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m DEPARTMENT OF BUILDr,\'G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AF FIDA.Vrr
(li censce/perml ttee)
with a principal place of business/residence at:
SSZ-1
(5trret/city/st2lr_/2ip)
do hereby certify, under the pains and penalties of perjury, that.
(✓�I am an employer providing the following workers compensation coverage or my
employees worming on this job.
ons'=A Corspanv) (Policy Number) (Expira on Date)
( ) I am a sole proprietor, general contractor or homeowner (circie one) and Dave hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (RTiratioa Date)
,,
(Name of Contractor) (Insurance Companv/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy NumlKx) (Expiration Date)
(Name of Contractor) (InS ancx,- Compauy/Podcy Ntuntxr) (Expiration Date)
(attach additional sheet ifncccns w is�u)fonnstioa pertaiaiag w all corLt a rs)
( ) 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 tbat wirde homoownen who curploy p zr.=to do mxix icrL=ce,cowuuctioo or repair work ou a dv cuing of
not morn than tbrrx units in wEricb tfx homoow�residcs or on the Vwads appatttenant thereto arc not gczxrally w=&—td to be
catpioyrrs and r tha Mika%o0aVauatioa Act(GLI52,-s 45A application by a homeowm for a bccasc cc permit may cvid—the
lc VI alum of an employer under the Wodcoes Compomation AaL
1 understand that a copy of this—t an,cat may be forwarded to tbo Dopertm of Industrial A=&-&Offioo of Irawanco for tho
coverage verification and that failure to&sure cot ntp under s4ejoa 25A of MUL 152 can Iced to the imposition of criminal p-at -
00—tiag of a fine of up to S 1,500A0 and/or imprisotznxai of up to one year and civil paw0cs in the fain of a stop Work Ordc and a
find of 5100.M a day, against mc.
For dgHCtmdal arse oaty
Permit Number
00 - '�-- MnP Lot# _ I
j Signature i enn-Atcc
Version 1.7 Commercial Building Permit May 15,2000
ECTIDN 10-STRUCTURAL PEER REVIEW'(780 CMR 110.11) '
dependent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
ECTION 11 =OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNERS AGENT OWCONTRACTOR APPLIES FOR BUILDING PERMIT
/ / as Owner of the subject property
ereby authorize L nNU Ael c1 to act on
y behalf, in all maths relative to work authorized by this building permit application.
gnature Ownerli Date
as Owner/Authorized Agent
ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
iowledge and belief.
gned under the pains and penalties of perjury.
int Name
mature of Owner/Agent Date
ECTION 12 CONSTRUCTION SERVICES
T.1 Licensed ConstructionSu ervisor: Not Applicable ❑
l of License Holder: �}yr .��`?��3
License Number
�� Is/'!�C oti, ���' • p , .✓oaf o`�-/'i� '� / 0
]dress Expir on Date
natu Telephone
,ECTION 13'-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Vorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
vill result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... 0--- No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
ECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
ONSTRUCTION'tONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
1 Registered Architect:
Not Applicable ❑
3me(Registrant):
Registration Number
idress
Expiration Date
gnature Telephone
2 Registered Professional Engineer(s):
ame Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
Mme Area of Responsibility
idress Registration Number
gnature Telephone Expiration Date
3me Area of Responsibility
idress Registration Number
;nature Telephone Expiration Date
me Area of Responsibility
idress Registration Number
!gnature Telephone Expiration Date
.3 General Contractor
.O SAA/N�'C�P' �r/'K� -ti-G-• Not Applicable ❑
:ompan ame:
espon ble In Charge of Constr tion
]dress
onatu Telephone
Versionl.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 ❑ I 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
ECTION,4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000'
:UBIC FEET OF ENCLOSED SPACE
AA ter Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
xterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ I-r- Accessory Building [ ] Repairs [ ]
,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 [ia/ 2A ❑
Educational ❑ 2B I ❑
Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
Mercantile ❑ 4 ❑
Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
Utility ❑ Specify:
Mixed Use ❑ Specify:
Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
isting Use Group: Proposed Use Group:
fisting Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
ECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE,USE ONLY""
oor Area per Floor(sf) 1 st
— �
x� 4
2`1
d 3rd
Xj
Al
d 4th 1" fit,
y
S
'n
Dtal Area (sf) Total Proposed New Construction (sf)
)tal Height(ft)
Total Height ft ..... az
e3:r
Version 1.7 Commercial Building Permit May 15,2000
ft y�`-,f art ampton
r ... . .___.._.
I � _....-$� � � artment
212 a ' Street
1102 RdIb 00
I Northampton, MA 01060
ph` 4t =41 X87=: 240 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 1-SITE INFORMATION
.1 Property Address: his sectran to�ecompleted by gffrc � ��
t
C x
u�- a
Zorie Overlay Distrrct..
Efm'St.Dlsikrlct CB District '
3ECTI - PROPERTY OWNERS HI AGENT
' 1 Owner Record:
T
ame(Pri ). Current Mailing Address:
A.1 ) Li k.>I
ature Telephone
.2 Authorized Agent:
1 4,4& OX 4 Svdv Z. 13 l D J17
Vame(PrirL- Current Mailing Address:
gnatur Telephone
SECTION 3:- ESTIMATED'CONSTRUCTION COSTS
tem Estimated Cost (Dollars)to be Official Use Only
completed by ermit applicant
t. Building r y (a) Building Permit Fee
2. Electrical _ (b) Estimated'Total Cost of
v Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =G + 2 + 3 + 4 + 5) Check Number
!his Section For Official Use Onl
Building Permit Number: o� Date'Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0815
APPLICANT/CONTACT PERSON ZAMORA CONSTRUCTION INC
ADDRESS/PHONE 134 DEVENS ST (413) 543-6552
PROPERTY LOCATION 54 INDUSTRIAL DR
MAP 25A PARCEL 190 001 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 I
T_ypeof Construction: CONSTRUCT 2 INTERIOR OFFICES WITHIN EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 021483
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Pemut 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 Co sion
y 1Z-1
Si gnature 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.
/RJAL:DR BP-2002-0815
COMMONWEALTH OF MASSACHUSETTS
,31ock: 25A- 190 CITY OF NORTHAMPTON
c: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0815
Project# JS-2002-1365
Est.Cost: $13500.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
UseGrou: ZAMORA CONSTRUCTION INC 021483
Lot Size(sa. ft.): 98010.00 Owner: PIONEER VALLEY TRANSIT
Zoning: GI Applicant: ZAMORA CONSTRUCTION INC
AT. 54 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
134 DEVENS ST (413) 543-6552 Workers
Compensation
INDIAN ORCHARDMA01151 ISSUED ON:411102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 INTERIOR OFFICES WITHIN
EXISTING
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/1/02 0:00:00 3382 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
atK^"fPT Plumbing ❑ Building ❑ Electric
e City of Northampton
BUILDING INSPECTION LABEL
APPROVE-D--
dZ-�&+ Inspector
Date, ���
54 INDUSTRIAL DR BP-2002-0815
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 190 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0815
Project# JS-2002-1365
Est.Cost: $13500.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ZAMORA CONSTRUCTION INC 021483
Lot Size(sq. ft.): 98010.00 Owner: PIONEER VALLEY TRANSIT
Zoning: GI Applicant: ZAMORA CONSTRUCTION INC
A
FA ItyDlJ.D i f-(I/1L_ DR
Applicant Address: Y Phone: Insurance:
134 DEVENS ST (413) 543-6552 Workers
Compensation
INDIAN ORCHARDMA01151 ISSUED ON.•411102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 INTERIOR OFFICES WITHIN
EXISTING
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: & L(`�� -
Rough Framer K ,5 7-0 &�
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Ll K
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/1/02 0:00:00 3382 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo