25A-188 (5) o Re xlilZf��111�JIIII -
6 �aaaxrhnsrttsi'
DEPARTMENT OF BUILDI1tG INSPEC'T'IONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE AF ' AVIT
(Ii censerJpenrli tt ce}
with a principal place of business./residence at:
io o y- (phone#) a 5-3 _. cf y 3
(Strcet/city/stair/zip)
do hereby certify, under the pains and penalties of pe,"ury, that:
O I am mi employer providing the following werr,ci's compensation coverage for my
employees working on this job:
(Insurance Company) (Polio Number) (Expiration Date)
O 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 Munger) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneceuary to include information pertaining to all coatrad )
(VY'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 homcownas who employ pasom to do mainirnnnee,wmh-U too or repair work on a dwttling of
not mace than throe units is vdnch the homeowner reiidn or on the grouads appurtenant thereto ate oot&cacrally oomidcrcd to be
employ=under the vem er's companatica Act(GL152.ms 1(5)),application by a homeowner for a!incise a permit may evidence the
legal etatua of an amployer under the Wor�e Compoosafion Ad
I understand that a Copy of this statcmenl may be forwarded to the Department of Indudrial Aocidm&Offioo of Iasur. for d 1c
coverage vaificaiioa and that failure to secure cover g under soc6on 25A of MGL 152 can lead to the imposition of criminal Pcoaldcs
oomL%ting of a fine of up to S1,500.00 andloc imprison n of up to enc year and civil pcaaltia in the form of a Stop Wort Ord--and a
fine o(5100.00 a dlay against tun
Foc dq—troy use oaly
r Pc=t Number
Maps — Lot#
Si of Liccusec/Pe 'ttee
Version 1.7 Commercial Building Permit May 15,2000
;ECTION,10-STRUCTURAL PEER REVIEW,(780 CMR 110.11)
ndependent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
-)ECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
)WNERS AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
MQ`�Yl ew I nor S 0-- as Owner of the subject property
ereby authorize to act on
ly behalf,in matters tive to ork authorized by this building permit application.
,ignat re of Owner Date
as Owner/Authorized Agent
iereby declare that the statemerMs and information on the foregoing application are true and accurate, to the best of my
mowledge and belief.
Signed under the pains and penalties of perjury.
Tr
(,rv. a- C"`^
°rint Name
Signature of 0 er/Agent or Date
SEC1"ION2 CONST ACTION SERVICES,
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: E; vin a %�—
DG Fry Lf
License Number
FAO �0X 07
Address 'A Expiration/Date
Signature Telephone
o� 5S3 —cl 4 � 3
SECT 1 '13 WOREtS,1 O30N1pENSA7I;ON IN5CIRANCE AFFIDAVIT,(M.G.L c'.,'152,'§-25 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...... 11
Versionl.7 Commercial Building Permit May 15,2000
;ECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
:ONSTRUCTION CONTROL PURSUANT TO 780'CMR 116:(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
).1 Registered Architect:
Not Applicable ❑
Jame(Registrant):
Registration Number
,ddress
Expiration Date
signature Telephone
32 Registered Professional Engineer(s):
same Area of Responsibility
,ddress Registration Number
Signature Telephone Expiration Date
lame Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
lame Area of Responsibility
address Registration Number
Signature Telephone Expiration Date
lame Area of Responsibility
address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
.ompany Name:
2esponsible In Charge of Construction
address
>ignature Telephone
Version 1.7 Commercial Building Permit May 15,2000
Water Supply(M.G.L. c. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
'ublic ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAM T N ZONING
i Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Siz
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:
Versionl.7 Commercial Building Permit May 15,2000
>ECTION 4- CONSTRUCTION SERVICES FOR'PROJECTS'LESS THAN 35,000
:UBIC'FEET OF ENCLOSED SPACE
nt rior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
:xterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ J Repairs [ ]
(J OA& ,C, o %1-d
;ECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
Business ❑ 2A ❑
Educational ❑ 2B ❑
Factory 2� F-1 ❑ F-2 ❑ 2C ❑
!
High Hazard ❑ 3A ❑
Institutional ❑ 1.1 ❑ 1.2 ❑ 1-3 ❑ 3B ❑
1 Mercantile ❑ 4 ❑
Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
1 Utility ❑ Specify:
1 Mixed Use ❑ Specify:
Special Use ❑ Specify:
COMPLETE THIS SECI(ON IF,EXISTING BUI,L`DING UNDERGOING RENOVATIONS;ADDIT,IONSANDLOR CHANGE IN USE r
_xisting Use Group: Proposed Use Group:
xisting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
�EtTI01V tULIDI) GHEI�G1T AND AREA
,.._
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Q '
-loor Area per Floor(sf) 1St
2nd
.st �
3rd ,
nd
3`d 4th
3�Y
'th / Re
r ,
? n t 2
otal Area (sf) Total Proposed New Construction (sf)
-
-----------------------------------
otal Height(ft)
Total Height ft .`Fg4 ;
Version 1.7 Commercial Building Permit May 15,2000
rthampton .eu
CE V B 'I i epartment .' utlrfv Pe i � ti
i n Street ew aEs a iii`
100
SEP 12 4Mrth n, MA 01060
hone 413.58 -12,10 Fax 413-587-1272
DEPT OF BUILDING INSPECTIONS l '
MA 0 1060
APPL , RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
F
L �
ECTION 1- SITE INFORMATION
,
This section to be
1 Property Address: "completed by office
Mp Lot Unt
Cl �-A S t� a�z � r �Jl • �i
g ' � Z0"e
Ouerlay Aistr�ct Or.R cXs awpra ^
r � a
Elr►i'$t�lsfrt�.�.. .�... >"•CB D�str�ct _..� ,�.��� �:��N.._�
3ECT10N Z; PROPERTY!PWNERSHIPlAUTHORIZEn AGENT
vti .
2.1 Owner of Record:
(q al-kel, Mn Tz �f CSo� r3� f ��� d,a, ► ,
'lame(Print) Current Mailing Address: D I 00 7
5-it If – Q I `I-4-
Signa ur Telephone
2.2 Authorized Aeent:
PO BOX 61 7 AtA,, p ",A- Y%
Name(Print) —u Current Mailing Address:
4-c ~ o't 5-3—1`1,p
Sig re 0 Telephone
SECTlON:3k ESTIMATED'CONSTRUCTION""COSTS
Item Estimated Cost(Dollars)to be b fficiaJ Use,,4ly '
completed b ermit applicant
1. Building g�O , (a)t3uitdrng Permit Fie.• '
2. Electrical (b) Estimated'Totai C'ostm"
Cobtttuction,.fram""6 ,
3. Plumbing i uNir g Perrrlit'Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 3 �'D d Check Nu'm er
This Section For Official Use Only
Building PerrnitNumber: Date Issued:
Signature '
Bu�lding Comm�sionerflnspector of Buildings Date
File#BP-2002-0289
APPLICANT/CONTACT PERSON JIM EAGAN
ADDRESS/PHONE P O BOX 697 (413)253-9160
PROPERTY LOCATION 99 INDUSTRIAL DR-HOT MAMAS
MAP 25A PARCEL 188 001 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 IM
ineof Construction: CONSTRUCT INTERIOR PARTITION WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accesso!y Structure
Building Plans Included:
Owner/Statement or License 068445
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF0.XkATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 Stree ission
Signature of Building Official D to
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.
DR=R" MAMAS
lat
BP-2002-0289
CIS#: COMMONWEALTH OF MASSACHUSETTS
j;h lour 25A-189 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0289
Project# JS-2002-0438
Est.Cost: $3800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JIM EAGAN 068445
Lot Size sg. ft.): 172497.60 Owner: FINN STEPHEN C
Zoning: GI Applicant. JIM EAGAN
AT. 99 INDUSTRIAL DR - HOT MAMAS
Applicant Address: Phone: Insurance:
P O BOX 697 (413) 253-9160
AMHERSTMA01004 ISSUED ON.91181010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT INTERIOR PARTITION WALLS
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/18/010:00:00 1784 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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