25A-185 (48) rr a �i� t� ��rrfl�r�l�t��utr Y
� � �asaacbrrsctta —
e
m flEPMTt+ifNT Of B{ IWING fi4Sf;ECfj0t4S
212 Main Street ' Municipal building
Northampton, Mass. $10(50
WORYCEI2'S COI1WTWSAaTOV INSIIIfUN AFIIWAVIT
with a principal place-of residence t
6— (Phoiie4)
(atrcct/ciry/azir/zip),�y�� �/T�''b
do her) certify, under the pains and penalties of perjury,�diiat,
� J�vCr .
A')Gb m an employer providing the following worker's compensation coverage for my
ettl¢lt3yces wori ng ow,jobs
(Instcrance Company) (Policy Number) ( xpiratioo Date)
( ) T am a sole proprictor, general cofactor or homeowner{circie one)and have hired
the-co==ars listed below who have the following worku's compensation policies:
i
(Name of Contractor) (Insuranoc Corupany/Policy Number) ()_.puntion Late)
(Name of Contractor) (Insurance Comparry,%Lcy Numbcr) ZExpuatiou Date)
(Name of Coamctor) (Lnsu=cr_Compauy/PoticyNwnber) (E.xpiradouDate)
(Name of Contractor) (Insurance Company/Poticy Number) (EExpitadon Date)
Carry addiidomil dMd zraoodn-y to iacludc info .paaiaang W ooawacsM)
( ) I am a sole proprietor and have no one working for toe.
( ) I am a home Owner_preforming all tLe work myself,
NOTE;phase be aware that While boaxvwnen v6o employ pasom to do wamaea+ar,ao wnbcueo ar rw"work Oa a d—Ana of
not axwe than three veins in udaith the 6entaowoer resides or m the yrmu appaurtevamtha<oto arc ant guxsslty aom+dard w be
emplayen uodar the workees compensaaim Act(GL152,ss I(5)},applieuioe by a bommwaer for a Name or pumid may cvidcarx the
la491 A"M OC"*eple3.rasodar-I6o tuwlraCitaazQ.asa4an.Sd
I uodarauod*Anti a oapy orthia am—may be focw*rdad to Lire popanmcut of Jo&,*,al Ava4o d Othoe of[=Km*bw for dr.
oovertga vrriB dd and%M fadUM to scam COWMg4a under us aion 25 A of MOL 151 can lard ID do iatp�of-MEW petnlhm
oowi"of it floe of up to S 1}00.00 MWOC m4 isoomerd of up b ax yvw and rsvil pe k&jcs is the farm of a Stop`UOtt order and a
bw of S1DGM a day against me
For dgnrw=al L—mtp
/ Permit Number
Map#� Lot 9
Signaarrc of LiCtb.r�pJpr,rmitLct _
TO 39dd OlISOJS3/Nt1N33H ZIZZ99SETb _
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Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(760 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'13UILDING PERMIT
I, l� C 2-Y / !v as Owner of the subject property
hereby authorize HCc n 2 .L In c - _to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of caner Date
I, C7_3-a��/ _ l- d- r �� �✓ _ as Owner/Authorized Agent
hereby decla e 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.
l-
Print Na
/�- L -�- 3 /3 /o 3
Signatur Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable
} ❑
Name of License Holder: //i/ ! . / i (�t 1�I' J V.5 7
License Number
',-� S L��� ���C?"1�/`�'G`�6y'D1"J / '�^✓° l Jgj/1il i'MCI �
Address Expiration Date rA
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL.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...... ❑
x r
Versionl.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-116(CONTAINING 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
f6-C� /fv Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.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 DON'T KNOW YES
YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis ry 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:
s -
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 Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
J� Accessory Building [ ] Repairs [ ]
i0l 3741
SECTION 5 - USE GROUP AND CONSTRUCTION'TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business 2A ❑
E Educational ❑ 2B ( ❑
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 OE C- ONLY
�. ��'�. .
Floor Area per Floor(sf) 15t N
Wl' � N
�a s "
�`n 5 s%
2^d ' s F '
1st , s_, s
2nd 3rd t
Mix
4 t
3rd ..
z..
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft -- -- -----------
Version 1.7 Commercial Building Pen-nit May 15,2000
Depart ent useori
City of Northampton Status of P r, I a
Building Department Curd CuflDr�vevvayPer
212 Main Street �wer/Se ttCAYalla171it j
P
Room 100 U+,at&/We11 Ava lab�l�ty�
Northampton, MA 01060 TwoSets a Struct�ad'Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Ste Plans
Qther,Spec�fy
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 ;
1.1 Property Address:
Map Lot J.... Unit
�� �/✓�,����� /.1 !` �� Zone Overlay District
/' (f Elm St.District CB District
SECTION 2 - PROPERTY,OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Czv C �-)- �� ►ti y� Inc ���y,`z l�r. 1jQry'l z 4i) IW-0/060 '
Name( int) Current Mailing Address:
Signature Telephone
2.2 Authorized Afrent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building // (a) Building Permit fee
2. Electrical J (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �y
6. Total = (1 + 2 + 3 +4 + 5) Check Number C7
This Section For Official Use Only
Building'Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0726
APPLICANT/CONTACT PERSON HENNAN INC
ADDRESS/PHONE 57 WESTERNVIEW CIR (413)525-1100
PROPERTY LOCATION 45 INDUSTRIAL DR
MAP 25A PARCEL 185 001 ZONE GI
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: CONSTRUCT CANOPY OVER EXTERIOR STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License 057775
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 C ssion
� 7
Signature of Building Official L 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.
f
BP-2003-0726
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2003-0726
Project# ]S-2003-1180
Est.Cost: $4500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HENNAN INC 057775
Lot Size(sa. ft.): 950914.80 Owner: COCA COLA COMPANY THE
Zoning GI Applicant: HENNAN INC
AT: 45 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
57 WESTERNVIEW CIR (413) 525-1100 Workers
Compensation
EAST LONGMEADOWMA01028ISSUED ON:315103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT CANOPY OVER EXTERIOR STAIRS
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 si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 3/5/03 0:00:00 1116 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
45 INDUSTRIAL DR BP-2003-0726
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 185 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0726
Project# JS-2003-1180
Est. Cost: $4500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HENNAN INC 057775
Lot Size(sa. ft.): 950914.80 Owner: COCA COLA COMPANY THE
Zoning: GI Applicant: HENNAN INC
AT. 45 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
57 WESTERNVIEW CIR (413) 525-1100 Workers
Compensation
EAST LONG MEADOWMA01028 ISSUED ON:315103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT CANOPY OVER EXTERIOR STAIRS
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:D k 3-.)J4.p3 1
THIS PERMIT MAY BE REVOKED BY TH CITY OF NORTHAMPTON UPON VIOLATIPN OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 3/5/03 0:00:00 1116 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo