29-087 • �-�tiAMP�,
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m DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060 "
WORTER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permi�i�e)
with a principal place of business/residence at:
— � L ,eS �1v�`maids (phone##) �
(stz�t/city!:-ter�rJap}
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 working on this job:
(Insurance Company) (Policy Number) (Expiration 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:
'Mr
(Name of Contractor) (lnsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Pokcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach a kHoml sheet ifn6oessary to inchsde information pertaining to nE omtv'Ctors)
>�-Lam a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware this while homeowners who employ per�ow to do mamtcaance,omstr=on or repair work on a dvmllmg of
not mote than throe units in which the homeowncr reside or on the g roun6 appurtenant thereto arc not gc*tf y oomidcrcd to be
employes under the%orke`s ooaVcrssaticn Act(GL152,=1(5)),application try a homeowner for a Uccn3e or pesmif may evidence the
ie al datum of an employee under the Workeet compensation Act_
I understand that a copy of this rtaf--A may be forwarded to tho Dq.A..,t of l.6 s al Accidents'Off o0 of Insucwce for the
coverxgc vrzi&cation and that fad=to seatrc coverW under section 25A of MGL 152 can Icad to the imposition of criminal peaaltles
oomisting of a fine of up to S1,500.00 aadlor kap iso of up to one year and civil pcaaffia in the form of a Stop Work Order and a
fine of S 100.00 a day against me.
For depart MwW uao only
Permit Number
o/ p17 Lot#
gloab=of Licens=/Permitiee
Version 1.7 Commercial Building Permit May 15,2000
SCTlON10 ,STRUCTURAL PEER REVIIEW(780 CMR 11011)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 OWNER AUTHORIZATION TO BE:COMPLETED°'WHEN..
OWNERS AGENT OR CONTRACTORaAPPLIES FOR,BUILDING PERMIT
l 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
QL- C v r; -f as Owner/ horized A e
hereby declare that the statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
'-"
Print ame
ature of Own Agent Date
SECTION 12;-.:CON S,TRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
SECTIQN,13 -WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L. c.152, 250(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavi,
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 11 No...... ❑
Versionl.7 Commercial Building Permit May 15,2000
EC7lON 9-2 RO3FESSIONAL DES1`GN AND'CONSTRUGTION SERVICES FOR,'38UILplNGS AND'STRUCT17FtES SUB.IECTTQ,
CONSTUC7N CONTROL P; RSUANT TO"'780,C R 116',(CONTA„INING`"MORE THAN 3,51J�O,C`F O� ENCLOSI_D:SPIIC '
9.1 Registered Architect:
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
w Uy b c w UJO r-G Not Applicable ❑
Company Name:
Responsible In Charge of Construction
04 c c is
Addre
> c�lo r/DEL
ature Telephone
♦ f
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
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 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:
f Versionl.7 Commercial Building Permit May 15,2000
5'ECTION CONSTR'U; 'C"T"lO,�;NSE"RV'f(CES'TO-0,11 PROJECTS L SS THAN,35 Opp,
GUB�G' 1ET01NCLOSEDSACE + z
r
�,:"
AN
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
DESC2-P-7r- A ctv rvC,,F
"'77F.,SECTION 5 !USE GROUP ANt)CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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 ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS'.SECTION IF"EXISTING;"BUILDING"UNDERGOING RENOVATIONS,ADO.ITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SfCT10N 6yBU1LDtNG'HE1Gi�T"A1VD AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
xr
Floor Area per Floor(sf) St `'" `E� _ r 4 ~"
1st
2nd
ae
3rd
2nd v '
3rd n i
4th
Total Area (sf) Total Proposed New Construction (sf)
...................................
Total Height(ft)
Total Height ft ------------------- '
6�a fi}y
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
C E p pp�B ' g Department
D 1! U t5 Main Street
om 100
SEP 2 5 200�Vor ton, MA 01060 �t
phone 413 240 Fax 413-587-1272 tfe
A PLICA la1FIt1UfMROMABA-R106t1f 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
This section to be completed by off>ICe
1.1 Property Address: "k" t
Lit�� �FER
i nr
Zone Overlay District' �e
-Elm St District GCB District:
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
M a c-Ut rt.! M C C6 Al /Qy/f� mod.
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
-.c-6 /c-
Name(Print) Current Mailing Address:
A-74 J-7 1 A—
Sig re Telephone
SECTION 3--ESTIMATED CONST RUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only',
completed by ermit applicant
1. Building (a) Building Permit Fee
W G&,
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (l + 2 + 3 +4+ 5) Check Number
This Section For Official Use,Onl
Building Permit Number: Date Issued:
;Signature:
Building Commissioner/Inspector of Buildings date
' ' 8 ROAN RD BP-2002-0343
M1GIS#: COMMONWEALTH OF MASSACHUSETTS
29-087 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofmg BUILDING PERMIT
Permit# BP-2002-0343
Project# JS-2002-0521
Est.Cost: $4600.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group. John Corbett 104000
Lot Size(sq.ft.): 121 53.24 Owner: MCCONKEY MARVIN E&RUTH R
Zoning: Applicant. John Corbett
AT. 418 RYAN RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.91271010:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 Deaartment 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 9/27/010:00:00 1178 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo