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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOR.ICER'S COMPENSATION INSURANCE AFIMAVIT
(li censcelpermi ttee)
with a principal place of business/resideuce at:
(street/ci ty/stalr/n 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:
(Insurance Company) (Policy Number) (Expiration Date)
O 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 Comparry/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compam/PoLicy Number) (ExThtion Date)
(Name of Contractor) (Insurance Company/PoUcy Number) (Fa-phbon Date)
(Nance of Contractor) (Insumace Company/Policy Number) (Expiration Date)
(attach additioaat shed if neccs to include informaAoa pertaining to alt ooatracton)
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 vitd10 homeowners who employ persons to do constvdioa orrcpai work on a dwelling of
not more than throe units in which the homeowner raid=or on the groins appurtenwA thereto an not gcocrally oomWcrcd to be
employers undo tba worker's comprnxatioa Act(GL152,ss 1(5)),application by a homeowner for a Gecnsc a permit may evidence,the
Icgal status of an employer under the Worker'=Compeoeatson Ad
I understand the a copy of this ctv to t may be forwarded to the Department of lndssstrid Atxideats'Of im of Insurwce for the
oovcage verification and that failure to secure coverage under stet oa 25A of MGL 152 can lead to tbd impos—of criminal pea&wcs
oomuting of a fmc of up to S 1,500.00 ar Nor of tip to one year and civil pcmltics in the form of a Stop Work Order and a
fine of 3100.00 a day against mc..
For dgrsrhrrr£al arse enly
Permit Number
Map4 Lae
St tore of LiccnseeJPermiU-ce ��
Y
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CM 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I''n rV ).-(r-H�-f-h C t��e_ s.s O C{ � I=LL,as Owner of the subject property
� FZ ►4 �� 1Jc� US
hereby authorize 'th
act on my behalf,in all matters relative to work authorized by this building permit application.
L, �. -(o 0 fD
Signature of owner �.., Date
l 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: .r Not Applicable ❑
Name of License Holder'"
License Number
Address Expiration Date
lephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit mu t be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the buildi rmit.
Signed Affidavit Attached Yes No 0
Feb 06 06 09: 201a P
Vcrsionl.7 Commmiul Building Pennit May 15,2000
SECTION 8-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 38.000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect
Not Applicable 13
�,.. t- s C Ct C�c,d rti4��N, Alit
Name(Rep nt):
C / I Registration Number
1 3o 3
Ad sta
/ p / X65(. -%&L`Cr' Expiraton Cato
nature Telephone
82 I red Pimloftslonal Engineer(:);
Name Area Of Rssponsibilty
Address Registration Number
Signature T6bpfana Exwi�tion Dale
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Namo Aroa of Responsibility
Acidness RegistraWn Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Nurrdw
Signature Telephone Etiration Onto
8.3 General Contractor
Not Applicable❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
X 8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size c�I9 _15 7S S �r4 tv
Frontage 0� 1 s p-rYl
Setbacks Front 1�d j S p tx l!,. ` 'Z(
Side L:i Z)a I R: i L:6 R: 1% / i5-
Rear �06, / SA-ft t—�
Building Height a6 t ►1 14'r►'1 I 3-5
r
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved e�C} -57 0)0
parking) Al(O )
#of Parking Spaces
Fill:
volume&Location)
A. Has a S t Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page` and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES er NO 0
IF YES, describe size, type and location: N — V,) f�4-'�A 01' V,PriV tV & t Q-7 y
E. Will the construction activity disturb(d®ng,grading,excav or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water(Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ P►dditions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other❑
Brief Description Enter a brief description here-..
Of Proposed Work: R -= 13v)i- IJ PO/q,/ / C
c
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 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 26 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
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 OFFICE USE ONLY
Floor Area per Floor(sf)
1'�
1�
2
2"d 2W
3rd
3rd
4m 4m
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water S ly(M.G.L.c.40,§54) 7.1 Flood Zone Information: .3 Sewage Di sal System:
Public Private [] Zone Outside Flood Zone Municipal On site disposal system[]
Versionl.7 Commercial Building Permit Ma 15,2000
t ryep rim @hit use pnty'
City of Northampton Status of Perirnit:
Building Department curb Cut/phyowayPermlt -
212 Main Street Sewer/peptic Availeliility
Room 100 WaterMfell Avala¢ility y
Northampton, MA 01060 TWO Sets of Structural karis
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other,Specify
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 section to be completed by office
"� ?i 71 �3 1�i 1� G 1= R tl 141 Map �� Lot °l '�" Unit
ri L j?-fh 19 rn V t-6 rJ ^CYr P VS Q /'G6 Zone (b Overlay District 'X-
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Nvl�l'h iAw" 1i01"a rU H et4 L.-rh C 0 Kl" Current Mailing Address:
t�S 3 Q C 1 fi 1� S c. �3 7 r'b 32 AJhri, xr m cS'S
Signature Telephone / 13 &16 3 0 0
OF
2.2 Authorized Agent:
Name(Print) FI'N N D C r!1 )o 03 Current Mailing Address:
/ Sf r'mr7w/- gvvv. f3Rt'06-e N0 fir..
Signature Telephone '�Q ® q r
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building �� i Dd (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6 2 ( 6
3. Plumbing Building Permit Fee �}
4. Mechanical(HVAC) rl U.) Cl G
5.Fire Protection C PC,0-9-1)
6. Total=0 +2+3+4+5) 1'3-/ 006 Check Number 3 if This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date FEB -i
File#BP-2006-0799
APPLICANT/CONTACT PERSON NORTHAMPTON NURSING HOME INC
ADDRESS/PHONE 737 BRIDGE RD NORTHAMPTON
PROPERTY LOCATION 737 BRIDGE RD
MAP 18C PARCEL 048 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
uiIding Permit Filled out
L.,Tee Paid (0S-"50 kl
Typeof Construction: Rebuild portico roof
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License ���s
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91ILMATION 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
Signature of Building Official 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,
737 BRII)GE RD BP-2006-0799
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: I 8-Dag CITY OF NORTHAMPTON
Lot:-001
Permit: Building
CateQoa. BUILDING PERMIT
Permit# BP-2006-0799
Project# JS-2006-1221
Est. Cost: $21000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: REINHARDT ASSOCIATES INC MA2843
Lot Size(sa.ft.): 272685.60 Owner: NORTHAMPTON NURSING HOME INC
Zoning.URB Apolicant: REINHARDT ASSOCIATES INC
AT. 737 BRIDGE RD
Aoolicant Address: Phone: Insurance:
430 MAIN ST (413) 786-9600
AGAWAMMA01001 ISSUED ON:211712006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD PORTICO 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 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:
FeeType• Date Paid: Amount:
Building 2/17/2006 0:00:00 $105.004985
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo