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32C-121 (16) � 0 $ « � -Z,5 . ~ � e \ � � 3 e m 2 2 ( / ' CL 1 - -/ m » . w / � w : ® u w m § ƒ r L u \2 ~ LL Q m CL m 0 ƒ . }f ul k »� ® z_ . 2 ) 0 / 2 m m & \ Z e 4S W Q Z §� \ t / O / 00 0 A 0 / Cl. 2 ƒ U « / T- \ Z e I m C) / � 0Z K0 ® CN f / . / 0 ' 7 00 CL ƒ � / / � / f $ \ m , 6 / /� 0 \ \ N a, co m = « W o ? 0 / o E Z O ol / \ / ƒ § / ? \ m 9 2 6 ® L o > . ® 9 � ƒ ƒ $ Q 0 0 \ ' , I . / S \ 2 1 R J \ > \ ± Z \\ ' � o ( / U) \ \ Z G > §. / i % Qm T \ $ \\ 0 , ' \ § 0 z \. l � // / \, rt ® N m n 2 5 \ 2 } Z R / R / \ q / \ ° � ƒ o = m .f / o / - 0 Z ® ~ >-o / ® T r ( --W & w m m 9\] / / cr® � / • m ~ � / 0 © / r © m ®\ \ %� - > / N E M. e ƒ Z / f \ + , 2 ® o g � % $ . z -2 . . / � e � . . � p a7 ro A 3 N ' , C y O ro ;o 9 � m z 7� Z ti � ❑ C '� � c o c o c o Gf Di C7 G O N b 7 tJ rL h Z W O D W 00 > p a �' 0o b C C C C1 L41 j > o �- .fir mC U x cr cc C � c m � 00 " :c o o c X O c c m 0 o Z c c ro C7 It Z s ro O 0 n r C n T m o � � m z d x y v 7L ro ) b � � 07 o OG O ^] C It r cr V y p yy O C6 [ ~ Z o' a cr C7 CIO O Q y r O n O � ro n N 3 m I < C < z � ❑ o � a y � ro CD CD b Z m z m 2 O o c o oa Co d O d O O p 'T7 N N { O ° G `m m f> >r>� C1 0 n A Cnr > n F h O CD m z� E. o a1 O ff. O 6A W �p O A D O C C `' C C Z Cl•1 O O O >a xmx It 0 - o r �, > x o 0 '"� z z W > "i N N � . O 1-0 r CIO R°O �Tl n TA C N ti N °c c a Z o •oo N c ° _ ° � N i r sec S 9 a C) k� CD v �- � X. 4'` /�V � � � � � � � \ �.- � _ .� � � � �-�� C�IQ (6 C C z � Cs vo The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` 600 Washington Street Boston,MA 02111 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [J I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors -- I am a sole proprietor or partner- listed on the attached sheet. 7. ]Remodeling ship and have no employees These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp. insurance.* - required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions J.❑ I am a homeowner doing all work officers have exercised their 11.F-1 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4) and we have no _ , _ 13.❑ Other employees. [No workers'. comp.insurance required.] '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 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 the policy and job site information. Insurance Company Name: Policy#or Self--ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration 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' surance coverage verification. I do hereby certify urger a pains pen Ities of perjury that the information provided above 's true and correct Si nature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official —City or Town: _ _. _ __ ___ _- Permit/License# Issuing 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 4 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR.11011), Independent Structural Engineering Structural Peer Review Required Yes _ No 0 SECTION 11 -OWNER AUTHORIZATION 7.701 BE COMPLETED.WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT p ----- ._ __.. as Owner of the subject property hereby authorize �''�� I- - _.-''to act on my behalf, in all matter lative to work authorized by this building permit application. Signature of Owe 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 un pains nalties f per'u Pri t N tigKature of Owned Date SECTION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:'= >2" License Number Vt AddressW Expiration Date nature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L:c.15;,:&::45C Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resulf in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 0 No s► ' Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONRSERVIGES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF E. LOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): -- -- _` Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): t Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ._........._.____....._....._.._---........_.......... ..__...._. Name Area of Responsibility i Address Rftgistration Number_ Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ........._ r _ ................ _...._ Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: ss Responsible In Charge of Construction Ad Tess___ ure Telephone Version 1.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON,ZONING ' Existing Proposed Required by Zoning This column tb 5e filled in by Building Department Lot Size ' � �..w..�....x._.. Frontage Setbacks Front " Side L: .-. R E.—._�-j Rear _ Building Height Bldg. Square Footage `_ % Open Space Footage (Lot area minus bldg&paved _ i� _ ._...w parking) #of Parking Spaces Fill: _. (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF,YES date issued: i IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page; and/or Document#` B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q 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 0 NO 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r , Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 a CUBIC FEET.OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions fQ Accessory Building Exterior Alteration ® Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter a brief descri`tion here. \ Of Proposed Work:Cc,St,, 'Cc fCa.�� wc� �hw✓� iDOI S. SECTION 5-USE GROUP AND CONSTRUCTION TYPE` USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1B ❑ ❑ A-4 El A-5 El B Business ❑ 2A ❑ E Educational ❑ 2B r ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑ M Mercantile ❑ 4 ❑ R Residential K R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: _M M Mixed Use ❑ Specify:j S Special Use ❑ Specify: COMPLETE THIS SECTION. EXISTING BUIL DING.UNDERGOING AENOVATIONS,!ADDITIONSANDIOR 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 St 1 E 2nd 2nd 3 rd 3rd d' 4 4 h Total Area(sf) Total Proposed New Constructions Total Height(ft) 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[] Version 1.7 Co rc' i ermit Ma 15,2000 - �' .� "��e�a i~•°dos do�tl� � �_ � �;' City of Northampton _ uilding Departments wa 212 Main Street Room 100a � s ECG Northampton, MA u 01060 11t BU rl�'413-587-1240 Fax 413-587-1272 "It FAPPLICATION 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 1.1 Property Address: ao 1 Map Lot Unit Zone Overlay District J�LUf �u J- -- Elm;St:District ca District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ Name(Print) Current Mailing Address: Signature Telephone 2 2 Authortze gent: 7tt CA.l!A�>.._ Name(Print) Current MMailingAddresL: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS` Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �U� (a)Building Permit Fee 2. Electrical X (b)Estimated Total Cost of v _ Construction from 6 3. Plumbing _ Building Permit Fee F 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number Q This Section For Official Use Only Building Permit Number Date Issued Signature:_ Building Commissioner/Inspector of Buildings Date File#BP-2013-0165 'Zf)0 k v APPLICANT/CONTACT PERSON HANS DALHANS q ADDRESS/PHONE 11 CHERRY ST EASTHAMPTON (413)977-6094 Gtl� S cos PROPERTY LOCATION 20 FRUIT ST MAP 32C PARCEL 121 001 ZONE URC(100)/ �0 u1b THIS SECTION FOR OFFICIAL USE ONLY: r ,�'(S�Pfd PERMIT APPLICATION CHECKLIST r �� ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT OVERHANG FOR STORAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 101628 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition Delay 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.