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31B-051 (21)
<L O Oafl � B �:ssschusetta' DEPARTMENT OF BUILDDZG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT with a principal place of business/residence at: Ry /.JO /• /J yl C.i .+� •.!//U!J (phone#) Z...S3ra'2;7 (street city star 2dp) do hereby certify, under the pains and penalties of perjury, that: ( an employer providing the following worker's compensation coverage for my employees working on this job: S- *urancc Company) (Policy Number) OTirddon 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) f (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/PoEcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sheet ifnearsary to include infonn.rion pertaining to all ocatrad ) ( ) 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 while homeownera who employ pasons to do rttairde,a nM=stnution or repair work on a dwelling of not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not gc orranY ooandend to be employer;under the woricn`s compensation Act(GL152,ss 1(5)),application by a homeowner for a license a permit may evidence the legal flatus of an employer under the Workoet Compensation AcL I understand that a copy of this v atemeut may be forwarded to the Dtpwt, m of Io&n al A=&-a&Offioo of Inawanca for the covetttge verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to$1,500.00 w0or'icmpriso�of up to one year and civil pemlt es in the form of a Stop Work Order and a firm 0(5100.00 a day against ono. For dal tree only Permit Number fit G ll© Lot# Si of Licensee/p rmitxee e Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... f� SECTION;11.OWNER AUTHORIZATION.-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES'FOR BUILDING PERMIT as Owner of the subject property -� � hereby authorize riz to act on ! my behalf, in all matters relative t work authoed thi u' ing permit application. Signature of Owner Date ?'"19((aLI�A Gc6610as a eNAuthorized 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. cx-- 6C66 Print Name Signature of Owner/Agent Date SECTION;12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: 3 ` Not Applicable ❑ Name of License Holder: S' !a 1p ©30 2-e License Number Address Expir ion eate si ture 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- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTI1ON'CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 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 z�'a''5.,x'-- d/(z� /a etxw �5;'e Le:�. Not Applicable ❑ Company Name: Responsible In Charge of Construe ion Address yi3Zs3a�� Signature C, Telephone Versionl.7 Commercial Building Permit May 15,2000 7. Water Su pply(M.G.L. c. 40, §54) 17.1 Flood Zone Information: 7.3 Sewage Disposal System: Public Private ❑ Zone: Outside Flood Zone Municipal UkOii site disposal system ❑ 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size PAM E -Frontage Setbacks Front Side L: S— R: © L: .5—R: 6 Rear f15D f Building Height r 041 Bldg. Square Footage S-0V 36 % Open Space Footage �. % (Lot area minus bldg&paved C parking) #of Parking Spaces Fill: 1r 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 t// YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO �ON'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: 54—2Z,, 7-5r 1y j,x/0/ 4y,4 red D. Are there any proposed change to or additions of signs intended for the property?YES No IF YES, describe size, type and location: &7,_,c yTi*) Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONS'TRUCT'ION SERVICES"FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED`SPACE Interior Alt 'ons Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ ew Signs [ ] Change of Use ther [ ] J; �N LL ccesso uilding[ ] epairs [ SECTION 5, USE`GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business fiY 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1.1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile 0111 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: l M Mixed Use ❑ Specify: ,e Sfiecv ao l kJ er .e Q r= i'-. J,1 IM11R, S Special Use ❑ Specify: , t157`11(1-) 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 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION FF( ~^ ' y Floor Area per Floor(sf) 1St f 140 t 2um /X44 p[�Xi�Li�c OV ANKIWI t �) X/Od 2nd 1s c ' y 2nd '�[/�JQ G^rt/ vVI9�/l 3fd �6a � 4th 3rd / ! 4th A ! y N Total Area (sf) (57, Total Proposed New Construction (sf) yt 5—,-0111'_ i --------- Total Height(ft) Total Height ft ---r,�=`-�-------- / '— Versionl.7 Commercial Building Permit May 15,2000 s pity of Northampton 0tailding Department 3 0 2000 212 Main Street Room 100 17 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-SITE INFORMATION 1.1 Property Address: This set r't,i< p off 1fI y s Map f y x /ice f Uric l i t s Elm SR''L?„trig � z Dj „ SECTION 2- PROPERT,Y.OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: (n� MP. G, G� E CG 320 GREEN HILL Kd . �►acjMrY�c y l Name(Print) Current Mailing Address: 29- ature Telephone 2.2 tho zed Agent:Nam (Print) Current Mailing Address: �jofio�t� ��?ooD Signature Telephone SECTION 3 ESTIMATED C(1N5TRUCTION 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 Cast of Construction from 6 3. Plumbing Building�Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 + 3 +4 + 5) x,,10 5Z�? �' Check Number This Section For Official Use Only Building Permit'Number: 6 Date Issued: Signature: Building Comrnissionerllnspector of'.Buildings Date File#BP-2001-0459 APPLICANT/CONTACT PERSON James Marley ADDRESS/PHONE P O Box 168 (413)253-2798 PROPERTY LOCATION 135 KING ST MAP 3 1 B PARCEL 051 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Al Fee Paid lypeof Construction: INSTALL FIREDOOR/WALL&INSTALL OVERHEAD DOOR&COUNTER TOPS New Construction Non Structural interior renovations _ Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 030787 3 sets of Plans/Plot Plan THE F LOWING 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 sion Permit from CB Architecture Committee Signature of Building O 1 v 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. x M+.,a••.:n},�» ra'V""+'fu-ere `.-'"'""",. a�e..,.�.w,n�,..r-+-s.....;�^c "� `;"..+.----„ M"INK M�, 135 DING ST BP-2001-0459 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3 111-051 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0459 Project# JS-2001-0783 Est.Cost:$20500.00 Fee:$100.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: James Marley 030787 Lot Size(sg.fQ: 18382.32 Owner: GOLDBERG BARRY G&ANNETTE E Zoning:HB Applicant: James Marley AT: 135 KING ST Applicant Address: Phone: Insurance: P O Box 168 (413)253-2798 Workers Compensation BELCHERTOWNMA01007 ISSUED ON.-1113100 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL FIREDOOR/WALL & INSTALL OVERHEAD DOOR & COUNTER TOPS 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:%1341.0 9,�gr. ✓�. ./' Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: Or' (1-3 Q-0414 Iry t r THIS PERMIT MAYBE REVOKED BY THE CITY ESianature:HAMPTON UPO OLATION ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc Fee Type: Receint No: Date Paid: Check No: Amount: Building 11/3/00 0:00:00 1245 $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo