31B-051 (19) 0g'CHN'1PT0
s� a� Grit 7 lorf �x#I X111{7 1aIT
B B laso itch ttsrtta'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
-- WORKER'S COMPENSA/T/TON INSURANCE AFFIDAVIT
with a principal place of business/ at:
Jz'.2o %JJ�OT '1,,oV, ,,o4 m aldoL (phone#) _,S:3-2798'
(street/ci ty/scaf r/�p)
do her by cify, under the pains and penalties of perjury, that.
( I am au ert employer providing the following worker's compensation coverage for my
employees working on this job:
7S�TX g9S7
2nce (Policy Number) (Expiration Date)
��i4Y1 r e
( ) 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 Com}rany/Poticy Number) (Expiration Date)
r.
(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 shod ifneocssary to include infotmarioa pertaining to all ooatrec s)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that vbile homeowaecs who crnploy persons to do r* imma ncc ooasfrud on or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtcaant thereto arc not grnCralty considacd to be
employixa under the wmikc's comP=s4oa Ad(GL152.ss 1(5)) application by a homeowner for a 11ctrtse or Pe Mit may evideaoo the
legal status of an employer under the Workoet Compemaiioa Act_
I undetstaad drat a COPY of this ctaremmt avty bo forwarded to the Dcpertmcnt of Industrial Aoad a&Offioc of Iasucsnce for the
oovaage verification and that failure to accrue covtmgc under section 25 A of MGL 152 can lead to the imPosition of criminal Pcaaltiea
oomisting of a fine of up to$1,500.00 andlor kapriso�of up to one year and civil pcnattits in the form of a Stop Work Order and a
find of S 100.00 a day against tee.
Far dgrartab�—,301Y
Permit Number
Map# Lot#
W
of Li rmit t e e
Version 1.7 Commercial Building Permit May 15,2000
`S�e1 i3ry, 11»
SIONpr pER";3r1>rus �lvi �o� � *
s.
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTJON 11 ,0 IER AUTHORIZATION 4�TO BE COMPLETED�`WHEN
OWNERS AGENT OR,dNTRA' O §-,t
OR 'G"PERM!
..x4a 1 .�.a,.,
I. �T� '��� Qom- CW�� FA��+ as Owner of the subject property
hereby authorize _� to act or
my behalf m ers r tive to wn-rk authorized by this building permit application.
Sig at w r Date
I, ,J. a f'ylarl�goe 1,0'' as uth ent
hereby declare that the tatements and information on the foregoing application are true and accurate, to my
knowledge and belief.
Signed,under the pains and penalties of perjury.
J
Pg S 0 ner/A nt Date
SECTION.12-CONS';X0 I•ION"SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jr-- 0 ?7
License Number
y�o �`��� /�� el �e�a�i�✓a A, 7- 16 - 0 3
Addr s Expiration Date
7 Z_A72� 3
Si nature Telephone
SECTION 13 -'WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.jc.152,§25C(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....... No...... ❑
Versionl.7 Commercial Building Permit May 15,2000
5EC71 PRfJFES3a��ON LD SIGIAN O fiRtIFIOIV°SER1%ICESS F " ND ;, "
E , , ORkBUILDINGSiATR�� ES;Sl16JE TfJ
C,QIVSTRL�CfipNONTROL PUR3tANT 7a 7 „ AMR 116.,('C,ONTAI►V[N+l%,MOE,7HAN,35.Op,O I �LOSD' P1E)
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
/1 i47 �i6 ce Not Applicable ❑
Company Name:
lei
Responsible In Charge of Cons uction /
Ad ss
.2s� ;27 7
na a Telephone
Version 1.7 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 ❑
S. 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_
Noe
IF YES, describe size, type and location:
f Version 1.7 Commercial Building Permit May 15,2000
w k b
SEt94�C£iNS`fRllcT otR�rlats �o �.� csRs�r s ;c>QQ
CUBIC '�T�OF CIS
MI
f....,:
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
SECTION 5 USE'OROUP AND CONSUCTION TYPE,
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi Rh Hazard ❑ 3A ❑
Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential 10 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 SEGT'0 JF,EXISTI,IVG BUILDING UNDERGOING;RENOVATIONS,ADDITIONS ANDIOFt CHANGE,IN USE
Existing Use Group: =Proposed Use Group:
Existing Hazard Index 780 CMR 34): Hazard Index 780 CMR 34):
SECTION&BUILDING HEIGHT AND'A,At*EA
a, 3
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) St ~ '
1st
2nd
3rd
2nd u '
3rd 4th
4th
Total Area (sf) Total Proposed New Construction (sf) h
g ...' y
a
Total Height(ft)
Total Height ft --------- p 3 r m
w Versionl.7 Commercial Building Permit May 15,2000
City of Northampton
Building Department
212 Main Street
Room 100
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
SEC i lON 1=SITE INFORMATION
;. ,
1.1 Property Address:
Overlay
aC
, WI..;;NU
IM
IN
flm StDstrict CB District
SECTION 2. .PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
/.� .,-ev .6e�4 � o 6—'relel t
Nam t Current Mailing Address:
f13 SY 7 6 y�s
at Lo Fe—' Telephone
2 2 Authorized Agent:
Name(Print) Current Mailing Address:
27
ature Telephone
SECTION,3''..E5IIMATED'CON5TRUCTION C05TS
Item Estimated Cost(Dollars)to be Official Use
completed by ermit applicant
1. Building �5-0 0. (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) Ghec, , umber
Tk�is S tioin; or 0##iclal..Use o
Buldirtg Permit„Number: gate issued,:
,
ignatu'rle:�
,Buiid!Og Commissioner/Inspector of Buildings pate-'
5 KING�T BP-2002-0719
GIS#: COMMONWEALTH OF MASSACHUSETTS
a".Block:31B-051 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0719
Project# JS-2002.1182
Est. Cost: $500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: Diversified Construction Services 030787
Lot Size(sg. ft.): 18382.32 Owner: GOLDBERG BARRY G&ANNETTE E
Zoning:HB Applicant: Diversified Construction Services
AT: 135 KING ST
Applicant Address: Phone: Insurance:
PO Box 168 (413)253-2798
BELCHERTOWNMA010070168 ISSUED ON:2121102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT I NTERIOR PARTITI ION WALL
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/21/02 0:00:00 1803 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo