37-060 (5) • O O
9� `g C1Lx of wart11ailip flail
B B f�lasaarF(nsrtts'
m DEPARTMENT OF BUILDING INSPECTIONS V�'�t
212 Main Street ' Municipal Building Northampton, Mass. 01060 '
WORI{E 'S COMPENSATION INSURANCE AFFIDAVIT
z,
(li cen-ser�Permi titee>
with a principal place of business/residence at:
A&3 !Cb f,t? �l / � 0/3 s (phone#) O3 ZZ/1
(street/ci ty/stateJap)
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:
Gami_rance 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/Policy Number) (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 additioml xhca ifnocenixy to include informirioa pertniuing to ell oodradora)
(/I am a sole proprietor and have no one working for me.
P P g
( ) I am a home owner performing all the work myself.
NOTE:please tx aware t>iat while homeorvncrs who employ pazovs to do ai�ca= a=stixtion or repair work on a dwelling of
not more than thteo units in which the homeowner reside or oo the grounds 2pptutenan2lherdo ate not Ccictslly oomidcrcd to be
employr7a unda the woz+4es oompensation Ad(GL152-s 1(5)�application by a homeowner for a Gecase or pcmit may evidence the
legal etahts of an employer coder the Workoet Compensation Aa-
I understand that a copy of this rtatcmmt may be focwardad to tho Dcpertaxut of Indu3tial Accidents'offroc of Insursoce for dw
oovez g vc ificadon and that failure to toc=coverago under soctioa 25A of MOL 152 can lead to the impositioa of criminal penalties
ooasisiing of a fine of up to S1,500.00 and/or impriso of up to one year and civil penalties in the form of a Stop Work order and a
fur of 5100.00 a day against m
1 For dgmtn-a !use only
Permit Number
i' Map# Lot#
Si Liccnsee/Permit tee Date
Version 1.7 Commercial Building Permit May 15,2000
ON
SECTION]1]�3'STRU Tl' At PEER RE�iIEW(780 G IR D 1 3 }
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
'SECTION 11 OWNER AUTHORIZATION TO BE�COMPLETED�W,HE
O N
WNI_RS AGENT OR CONE ACTOW APPLIES FOR3iBUILDING'PERMIT`
as Owner of the subject property
hereby authorize L t� to act on
my behalf ma ers elgAhto rk authorized by this building permit application.
aw `dl
SignaKW0;65;6wdK Date
I,� , as Owne uhereby declare that t e statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Na
Q
Signatur Owrijr/Ageof Date
SECT"QN 12 CO IST0 UCT1 6N"S;ERVICEs
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
44f�� C91, Cs -0520�3
f/�r rya % ��-(�� �w License Number
M c'w � X�- M
Address ; Expiration Date
Sigryatu t1b Telephone
Olt—"
SE '-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 o the building permit.
Signed Affidavit Attached Yes....... No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION I tOFAES510NAL DESiG ,Q CONSTRUCTION SERVICES FOR BUILD'�N S '� ID�,TRUCTWS S(113......
3 W Y
CONS7RUC11�3N GOIVTR,OL,,.AUFi �1�N 0,78TC�VIR 116(Cdi4tAINII G .MORE LOSEp
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
9.33��G��eppneral Contractor p
6 VI �5 Ul Lbt A + �L M0 b 1E L AJ( Not Applicable ❑
Company Name:
Responsible In Charge of Construction A�OIZT��
C0 ��117
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
7.Water Supply(M.G.L. c. 40, § 54) 17.1 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
;z>
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
Wy }' y 3 y 3 I' 4s 3
SECTION 3�C0NST0Q J
LOS' S��/(G�S 3F(J�13PE�O,�EG"CS LI*SS THAN 35 OQQ,
Gt�B1G I~E OF NGI PSG g "
�
Interior Alterations - Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
,r�oo,�s/T��1�/Y � ❑ ❑
ExteriorAatio s emolition❑ New Signs [ ] Change of Use [ ] Other
[ ] `
7 Accessory Building ] Repai-rs [►
SECTION 5""-.U5E GROUP AND CUSTRUGTMpN TY E
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
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:
'COMPUTETHIS'SEC7[QN 1F EXISTING,BUILf�IN.G UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE'-lN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTl0N.6:BUILDING H EIGHT=AND iARIEA'
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION `' ; m
=UY,
Floor Area per Floor(sf) � tiyy&' P
St
lst 2nd
3rd a z
2nd
4m
rd r
4th ,, c
Total Area (sf) Total Proposed New Construction (sf)
sf
----------------------------------- �
Total Height(ft)
Total Height ft-------------------
�,
Versionl.7 Commercial Building Permit May 15,2000
1h U Vj 11310
Cit orthampton
200fui Department
SAP 2 2 in Street
Ro 100
DEPT of U4l`DINGIN" dmpt n, MA 01060
NOR, 0 Fax 413.587.1272 i
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECT101 1=SITE INFORMATION
f
1.1 Property Address: '
a�x t
�2
Coo UG 5we i yM�p ��
� �
A
� ''�
d 1 D
~
El St fDi$4rictCB Dls#rct y
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: r It L1(2 6AJ l e )MA.
11 BIZ Cl/0�
Name(P i Current Mailing Address:
q13 ° X86 - 6716
Sign tuev Telephone
2.2 Authorized Agent:
37-o „f U ' �(; h P
Co e- S qr3-<6,6 r ( �/o
Name(P n (Current Mailing Address:
S 7ig—nWu"rV Telephone
SECTION,3 =ESTIMATED CONSTRUCTION=CO5TS,
Item Estimated Cost(Dollars)to be Official Use_Onty
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical ` (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check Number -
This=Section For Official Use',Onl
t ulld ng'Permit Number, Date Issued:-
Signature:
Suijdin'g Commissioner/Inspector of°quildings Date-
File#BP-2002-0375
APPLICANT/CONTACT PERSON JEFFREY GALE
ADDRESS/PHONE 179 CAPTAIN BEERS PLAIN RD (413)498-2211
PROPERTY LOCATION 272 GROVE ST
MAP 37 PARCEL 060 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: INTERIOR REPLACEMENT DOORS KITCHEN CABINETS&INSTALL SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 056043
3 sets of Plans/Plot Plan
THE FqtLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOKMATION 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 Street Commis
Signature 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.
-272 G&VE T BP-2002-0375
GIs#: COMMONWEALTH OF MASSACHUSETTS
' - CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2002-0375
Proiect# JS-2002-0564
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JEFFREY GALE 056043
Lot Size(sg.ft.): 71 91 7.56 Owner: TRI COUNTY YOUTH PROGRAMS INC
Zoning:URB Applicant. JEFFREY GALE
AT: 272 GROVE ST
Applicant Address: Phone: Insurance:
179 CAPTAIN BEERS PLAIN RD (413) 498-2211
NORTHFIELDMA01360 ISSUED ON:1015101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INTERIOR REPLACEMENT DOORS, KITCHEN
CABINETS & INSTALL SIDING
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 Sianatare:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1015 1010:00:00 366 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo