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25A-140 (4) (rri-�) ofl�o�ffla111}ltolt �lcss itch ncctta _ `r DEPARTMENT OP DUILDp\1G INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 NYORIQ;1Z S O\ TENSATION URAN''CE A r AVIT Qi CcnsccJpcmmi(tcc) pi�mipal place of business/res encc at: - (phone:') (stmt/city/szalcrap) D�3�/ do hereby certify, under the pains and penalties of perJury that ( ) I am an employer providing the followine worker's compensa:-lon cove mge for Illy eluplovees worldng on Otis job. (Ias.lr�c- Coo=y) (Polio: Nu_bccr) ---- (Tlxpiraori Daic) O I am a sole proprietor, general contractor or homeowner (ci:cie one) and have hired the contractors listed below who have the following worker's caonen-,,,-tion policies: (Namc of Con!mcto�) (InRlranc; Compan}'iPobc, Num!, ) (_xpimt:on Datc) (Name of Contractor) -- (lnsurancc Company/Poky Nuck-rr) (Explr ilon Date) (Name of Contractor) (Insurance Compan)•/PoUq. Numb J) (ExpLmuon Date) (Name of Contractor) (IDSlrail Company/Policy Numb,r) (L-xpiration Date) (toz c3i idli;iocil sxcf if coots.:}•to cnc!udr inform�zioa post amg to ail oou'sac.:4 �am a sole proprietor and have no one working for me. ( ) I am.a home owner perforating all the work myself. NOTE:plc-s4 be aw-arc ttu-, .j,^Jc hoar=owe "to cmplay pezoni co 6o c=--,rl c�uo c rc?au-orx oo.d—Lb--&or not mote than E _tmi'�inµdeb the bones vcr rtvd,oc oa the avuads aapurtcnsm tbc_-y-,o LT oo(GcazaUy oecj:&- to be employes undo the i.v{ _t eo Alt(GL152,3z 1(5)),ni�PUratioo by a homcowzr_r for c t, .or permit=y mdcooc the Iega-1 rLwu of an er.,iloyor under dso Wocti.oe,Cop. l; Ad I uod�i d CL d>copy of thi,cxuj® O,y bo for xnrdod to Lb.D.P_,mcni of l daa ,j l Amd..&Offioo of Irisuriocu for tb� eovexsc v nficuioc ad the w coairc oovcra tinder u=on 25 A of l,(01-152 on lud io the imposition of c iminsl pcO+W- 00mis6ng of a riot of up to 51-500.00 K�C� of up to ooc year tad aril pm,.1L0 in t_`x fowl or n Stop Work Ord-rnd e rim 0(S100.00 c day tpaast tnc For dcp-rux-;�u is onl y Pcnilii Numbcs Sign ��P;; Lot Tr of I.ICLnSCe1I e cn1 ttc Version 1.7 Commercial Building Permit May 15,2000 STRU51ryRAL PEER.REyjIEW( 8f MR 11t 1) ndependent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ 5EC'L•IQN QWNE 2 At)TH©RIZI� IDN T!Q BE-CQMPLETEQ WHEN fNNER AGEI+ ©I CONTRACT©R APPLIES�'OR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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 gnature of Owner/Agent Date SCTIa1V 12 :° t�l+lI'RIIIT1+pI ',SI;RVIS 10.1 Licensed Construction Su er ' C \ Not Applicable ❑ Name of License Holder: c -S,ev License Number Address Ex iration Date zzv i re Telephone ®i SECTION 13 -W ORKS'COMPENSATION INSURANCE AfIDAYIT{M:G.L. C.1a2, Cl } ' 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....,....ZNo...... ❑ I w • *- Versionl.7 Commercial Building Permit May 15,2000 S Cfi ?I!+1 P >: SStaIVAIr QE511aN A>+� C4NS7'RUCT10� ,SERVICES- 'QQ BUII*1?INGS ANn TRtJ t1RES IJBJEC7 t0 I ON' R .1�"tJI SETA 1 Ta 7 t1 CMR 1�S(CC"NTAIN'ING lair ONE THAN'3' , t?CAF,+D E C f� Cl tPACE) 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 gnature 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 001%dress Signature Telephone _ J 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: 104blic ❑ 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 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 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: f Versionl.7 Commercial Building Permit May 15,2000 CON TRUGTI0N SERI FC Et FOR PROJECTS:: SS"THAN 35 flt SPACE Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] SEIIQN USE"GROUP°ACID CCIN ?I2UC7#l +t TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 213 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H Hi Rh 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: Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETi TINS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDIOR: HANGS IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): EtZ7'ION 6'0LItL©ING;HEIGHT"AND"AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St nd 1St , 3rd € ryry F k?k / 2nd g y 3rd 4tn `is �z` `3 y *!: „,h r yn r th z May otal Area (sf) Total Proposed New Construction (sf) e y .................................. iE ' wg a Total Height(ft) Total Height ft ---------- s � Version 1.7 Commercial Building Permit May 15,2000 r D` -- _ of Northam ton p= t i in Department f� ( 2000 g p tRoom Main Street 100 DEPT OF bUi t) ,G IN�FL- T ONE NORTHLfA i C��A 9141'orjhpton, 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 T AN A ONE OR TWO F#MILY DWELLING 1p If 1 1 I't E IN f3RMATION 1.1 Property Address: y v PR ERTY Qlritf�lEl 5HIP/AUTHORIZED AGENT 2.1 Owner of Record: �% e(Prin Current Mailing Address: r 1 Signature Telephone 2.2 Authorized A nt: Name "C/ Current Mailing Address: Signature Telephone ( ESMATD Ct�NSTRU �dN CO5TS Item ��!' ° Estimated Cost(Dollars)to be Official Use Only • completed by ermit applicant 1. Building (a);130ildl,tvPenn, 5*ee 2. Electrical (b) Estimated Tota,"Cost of Construction from 6 3. Plumbing Building Permit Fee, 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) Check Number This Section: or Off iial tlse"+ nl el 61jdirt Perrhit Number: Rate Issued: gnature Building Cortcrtissicnerllrispector Date 34 BATES ST BP-2001-0160 GIS#: COMMONWEALTH OF MASSACHUSETTS M.Block:25A- 140 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofin g BUILDING PERMIT Permit# BP-2001-0160 Project# JS-2001-0267 Est.Cost: $6135.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Robert Thibodo 118441 Lot Size(sq.ft.): 9539.64 Owner: FEICK ELIZABETH C Zoning.URB Applicant. Robert Thibodo AT. 34 BATES ST Applicant Address: Phone: Insurance: P O Box 201 (413) 586-0391 NORTHAMPTONMA01061 ISSUED ON.8114100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE SLATE, INSTALL PLY & SHINGLE ROOF 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 Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/14/00 0:00:00 7392 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo