38B-143 City of Northampton
r , ; Massachusetts 'e
A*
DEPARTMENT OF BUILDING INSPECTIONS 5
212 Main Street • Municipal Building
Northampton, MA 01060 '
INSPECTOR
Louis Hasbrouck Fax: 413-587-1272 Chuck Miller
Building Commissioner Phone: 413-587-1240 Assistant Commissioner
CONSTRUCTION CONTROL DOCUMENT
(For professional Engineers/Architects responsible for Entire Project)
Project Title: NrW FwT'tgyyo�- EGFll?f G0HZf.> Date: A L ZZ, ZO1 f
Project Location: III GOLUM1ftS Aykmut: Map:j�6 Parcel: 10q Zone: UP
Scope of Project:g1zaf— S-,rA-ic!r5 4 Dl&c1- ' L-1 111EV IN1014.2' F15WAV KK
In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107.6:
I, F-1c f-P t• VWT-5 °G' Mass. Registration#
Being a registered professional Engineer/Architect hereby CERTIFIES that I have prepared or directly supervised
the preparation of all design plans, computations and specifications concerning:
AENTIRE PROJECT
For the above named project and that to the best of my knowledge, such plans, computations and specifications
meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices
and all applicable Laws for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that
the above mentioned portions of the work proceed in accordance with the documents approved for the building
permit and shall be responsible for the following as specified in Section 10.7.6.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction documents as submitted for the building permit, and approval for the conformance
to the design concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed
In a matter consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent
comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory
completion and readiness of the project for occupancy.
�\SZERE D ARl
Q y ATS'l 1
b #
Signat S of Registered Pr x No.8355 cr,
VJESTHAMPTQN
PAASSACIIUSETTS �
ZZ D y of 20 14 4" No MP�����/�
(seal)
The Commonwealth of Massachusetts
.1
Department of ltzdustrial Accidents
Office of Investigations ti ,
600 Washington Street
Boston, MA 02111
'fR
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C�-fL ,C ��} S'
Address:
City/State/Zip: pct O 13 0 ( Phone#: t -�
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 2 4. Ef I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
_2._❑_I am a sole proprietor or partner- _ listed on the attached sheet. 7. o,
ship and have no employees These sub-contractors have g, ❑Demolition
working or me in an capacity. employees and have workers'
g y p � com ins`urance.$- 9. ❑Building addition
[No workers' comp.insurance p•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
❑ I am a homeowner doing all work ❑
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c 152,.§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.] S
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information. `r
Insurance Company Name: [.AIL Lek
Policy#or Self ins.Lic.#:�� � Z& 7,7 Expiration Date: r � �
Job Site Address: 013 . City/State/Zip: !�&O,S,,It owkz
Attach a copy of the workers' compensation policy declar tion page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided is true and correct.
Siiznature:� � Date:/�'►L?(L 1 / l T
Phone#: �� 571-) - '
F fficial use only. Do not write in this area,to be completed by city or town official
--- ty or Town: ---__ -____ ._ __ _ _ _ ___-_ Permit/License#
suing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
J
SECTION 10-STRUCTURAL PEER REVIEW(78U CMR.11011),
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 OWNER AUTHORIZATION TO;BE OOMPLETEDi WHEN;
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGTERMIT
as Owner of the subject property
hereby authorize ._...........__ .._._
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner r� µDate
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. ;
Print Name
• l '
$i nature of Owner/Agent �— Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:_ 1 .0 4 ..._._.� . 3 – m. ••-. .• I- -' -y.
License Number
Address Expiration Date
Sign atu f Telephone
SECTION'13-WORKERS';COMPENSATION INSURANCE AFFIDAVIT(M G L c..152,§25C(6A
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 0 No
w
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL..PURSUANT TO 780 CMR 11. (CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
-' Not Applicable ❑
Name(Registrant): Leif--
S- T i Registration Nunjb er
Addre e
Expiration Da_.._� � .
Si u Telephone
.2 gistered Professional Engineer(s):
s ;
Name Area of Responsibility
x
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
........._..............—..-----.._..............
.
i
Name Area of Responsibility
i
Address Registration Number
1 r i
Signature Telephone Expiration Date
9.3 General Contractor
� f �r [I Company lame. Not Applicable
Responsible In Charge of Construction
r
Signature Telephone —1
Versionl.7 Commercial Building Permit May 15,2000
8..NORTHAMPTON.ZONING. ,
Existing Proposed Required by Zoning .
This column to lie filled in by
Building Department
Lot Size
Frontage
Setbacks Front
a L_.._ J" _
Side L:11-----j R:L� L: 1 R:
Rear
Building Height
Bldg. Square Footage _ .." "_.._ ...; % ii �
Open Space Footage %
- (Lot area minus bldg&paved
#of Parking Spaces
Fill:
2 t
(volume&Location) ---------�-- ,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW 0 YES _.._.,,._._
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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: 's
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 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❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description #
P Enter a brief description ere. J�a/ )
� aA /�NmY~V /�
Of Proposed Work: d
� 3�Q
r (�G� QG�� o� jpfr p�/cif G
_ _._S L
SECTION 5-USE GROUP AND CONSTRUCTION TYPE i
lvt4n) 6,USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 1:1 A-1 El A-2 El A-3 1A ❑
A-4 ❑ A-5 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 26 r ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ -- -- 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U Utility F-1 Specify:
M Mixed Use F-1 Specify:
S Special Use ❑ Specify: '�.�..�.� ._._�_. ..v.._..�.....�....�...__...r_.._.�_._�,�.._.���.,.._._.. �
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) ..._.v __.__...w _: Proposed Hazard Index 780 CMR 34) .__..._. ._w_,._ _._•__.. __._.
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION. OFFICE'USE ONLY
Floor Area per Floor(so
1 St
2nd ,......_.._._._»......__.__......._ .,,..... 2nd
._ _._._.__.._-_.___,.._._.�...__.._..._._.�.._._____�_.� -
3rd 3`d
4th _..___. _____ _ _.__.�� 4m
3 ,
Total Area(sf) Total Proposed New Construction s
_ __.
._ ...._..
Total Height(ft) I
---- -- - --._. - Total Height ft
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 E]
r
Versionl.7 Commercial Buildin Permit May 15,2000
v r ' ' DepBrtme GSe�or1E � w x
�C V 11r�� r a ski k a p F v � ' "W" c 14 wig v
i of Northampton stags o.fP; e
3 �tm7{rgtx>'°tL,N^��S 1�k w'�c�kL�fi^'�e •g��rr� ,�dt 'aT' �� +Y
ilding Department CGrWUUVD veway Pet? tt r�
AFR 222014 12 Main Street sewer/S"epi q1u.-kva,latittttjt
Room 100 Vifatet/UMfIlRvatfablfif � e � " .,.
ort ampton, MA 01060 Twa=$eCs of Structtiia Plane3f �_ `x
Electric,Plumbing&Gas Inspec i n ; Yx
NOrtharnrton, gOQVI 87-1240 Fax 413-587-1272 t?lof( tte Plans `x ,
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
Thais section.to.be completed byoffice
.:Map. Lot Unit
d 0& Zone Overlay District
---- _..... _ � _ _ ' ':E6'St:District 'CB District`
SECTION 2-PROPERTY OWNERSHIP/AUTKORIZED AGENT
2.1 Owner of Record
Name(Prin Current Mailing Address:
Signature �y"`�p Telephone
2.2 Authorized Agent:
._....
Name(Print) Current Mailing Address
r
Signature Telephone
SECTION 3=:ESTIMATED:CONSTRUCTION COSTS'*'.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Building Permit Fee
2. Electrical Zd <' (b)Estimated Total Cost of
Construction from- 6
3. Plumbing K Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
loll
_.6. Total +2+3+4+5) Check Number
This.Section.Foe'Official Use Only
Building Permit Number Date
Issued
-- -Signature:
Building Commissioner/Inspector of Buildings Date
��ONI til ��-
File#BP-2014-1095 1�,
APPLICANT/CONTACT PERSON TOSHI KASHIMA PO
ADDRESS/PHONE 15 UNION ST GREENFIELD (413)774-5402 NOT
PROPERTY LOCATION 19 COLUMBUS AVE 5Q
MAP 38B PARCEL 143 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY: J�^'
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT FIRE ESCAPE FROM 2ND&3RD FLR DECK RENOVATE 2 KITCHENS
&2 BATHS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 060134 // o
3 sets of Plans/Plot Plan aq"yS
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF¢RMATION 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 Permit DPW Storm Water Management
Demo ' ' elay — �(!3 41—/
Sig e of B i ding 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.
19 COLUMBUS AVE BP-2014-1095
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 143 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-1095
Project# JS-2014-001466
Est.Cost: $75000.00
Fee:$450.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TOSHI KASHIMA 060134
Lot Size(sq. ft.): 11761.20 Owner: PACOSA PETER A
Zoning. URB(100)/ Applicant: TOSHI KASHIMA
AT. 19 COLUMBUS AVE
Applicant Address: Phone: Insurance:
15 ANION ST (413) 774-5402 WC
GREEN FIELDMA01301 ISSUED ON.51112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT FIRE ESCAPE FROM 2ND&3RD
FLR DECK, RENOVATE 2 KITCHENS & 2 BATHS
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 5/1/2014 0:00:00 $450.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner