Loading...
25A-182 (31) 4�ttAMP� GSf� of 'Wa rt4ail tau $ B �asaarhaartta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT .censerJpermittee> with a principal place of business/residence at: o. Lx G a`i� ( city/statelrip) do hereby certify, under the pains and penalties of perjury, that: (Iaam an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiratio Daze) ( ) 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 Company/Policy Number) (E)piration Date) ,f (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sfiea ifnecr�uy to include information pereaining to all eoatn d ) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:phase be aware that while homeowners who employ prices to do maim�o=shuetion ar repair works ou a dwelling of not more than throe units is which the homeowner resides or on the gzounds appurtenant them to an not generally 000sidered to be employers under the worker's oompeusation Act(GL152,,s 1(5)),application by a homeowner for a liaise or permit may evidence the legal status of as employer under the Worker's Comgomation Act I understand that a copy of this efatcmcat may be forwarded to tbo Dtpartm of Indauhial Accidw&Oise»of Insruwce for the coverage verification and that failure to scare cowrngo under section 25A of MGL 152 can lead to the imposition of criminal penalties oonsistmg of a fine of up to 51,500.00 andlex imprtso�of up to one year and civil pemdltia in the form of a Stop Work Ordtr and a futo of 3100.00 a day against me. For dgmtmwb trio oaty Permit Number Map# _Lot# Si /Pemittee e one ` ` . VcrsionlJ Commercial Building Permit May l5,2000 SECTION 10-STRUCTURAL,PEER REVIEW(780 CIVIR 110.11) Independent Structural Engineering Structural Peer Review Required Yes......0 No......0 SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES,FOR 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 Signature of Owner/Agent Date SECTION 12 -CONSTRUCTIONSERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder 0 S 0 S-6 S7 License Number 0 c,-)./7 /-0 / 7dress 1 5 Expiration Dafe S"n Telephone SECTION 13-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, 25C( 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. Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-,PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION.0NT06L PURSUANT TO 180 CMR 116(CONTAINING MORE THAN 35,000 C.F.'OF ENCLOSED'SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): c/ ,�O Cj+0Ct1 � i�LLC��(C►{ (� �' p Registration Number Address 003-�aS"(�'�� I 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 .--_ ( �tS CiAL15-� , �, � • Not Applicable ❑ Company ' Aj,5 14 Responsible In Charge of Construction �� Address Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 17.Water Supply(M.G.L. c. 40, §54) 17.1 Flood Zone Information: 17.3 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 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: Version 1.7 Commercial Building Permit May 15,2000 SECTION 4 CONSTRUCTION SERVICES FOR PR©JECTS LESS THAN 35,000 CUBIC FLIrT' f)f",EIGLC>SC)SPACE Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition❑ New Signs [ I Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] s / SECTION 5-,ME GROUP AND CONSTRUCTION TYPE CP1q- F-- USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 113 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ 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'G BUILDING'HEIGH"f ANp AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION „ , ` ICE U "»„ el Floor Area per Floor(sf) I 1st nd 1st 2nd 3rd v f 3 rd 4th 14.6, Y yid r Pn ant /i3' I S 4th H a a Total Area(sf) Total Proposed New Construction (sf) ik 15W, 161 R ia� y .................................... LI c. ,. Total Height(ft) F y Total Height ft ------------------- y ' 2 F". t • Versionl.7 Commercial Building Permit May 15,2000 } City of Northampton _�;-RUilding Department 212 Main Street DEC 1 9 2000 Room 100 Northampton, MA 01060 �l'1 OFShi phone 4.1 ;5i 7.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION A-SITE INFORMATION ftis se ep t bed r �o�fl 1.1 Property Address: s y 3 9 4/ M10 y 211✓E' , w y � k I:I[ ,5t IIst � ' CB is#rat ? SECTION 2-.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 11'� T ( • c� jV J Name(Print) Current Mailing Address: `f/3-fig -3�79 Signature Telephone 2.2 Authorized Agent: p ol�l /-t v�lnl jam, 0, 7% W&OAb., r�T_ .0 9 s,-- Name(Print) Current Mailing Address: '/0 - 76 Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION CO TS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building oo . (a)Building Permit Fee' 2. Electrical (b) Estimated Total Cost of 0 Construction from 6 3. Plumbing 3 6 Building Permit Fee f 4. Mechanical (HVAC) _ 5. Fire Protection 7 S 6. Total =(1 + 2 + 3 +4 + 5) �j QQ Check Number -� This Section For Official Use Only Building Permit Number: '' Date Issued: Signature: Building Comm issioner/lnspectorof Buildings Date