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25C-085 (9) —------------ a m ��w r,��QC.zS �.__ Q-'C1tAMP�p �p ti 9 e Grit of 'Wart4a11yttin laSattCl(ttStttS DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S CONTENSATTON INSURANCE AFFIDAVIT (IicenseeJpermi tree) with a principal place of business/residence at: UL ✓r t1/`� i��L, (phone#) ' (street/city/stafr/np) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy 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 Numbcr) (Expiration Date) ,f (Name of Contractor) (Insurance Comparrv/Policy Number) (Expiraton Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) Gasulance Company/Policy Number) (Expiration Date) (Attach additioml shed ifnoD=sary to inchsdr information perta; to all ecatmci ) /Iam 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 be aware that while homeowners who unplay pasoa:to do maintenance auction or repair worfc on a dwelling of not store than throe units in winch 6a homeowner resides or on the ground,appurteawA thereto arc not generally wandered to be employers under the veneer's oompe u4ca Ad(GL152,ss 1(5)),application by a homeowner for a Gerasc or permit may evidence the legal status of an employer under the Workeet Compemation Act_ I understand that a copy of thin eta crocat may be forwarded to the Dtpartmcat of lndushial AccideatY Off oe of Insrrranoe for the oov=ge vmficstion and that failure to sauce covatage under section 25A of MOL 152 can lead to the imposition of criminal penalties 000sisting of a fine of up to$1,300.00 andlor impriso�of up to one year and civil pcnzhc3 in the form of a Stop Work Order and a firm of SI00.00 a day against tna. For dgxtttntdnl—-1Y Permit Number l� Map# Lot# rs Sip&we of LicensedPermitt:ee Date Version 1.7 Commercial Building Permit May 15,2000 SECIQN 0 STiURLhQEER�REVIEW780CIVIR,?11�Q )x3 ' Independent Structural Engineering Structural Peer Review Required Yes......❑ No......C311, ;SECTION 3 QWNER ►UTHORIZATIO TO�ZE!COMPL TED 1fI1HEN OWI±1£RSu 1 IJT flR G�NTRACTflR APPLIES.11 O,R'BUILDING PERMIT. f" I as Owner of the subject property hereby authorize r to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, DAL) y) /�� Ta &I gill. 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. 0 L) in 1J, �1 . Print Name Signature of Owner/Agent Date SECTION 12 CONSTRUCTION SERVICES, 10.1 Licensed Construction Supervisory: Not Applicable ❑ Name of License Holder: �Poy t /v< �`�G`tZA- C S ex 1i m, License Number `bill S Addre <" Expir onbaate Signature Telephone 5EG7'I( N 13; WORMERS'COMPENSATION INSURANCE AFIFIDAVIT(M.G.L:c- 152,.§,-25C(6)) , El nA 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....... E3' No...... ❑ Version 1.7 Commercial Building Permit May 15,2000 SECTION 9 3pROFESSI NAt. ESIG3N�AN,D GONSTRU(`TI'ONSERVIGES FOR BUILDINGS AN,D'. T121CTURESlfBJ3EC f,'�0 , CON nTRUCTl�N,GIN I°ROL P,URSIIA M,TpJ 0,`pm NG MORE THAN 3 , , ` "1!, F„ENCiOSk �SP 10E) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 92 Registered Professional Engineer(s): )VA 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 pply(M.G.L.c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage D' posal 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 3 760 354 8vS7` ev' ,e Sr Frontage Setbacks Front Side L: R: /F L: Ce t R: RearZ Building Height Bldg.Square Footage s-�a� % ��' Open Space Footage % (Lot area minus bldg&paved 3 a 77 3 077 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 3-3Z9 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.F. ,Ee /-/0y S-aY9) t�wvr c r r ox i3c�G I F ES, describe size, type and location:(2)1'-6-"Xz3 6" 44,06 "&V,' �'�t-<F, Rcv Fi?"r rap Z'-6",e q' C&9'AJr 0 6Nf 0/4 gW6 ® /`-&`X91 -e.1-emr e4w Sim of 84*. D. Are there any proposed changes to or additions of signs intended for the property?YES No ` �( NT eld IF YES, describe sizeG, type ZOrnf-5 f i Versionl.7 Commercial Building Permit May 15,2000 yu � �� :osircES � �R��i�° '�s �rH�,nr ,3PR 'VS,x . , n"q • .3� a 33u� 'rr ..33i 14 Interior Alteyztions Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ d / ❑ Exterior Alterations Demolitio New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] 12e�.�`._.� .f arc �olr•�� Jje.-,.j�-e hri v�� w��ls �'�can®f���-- ,�r� 5EGT10N 5 J, yGE�OtyP 1ND G �ISTRUCTION-*-Y, USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business 2A ❑ E Educational ❑ 2B ( ❑ 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 RENOVATION'S,ADDITIONSiANDIO CHANGE IN USE . .L,. Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUIt_D'11VG HEIGHT AND AREA ..r 3 h " BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) 1st J > 1st / 5. 7 2nd ►�"'� ?a h rd �Y)F 2nd //A 3 3rd 4th 4th AJ/A Total Area (sf) / 7/5- Total Proposed New Construction (sf) Total Height(ft) �o Total Height ft ----- --fit. a'q-L Versionl.7 Commercial Building Permit May 15,2000 Northampton B Department APR 1 3 2Ol ain Street R om 100 am ton, MA 01060 DEFT OF B 87-1 40 Fax 413.587.1272 NrOTTN. 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 ,wS�l�'E�`NFO�MAT�ION', ate? a3 1.1 Property Address: SECTION 2 PjROPERTY OWNERSHIP/A,UT140RIZED;,GENT'' 2.1 Owner of Record: A t,j.ti— M 0 661 C1 y Sl 5 pe.,.k 6 L aeo,S G ,..s-3 Name(Print) e Current Mailing Address: 62qk— )qyX&2 6//3 ) SFY-7231 Signature v Telephone ,` 2.2 Authorized Agent: j� Sl— (406UU (, 7 6jQ oY l '"'('¢, OAL),O�j e(Print) Current Mailing Address: _ Signature Telephone SECTIONS E5TIMA1`ED'CON5TRUCTIbN'COSTS 3f=� ,. .,,...,n ,u Item Estimated Cost(Dollars)to be ?fftc�al fJOn1 completed by ermit applicant 1. Building (a) Building Permit Fee S ova:oe� 2. Electrical (b)Estirriated rota{Ct710# �Zd ev Construction,#.rom= i 3. Plumbing Bmldi'ng Perini, jFee 4. Mechanical (HVAC) S i � 3 5. Fire Protection _( ) s Od.nd a. .. 6. Total 1 +2 + 3 +4 + 5 S Of�eck �1��1C�I11 P $ tlY n I Date Issue C yt 2t 3 = r y3 3 - s 3 , a x 1 5snex�lapetr ... �Itings File#BP-2001-0801 APPLICANT/CONTACT PERSON David Fortier ADDRESS/PHONE 32 Laurel St (413)586-8965 PROPERTY LOCATION 238 BRIDGE ST MAP 25C PARCEL 085 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid -- Typeof Construction: CONSTRUCT PARTITION WALLS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 008026 3 sets of Plans/Plot Plan THLLOWING 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 Co ission Permit from CB Architectur Co ittee � O Signature o uilding 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. �iDGE ST BP-2001-0801 CIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0801 Project# JS-2001-1508 Est.Cost: $23500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: David Fortier 008026 Lot Size(sq.ft.): 13764.96 Owner: MOGGIO MARK A&ANN MARIE Zoning.URB Applicant: David Fortier AT. 238 BRIDGE ST Applicant Address: Phone: Insurance: 32 Laurel St (413) 586-8965 NORTHAMPTONMA01060 ISSUED ON:4119101 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 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 Signature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 4/19/010:00:00 1073 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo C� ,04 X41.1 -�r ovt4 441C 1 r i t 238 Dkl!)GF s BP-2001-0801 GIs#: _ COMMONWEALTH OF MASSACHUSETTS Man:Blork_25C-0,.'. CITY OF NORTHAMPTON Lot:-001 Permit: Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0801 Project# JS-2001-1508 Est.Cost:$23500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: David Fortier 008026 Lot Size(sq.ft.): 13764.96 Owner: MOGGIO MARK A&ANN MARIE zonig:URB Applicant: David Fortier .AT. 238 BRIDGE ST Applicant Address: Phone: Insurance: 32 Laurel St (413) 586-8965 NORTHAMPTONMA01060 ISSUED ON:4119101 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 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: Footings: Rough: Rough: ` `-Rouse# Foundation: f 4F'T Final: Final: „_�/�I n'( Rough Frame: QK 7-�•©r Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: k 7 c2 Final: Smoke: FinaL•Qj( THIS PERMIT MAYBE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATI OF ANY-OF ITS RULES AND REGULATIONS. Certificate of Occu anc si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building , 4/19/010:00:00 1073 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo