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18C-048 (20) BLass AC4115ttfs u, DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORI{ER'S COMPENSATION INSURANCE AF r AVIT I, (licenseelpermitzec) with a principal place of business/residence at: . (phoney#) (strC,--U ity/sta&2h p) do hereby certify, under the pains and penalties of perjury, that: I am an employer providing the following worker's compensation coverage for lily employees working on this job: (Insurance Company) (Policy Number) (Fxpiration 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: caution Date (Name of Contractor) (insurance Company/Policy Number) (E� ) r. (Name of Contractor) (Insurance Cornpairy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioexI 6cd if nary to inc}ude informttioa pataiuing to ell oWtj'a tor') ( ) I am a sole proprietor and have no one working for me. ( ) 1 am a home owner performing all the work myself. NOTE:please be aware that vrhile homeowncra who employ persoas w do a n cc�wnsiructioo or repair work on a dv,-- g of not more than rhino units in which the homeowner resides or on tho gvjads apptutcaar3 thado arc not gcoa-slay ooandcrcd to be employers unAcr the worker's compcasslion Act(GL152,,ss 1(5)),application by n homcowar for a liana a permit may cvidcsr_e the legal o-w o£an employee underthe Workoea Compomaiion Act- I undustsnd that a copy of thin clnt=cat may be forvewd d to tbo Dcpxi tmcv of Io&ut d Aocidmt Qffioa of Imiirwoo for the cova-ge vaificatioo and that failure to secure covetago under section 25A of MCIL 152 can lmd to the imposition of aiininal penalties ooaiisting of a fine of up to 51,500.00 and/or imprison of up to ow Year and civil pciatties in the form of a Stop Work Ord--and a find of S 100.00 a day against me. ! Foe dgwtn�uio only Permit Number Mao, Lot# 4igna of L ^ Perini `✓ L_� Versionl.7 Commercial Building Permit May 1.5,2000, SECTION;10 STRUCTURAL PEER REVIEW.(7.8Q'CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -ate c�C3 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative t ork auth6fized by this building permit application. IS-6) 3 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: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature 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 CONSTRUCTION tONTRbIlL PURSUANT TO 780 CMR 116'(CONTA,INING 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 Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature 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 ❑ 8. 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 4--' 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 v 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 No IF YES, describe size, type and location: r 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 Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] VESC2+Piz w�: u c Q aoIW( 64" � u SECTION 5- USE GROUP AND CONSTRUCTION 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 ❑ _ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1.1 ❑ 1.2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ 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 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 OFFI WS © LY UX b V � Floor Area per Floor(sf) 15t -- V' 2nd 151 _ Mr- 3rd 2 nd � as 4th 77 3rd x� 4th � :•� r "gam Total Area (sf) Total Proposed New Construction (sf) A.,, Total Height (ft)F Total Height ft -------------------- N C no 1yL Co W f�t C S' p Northampton Nursing Home, Inc. 737 Bridge Road,Northampton, Massachusetts 01060 (413) 586-3300 • Fax (413) 586-4279 MAY 15, 2003 DESCRIPTION OF INTERIOR ALTERATIONS Tear down two 2' 6"x 8' walls for a open closet and a 10' x 8' wall, to open the room up, there is no electrical or plumbing involved in the taking down of these wall's. The walls will not be rebuilt just removed; the only cost will be for labor. RICHARD PERRY DIRECTOR OF ENVIRONMENTAL SERVICES Versiont.7 Commercial Building Permit May 15,2000 . City of Northampton t s of Building Department rlaC% ' y y 212 Main Street Room 100 Wa er1W v' llaf� fits .: Northampton, MA 01060 ets c � l phone 413-587-1240 Fax 413-587-1272 atlSite a} 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 This section to.be completed by',office 4 1.1 Property Address: Map 'Lot Untt Zone Overlay District`- 1�4I�-Trv, I0j::#+J inn 11,4,",',,� Elm St.District C&District SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ h '131 13 K 1 1) C�c -Rx A D Name(Print)) Current Mailing Address:: �1Na K-Pi P,01 (U tv 19 e6f7777—3 ---------- Signature Telephone 2 2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit a lican 1. Building ' (a) Building Permit Fee c 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) �`� 5. Fire Protection v 6. Total =G + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Permit Number:' Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-1039 APPLICANT/CONTACT PERSON NORTHAMPTON NURSING HOME INC ADDRESS/PHONE 737 BRIDGE RDA_-�3 B-p �✓�� �PROPERTY LOCATION 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 Building Permit Filled out Fee Paid Typeof Construction: REMOVE WALL&CLOSET TO OPEN ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• ­7 Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATIC INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Id Major Project: Site Plan AND/OR Special', ` ONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance O 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.