar under soctoa 25A of MGL 152 can lmd to the impos W of criminal pcnakics
consisting of a fine of up to 51,500.00 and/or imprisonmct of up to one yrar and civil pcnaltics in the form of a Stop Work Order and a
find of 5100.00 a day against me-
For dgmtmcdal—nary
(-7. Permit Numbcx
r' MZP4 Lot#
rt
(it gnab=of Lic=-1ci Permittee
Versionl.7 Commercial Building Permit May 15,2000
ECTION 10-STRUCTURAL PEER REVIEW(78Q CMR 110.11)
dependent Structural Engineering Structural Peer Review Required Yes......❑ No......
ECTION 11 -OWNER AUTHORIZATION -.TO BE.COM'PLETED WHEN
-WNERS AGENT OR CONTRACTOR APPLIES IF R BUILDING PERMIT
as Owner of the subject property
ereby authorize to act on
iy behalf lc all mat ers re ati e to work authorized by this building permit application.
ignature of Owner Date
&C, �����.-4 as Owner/Authorized Agent
ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
�owledge and belief.
igned under the pains and penalties of perjury
wcL
a m e
gnatur f ner/Agent late
,ECTION 12 -CONSTRUCTION SERVICES
0.1 Licensed Construction Supervisor: Not Applic�able ❑
iame of License Holder : J 1�5 �,(����'1/'l� 'rr' D D�C j_�
Sr�l�h '�ps., License um r
�h 2f Goc �Sf 5x�ac .
c!dr Expir tion Date
( � Tye/ _
a urd Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152, §25C(6))
Vorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
vill 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
ECTION 97. PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
:ONSTRUCTION CONTROL.PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.'OF ENCLOSED SPACE)
.1 Registered Architect:
Not Applicable
ame(Registrant):
Registration Number
Jdress
Expiration Date
gnature Telephone
-2 Registered Professional Engineer(s):
ame Area of Responsibility
ddress Registration Number
ignature Telephone Expiration Date
ame Area of Responsibility
adress Registration Number
gnature Telephone Expiration Date
me Area of Responsibility
dress Registration Number
gnature Telephone Expiration Date
ame Area of Responsibility
-]dress Negistration Number
gnature Telephone Expiration Date
,.3 General Contractor
— I P \) to03 , — Not Applicable ❑
om an Name:
� r(� �.
tesponsible n Charge of Construction J
ddr s
° 13
,r
I f)gnat Telephone
Versionl.7 Commercial Building Permit May 15,2000
Water Supply(M.G.L. c. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
ublic ❑ Private ❑ Zone: Outside Flood Zone ❑ I 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
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:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
:UBIC FEET OF ENCLOSED SPACE'
iterior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
xterior ations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
Accessory Building [ ] Repairs [ ]
-DESC2;-P-1 r ,3 vj� U Pa.� j 2� 1� l� (�e;� -rc e C gn r«e
ECTION 5 - USE GROUP AND CONSTRUCTION TYPE 63 0
USE GROUP(Check as applicable) CONSTRUCTION TYPE
Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1 B ❑
Business ❑ 2A ❑
Educational ❑ 2B I ❑
Factory ❑ F-1 F-2 2C ❑
High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
Mercantile ❑ 4 ❑
Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
Utility ❑ Specify:
Mixed Use ❑ Specify:
Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
f I(A.� Proposed Use Group: S f�✓1'1
:sting Use Group: ���_�
.fisting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
ECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFI=tCE°'USE ONLY
oe5 ►von �iP�� �70,�s Nat 1WI� _ x
y f
oor Area per Floor(sf) 1sc
g
2nd
-- 1%
3rdp
d to
d
4 �
h
ntal Area (sf) Total Proposed New Construction (sf)
�tal Height(ft) y
Total Height ft
w , r
Version 1.7 Commercial Building Permit May 15,2000
:City of hampton. 3
I n artment
G ,�I `Street
L_1n ���-•`"`
Roam 00
ornpt6 A 01060
1 �'.;'• ph 41 7-1240 x 413-587-1272
7-1.1
APPLICATI N T )GOmsTI I, $..REPAl ATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
y' f OTHER THAN A ONE OR TWO FAMILY DWELLING
>ECTION 1-SITE INFORMATION
L.1 Property Address:
This section to be,completed by Offic
—1 �
Map Lo# u Urt
y
f nor/ 55 O 106 Zone{
Overlay Des# r t
X
Elm St.District CB Distr ct `
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
..1 Owner of Record:
ame(Print) Current Mailing Address:
signature Telephone
'.2 Authorized Agent: t�pJ�iaS 1—�R(CLVL ' 2Qq �Cc a�' rjT ►�� l
UObA- --A,0%m i`�S:(yi Ej0(,P--1r,0
lame Print Current Mailing Address:
Jgnature Telephone
aECTION'3 - ESTIMATED CONSTRUCTION COSTS
em Estimated Cost(Dollars)to be Official Use Only
complete by ermit applicant
Bu"Iding Q A� (a;
File#BP-2002-0862
APPLICANT/CONTACT PERSON Skyline Design
ADDRESS/PHONE P O Box 142 (413)586-8491
PROPERTY LOCATION 175 INDUSTRIAL DR-ST GOBAIN
MAP 18D PARCEL 058 001 ZONE GI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid Zy
Typeof Construction: POUR 18 X 12 REINFORCED CEMENT SLAB&CLOSE UP DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 002722
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
-,X z,,( L/-/I-6 2
Signature of Buildin fficial 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.
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175 INDUSTRIAL DR-ST CQBAIN
BP-2002-0862
GIs# COMMONWEALTH OF MASSACHUSETTS
a . lock: 18D-058 CITY OF NORTHAMPTON
Lot: 1
i'gMA Building
T
Cate g=::Nons in r o a ' BUILDING PERMIT
Permit# BP=2QQ2-0N2
Project# JS-2002-0656
Est.Est.Cost:
Fee: 0.00 PERMISSION I5 HEREBY GR,4NTED TO:
Cost Class: Contractor: License:
use Girouu: Skyline Design 002722
Lot S�iZe(s ft.): 160307 80 Owner• OLDOAi LIMITED FARTNERSHIP
A tdcant. Sk line Desi n
Annd>cunt Address: Phone: Lnsu_rance:
P O � 142 41` 586-8491 Worker
Cramuenthon
FLORENCEMA01062 SSUD UN:4111102;a:06:00
TOpEREO"THE FOLLOWING WORK.-POUR 18 X 12 REINFORCED CEMENT SLAB &
CLOSE UP DOUR -
PO -t joj g VISIBLE ON#THE,_STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Flail:
Final• Final: 6�6
Rough Frame: �GQ
Gas: . Fire De artment Fireplace/Chimney. -<>
Rough:
Insulation:
Oil*
Final: S o e• Final: 0 j<
THIS PERMIT MAY RE REVOKED BY'SHE CIT F NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND;REGULATIONS.
C r ifi f c nc Siangure;
Fee T e: Receip t e: ante Check No: Amount:
Building 4/I
12 $50.00
212 Main Street,Pf � 40,Fax: 413)587-1272
Building: - -Anthony Patilla