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25A-188 (4) kj Ir tj to A 0 -140 V17, N,0 v OL Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER-REVIEW(780;CMR 110:11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SECTION 11-OWNER'AUTHORIZATION-TO BE,COMPLETED' WHEN OWNERS AGENT`dWCONTRACTOR APPLIES FOR BUILDING'PERMIT - l 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-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor::/� ( ` _ Not Applicable ❑ Name of License Holder : �vv�eS �i �'lJ� �M CS 07 3yq-( — e� �v License Number 5-5 ICt�h �°t' C.G�� C�w�D�+"') 4 0 1 U d 1,)/alo 12 s Address Expiration Date SigQature 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...... ❑ Version 1.7 Commercial Building Permit May 15,2000 SECTION 9; PROFESSIONAL DESIGN ANO L A ECT TO GS CON5TRUC7100,CONTRQL PURSUANT TO 780'CMR 116(CONTAINING MORE THAN 5,000 CAF 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: 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 PROJECTS LESS THAN 35,000 CUBIC'EEET OF ENCLOSED SPACE nterio erations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building [ ] Repairs [ ] L C 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 ❑ 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 OFFICE USE ONLY 5 Yfx r' it Floor Area per Floor(sf) St 1st 2nd ' 4 3rd e3 F nd 2 _ 3 d 4th z to gxa a OR Total Area (sf) Total Proposed New Construction (sf) � tea `; =, I wws ;'�'Z ---------- -- ------- - - ----- Total Height(ft) g ;u n Total Height ft ------ ---------- � � � OR 1tA�fPL0 Cry iafl�z#I��m�rutt 9 d f�tasaatchnsctts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'a Northampton, Mass. 01060 W01=R'S COMPENSATION INSURANCE AF MAVIT I, vole S A (li ccnsec/pelmi tiee} with a principal place of business/residenee at-. (strts.flci ty/stalc�2i p) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following workers compensation coverage for my employees working on this job. (Insurance Company) (Policy Number) (Expiration Date) ( ) 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/Poticy Numbcr) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Laairancc Compauy/Pokcy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (&-cL additional shod ifnoocnuy to include infocmx4oa pertaining to all oo�rn flora) ( I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homcownm who mplay pawns to do m&m ma a;0=s�oo or repair work ou a dwctling of not more than three units in which the homoowocr resides or oa the gvjn,:%appurtem tberdo arc not generally ooc=-A cd to be cmploy=under tbo workcr'a o mpcm4aa Act(GL152,m 1(5)�application by a homeowner for a Boerne cc permit may cvidcme the legal etatns of an employor undo the Workcez C,ompanxiim Act I uadcniind that a oopy of this a-fatcmcnt may bo f6murded to the Dcp�of Indzutr d Aocjdca&Oihoc of Iastusnoe for the oovcragc va-tficatioa and that failure to aeaue covaz v under section 25A of MOL 152 can lad to the imposition of criminal penalties ooa L%ting of a f oe'of up to S 1,500.00 a Woe im{xisoo of up to one year and civil pcmltia in the form of a Stop Work 0r and a fine o(5100.00 a day against mc_ For deputntrtsl use only Pcrmit Number �'� Map,# Lot# gnature of Liccnsee/permitice 2x22 1 @:@6 14014665834 FINN BLOCK ISLAND PAGE 01 versionl.7 COCrimercisl Bui{d{ng Permit Mwy'15,2000 City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 02060 phone 4.3.587,1240, Fax 413-5$7.1272 A;*LICATION TO CONSTRUCT.REPAIR;RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWCLLINO 0M 60.0 PZ>Z Party AddxP. 4c.I.Iwjo ,�� ��./.��►� Bye • -- -- ON �.�OwMe_r of 11Rltord: Current Matting Address: eplpe/•w a Signature Tel9 hone _ �.��Authgri:ed Atent• Current Mailing Addreac Signature Telephone Estimated Cost(Dollars)to be caT letec by armlt applicant qqct� ��jj1' y■� �Ay .,����,yy�� J%Ina Ar" RT. I�P•;1^,L'61*0tW1R 2. E''ectrical 13"' ' Vechanicat(HVAC) 5. Fire Protection _ f S. Total -(1 +2+ 3+4+5 NO 1{ M � .'., i IIII� ��...•I: ,.'.. � .: .�i M I1 I Huai ..�. � V. ' ! it{� 1�e,•50s�'�k Ipar) " ,11>!,:1 I ,d �F,,!w. �,`.,°d'I "AITQ 397d 631N3:) 3SVO JDIQ:IvH QL9fibp�>;tb Q0:0Z L90L/�L/0Z