32C-047 (4) s�oofl
Grxt� Xtd 'Xiart4aillp f all
B d �asaacllnactta'
DEPARTMENT OF BUILDITNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
wORKER'S COMPENSATION INSURANCE AFFIDAVIT
L
(1 i cease�JPermi tree)
with a principal place of business/residence at:
(phone#)
(streeuci ty/st a tf/ri p)
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:
ce 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:
Y"
(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 ifneasssry to include infocm,tioa perteiniug to all ooatraao,a)
( ) 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 wbilo homoowocra who employ pazom to do„ter;..m.nct comuuctioo or repair work ou a dwelling of
not more than throe units is which the bomeowner resides or on the grounds appurtenant thereto are not gencmily ooandaed to be
employers under the worker's oompeas4m Act(GL152,ss 1(5)),application by a homeowner for a licrrue or pcnuit may cvidcnoc the
legal status of an employee under the Wortrds CompensL6oa Act
I undetsta that a oopy of this statement may be forwarded to the Depwtnms of Indautrial Ao6daa&Oboe of Irmuraaoe for the
coverage verification and that failure to secure oovcrngo under section 25A of MGL 152 can load to the imposition of criminal penalties
oomL,emg of a fine of up to S1,500.00 andlor imprlsoamrtr!of up to one year and civil pcni ties in the form of a Stop Work Order and a
find o(3100.00 a day against ne.
For dq:artaomtal use:only
Permit Number Map# Lot#
tun of icenseelPermittW e
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(78QCMR 110,11)
idependent Structural Engineering Structural Peer Review Required Yes......❑ No......�
SECTION 11-OWN ERA"UTHORIZATION TO,
Bf".,COMPL'ETED "WHEN'
.:.OWNERS AGENT"OR CONTRACTOiR APR:LIES"fQR,BU"ILDING"'PE"RMIT
1, IRA ELFMAN as Owner of the subject property
hereby authori a MAROIS CONSTRUCTION CO. INC. to act on
my behalf, i I matters relative to work authorized by this building permit application.
Signat re Owner Date
1, IRA ELFMAN 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.
�� �ir rh✓�-ry
Print Name
Signature of ner/Agent Date
aECTJJJN 12"-CO:NSTftUCTlON:S"ERILICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: JOSEPH A. MAROIS
License Number
148 NEWTON STREET — SOUTH HADLEY, MA 01075 #016757
Address Expiration Date
413-533-1320 2002
Signature Telephone
5ECTION 1 =YllO"RKERS�;:C.OMPEN.SATION'JRS'URANC.E"AFFID%#�IT:{M.G:L. c..15 2,§25:C{r6))
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
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 ❑ 1 Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 9. 675 sq. ft 9.675 sq. ft
Frontage
Setbacks Front
99 . 1 i f 99 . 1 i f
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 xx YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW xx YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO xx 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 xx
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 9 PROFESSIONALDESIGN�AND CONSTRUCTION SERVICES --FOR'BUI.LDINGS AND'S:TRUCTURES°SU.BJECT TO
CONSTRTICtION-CO.NTROL:PURSUMTTO 78.0.CMR,I1,6(CONTAINING MORE THAN 15., 00 C F'..OV CLOSED SPACE)
9.1 Registered Architect:
Not Applicable
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
N/A
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
MAROIS CONSTRUCTION CO. , INC. Not Applicable O
Company Name:
JOSEPH A. MAROIS
Responsible In Charge of Construction
148 NEWTON STREET — SOUTH HADLEY, MA 01075
address
413-533-1320
S' re Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4=CONSTRUCTION SERVICES;FOR"-PROJECTS"LESSI"THAN"'35;000
CU.BI,C F££T-OF ENCLOSED SPACE
Interior Alterations Existing Vlla11 Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
pESCRTp cces y building[ ] Repairs [ ]
�LP�rn csr t ,;ty 41i �9
SECTI':ON 5 - USE°GRO ANDFCO"NSTRUCXION 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 119 2A Q
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
institutional ❑ 1-1 ❑ I.2 ❑ 1-3 ❑ 3B .❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R•3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513
U Utility ❑ Specify:
Mixed Use ❑ Specify:
S Special Use ❑ Specify:
GO"M"P1 ETE TH:{S"SI CT1, 1F EM TI`l�IG"BUILD,ING UNOE"RGOING;RENOVATIONS,A DD JT10l�JS"AtaiDIOFt CHANGE"111"f7SE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
5ECT10N°6"BUILD:ITVG.HEIGHT AND FAREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
*W14
Area per Floor(sf) St EXTERIOR
�5t 2.400 sci 2nd REPAIR
3rd � ��
2nd
rd 4th
th
112 N
Total Area (sf) Total Proposed New Construction sf
, f
Aal Height(ft) —
s,
Total Height ft --------•----------
Fy <
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
SECTION,1"=.51TE"INFORMATION
h� secioto � om ietrl �offibce4
1.1 Property Address: 6 � t �� �y
a
110 PLEASANT STREET - � sf xa _
�Mat' 1,,x
NORTHAMPTON, MA 01160 Z011exur�a+ r�ct r t
SECTlONx2 ;PR(JP£RT,Y.OWNERS IIP/A"UT IZED":AGENT"
2.1 Owner of Record:
IRIS REALTY, L.L.C. 1607 NORTHAMPTON STREET — HOLYOKE, MA
Name(Prin ) Current Mailing Address:
(413) 532-5100
.enature " Telephone
2.2 Authorized Agent: /A ��C�/���� �
MA
Name(Print) Current Mailing Address:
Sig ur Telephone
SECTION ESTI"MATED%CON ST:RUCTION:COSTS ,
Item Estimated Cost(Dollars)to be O Llse9nl'y
completed by ermit applicant
1. Building {a) Building Fern Fee;
4,400.00
2. Electrical of
Co"nstructcon from- 6
3. Plumbing :Building Permit 1~ee.
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3+4+ 5) 4,400.00 Gheck� uber
is°'Seciori
or"Official"Use"On)
Building`Permit Number: Date Issued:
„nature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0329
APPLICANT/CONTACT PERSON Marois Construction Co Inc
ADDRESS/PHONE 148 Newton St (413)533-1320
PROPERTY LOCATION 110 PLEASANT ST
MAP 32C PARCEL 047 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
TWeof Construction: REMOVE&REPAIR SIDING&CONSTRUCT INTERIOR PARTITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans included:
Owner/Statement or License 016757
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 fission Permit from CB Architec a Committee
Signature of Building Officia 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.
110 PLEASANT ST BP-2001-0329
GIS#: COMMONWEALTH OF MASSACHUSETTS
MR:Block: 32C-047 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0329
Project# JS-2001-0541
Est.Cost: $4400.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group: Marois Construction Co Inc 016757
Lot Size(sq.ft.): 971 3.88 Owner: ELFMAN IRA&CHRISTOPHER LAFLAMME
zoning:CB Applicant: Marois Construction Co Inc
AT. 110 PLEASANT ST
Applicant Address: Phone: Insurance:
148 Newton St (413) 533-1320 Workers
Compensation
SOUTH HADLEYMA01075-2378 ISSUED ON:1013100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE & REPAIR SIDING & CONSTRUCT
INTERIOR PARTITION
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:
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 Occupancv Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/3/00 0:00:00 1693 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo