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38B-246 (7) 1 L s � � a a F l tp i 4 ,n 1 ! ! f�A Q-��MpTO •�O a 8 �I I of Nart4aIIlpton _ 9 d �lassarhasrtts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKEWS COMPENSATION INSURANCE AFFIDAVTr (licensee/permittee) with a principal place of business/residence at: (phone#) (street/city/staIdzip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: y) (Insurance Company) (Policy Number) (Fxpimtfon 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/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poficy Number) ('Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E)piration Date) (attach addedaml sheet if neoenm y to include information p=tLu tag to all ooatreclors) (0) 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 whHo homeowners who employ persons to do mainteaaaor,construction or repair work on a dwelling of not more than throe units in which the homeowner resides or on the grounds appurtenant thereto art not generally considered to be employee under the worker's compeasatim Act(OL152,ss1(5)),application by a homeowner for a license or permit may evidence tho legal status of an employer under the Workeea Compensation Act. I understand that a copy of this cut-may be fm warded to tbo Depertmeot of Industrial A=i4m&Offioe of 109K wO for the covaage verificWon sad that failure to smart coverap under section 25A of MOIL 152 can lead to the imposition of ctiminat peaaltiea oomisting of a fine of up to$1,500.00 and/or imprisonment of up to one year and civil peed ies in the form of a Stop Work Order and a Sao of 5100.00 a day against me. For dgnat w dal use mIy Permit Number z•� / Malo _Lot# Signature of Licezrsee/Permittce Versionl.7 Commercial Building Permit May 15,2000 '�OTI(?I�I 10-STRUCTURAL PEER REVIEW(780 CMR 1]:0`.11) Iclependent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SE;T18N 11 OWNER kUTHORIZATION -TO BE COMPLETED WHEN CJ WN R AGENT QFI GOt+I[TRACTOR APPLIES.FOR-BUILDINO PERMIT as-Owner of the subject property hereby authorize to act on my b half, in all matt s relative to work authorized by this building permit application. �o Signature of 0 ne 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 penb4ties of perjury. Print Nam / Signature of Owner/Agent Date S,LCT It N lZ F C3NSTRU01014 SERVICES 101 Licensed Construction Supervisor:: 4 Not Applicable ❑ Name of License Holder: �'�'I A0 U , /l a r J o `ic a 3 License Number a g / Lao Y" I S st 161e6 t 000 a Ad s Expiration Date d - 7, 503 Signature Telephone SECTION 13-'WORKERS'COMPENSATION INSURANCEiA,P (DAVIT(M.>G.L.e.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...... 9— Versionl.7 Commercial Building Permit May 15,2000 SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FQR.BUILDINGS AND STRUCTURES SI;�BJECT TO CaNST UCTION CONT46L PURSUANT TO 780 CUR 116'(CONTAINING 114 RE THAWS 6.F.,t)F ENCLOSED PAC 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 do Ignature 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 ACI h 41- ab u t ��Ct r U C' /,;"I O �' Not Applicable ❑ Company Name: ^ C'P7 C' O Responsible In Charge of Construction 6 L5 � 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: ublic ❑ 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 SECT aN= " hIST#tUC71ON SERVICES FORPROJECTESS THAN5' 00 �CliBi11.QSED SPACE �*: -S. .ie�3i° �'r.�.°,b-i ;3 1 Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ [Roofing ❑ Exterior Alterations Demolition❑ New Signs [ j Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] SCTIO f '3POUP ANb CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business C( 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ L-5B 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ ❑ U Utility ❑ Specify: A Mixed Use ❑ Specify: i S Special Use ❑ Specify: COMPIxET 1HIS SECTION F,', XISTING BUILDING UNDERGOINGLRENOVATIONS ADDITIONS AND/OR CHANGE 1N ,USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SETN �3UNN.bNNG"T AND AREA �^ BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) St + ' , 1st 2nd 3rd 2nd 4th 3`d ?°'a 4th Total Area (sf) Total Proposed New Construction (sf) F ^ r Total Height(ft) Total Height ft ----------------- F /Sn� ` Version 1.7 Commercial Building Permit May 15,2000 City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587.1240 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 ECT10fV.1=SITE,INFORMATION 1.1 Property Address: Xhsp 0 1 9 AL, 1 ,4 ( A "One G.^^ h x 'LGTtCN? :P#t3PERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ame Print) Current Mailing Address: � Y� y�_-3 Signature Telephone 2.2 Authorized Agent: Name Print) f/ Current Mailing Address: 5 & 7x'33 Signature Telephone ECTN 3=ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be .Official Use Only completed by ermit applicant 1. Building 00 (a)Building Permitfee 2. Electrical (b) Estimated TotaL.Cost of Construction from(6), 3. Plumbing 0 ©0 i Building PerrnWfee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 + 2 + 34 4+ 5) ©0 Check Number /,006r �''a')._ This Section For Official'Use Only ,kBuildin Number.' Gate Issued: Signature: wilding 1 ommissioner/lnspector of Buildings Date File#BP-2001-0775 APPLICANT/CONTACT PERSON RENE ROUILLARD ADDRESS/PHONE 291 LOOMIS ST (413)562-9403 PROPERTY LOCATION 3 OLIVE ST MAP 38B PARCEL 246 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid jypeof Construction: CONSTRUCT WALLS&DOOR TO CREATE BATHROOM&CLOSET New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 042307 3 sets of Plans/Plot Plan THE OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § —w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 Signa a of Build' fficial 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. 3 OLIVE ST BP-2001-0775 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-246 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category'Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0775 Project# JS-2001-1451 Est.Cost: $9600.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RENE ROUILLARD 042307 Lot Size(sg.ft.): 7666.56 Owner: G&S SANDLER ACQUISITIONS LLC Zoning:URB Applicant.• RENE ROUILLARD AT. 3 OLIVE ST Applicant Address: Phone: Insurance: 291 LOOMIS ST (413) 562-9403 WESTFIELDMA01085 ISSUED ON:415 1010:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT WALLS & DOOR TO CREATE BATHROOM & CLOSET 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/5/010:00:00 1005 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo � r AE r � 7 OWN Yyr 3 s� r'4 . K joy OVA �01 ANT w , r h Y a s MAN y` Y f s S s � l C�7 MOM KjI µ' r f } z 1 x , 3 OLIVE ST BP-2001-0775 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38B-246 CITY OF NORTHAMPTON Lot:-001 Permit: Buildina Cateeory:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0775 Proiect# JS-2001-1451 Est.Cost:$9600.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RENE ROUILLARD 042307 Lot Size(a%ft.): 7666.56 Owner: G&S SANDLER ACQUISITIONS LLC zoning:URB Applicant: RENE RO U I LLAR D AT: 3 OLIVE ST Applicant Address: Phone: Insurance: 291 LOOMIS ST (413 562-9403 WESTFIELDMA01085 ISSUED ON:4 151010:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT WALLS & DOOR TO CREATE BATHROOM & CLOSET 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: •+ �� :� '1 Rough: //��G/ House# Foundation: Final: I jAlwl Final: UV—qC ._7&-r Rough Frame:a , � f, Gas Fire Department Fir 1 o Fireplace/Chimney: ace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: -a/ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy- Signature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 4/5/010:00:00 1005 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo