32A-121 (6) Keith Graham Construction
413-210-7717
Dec. 19, 2014
Dear Sir or Madam:
I request that you grant a modification to waive the requirement for control
construction for the project at 71 King Street in Northampton because the work is of
a minor nature,will not affect health, accessibility,life and fire safety, or structural
requirements and is impractical in that the cost of control construction is
considerable when compared to the cost of the proposed work.
Thank you for your consideration.
Respectfull
Kei am
Keith Graham Construction
16 Corticelli Street
Florence, MA 01062
The Commonwealth of Massachusetts
3 Department of Industrial Accidents
Office of Investigations
t r^_ 600 Washington Street
=' Boston, MA 02111
'. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibl_/
Name (Business/Organization/Individual): �q
Address: / r_Qi"7ZI*Ce°�/% J�/C'e1-
City/State/Zip: OrG7Ce A D 6/_-'Phone#: / Z 6
Are you an employer? Check the appropriate box: Type of project(required):
1. 1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Ix Remodeling
ship and have no employees These sub-contractors'have g. ❑Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp. insurance comp. insurance.T
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. o workers'coin right of exemption per MGL
y p 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
hnsurance Company Name:
Policy#or Self--ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der thepains andpenalties of perjury that the information provided above is true and correct.
Sienature: Date: l lrb
Phone#: 7 7/-7
F nhv. Do not write in this area, to be completed by city or town offeciaL
: - - — - - Permit/License#
ority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
[6. Other
Contact Person: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
4
SECTION 10-STRUCTURAL PEER REVIEW(780:CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION-.70.BE COMPLETE.P WHEN.'`'
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_..... _
as Owner of the subject property
hereby authorize -/ Y;( ESL
act on my beh matter I ve work authorized by this building permit application
Signature ner 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 penalties of perjury
-
Print Name
Signatur of Owner/Age Date
SEC ION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: Caf "�AYr,�, _. .._... ___ .�,:: _._ C. 0. t�
License Number
Addre Expiration Date
gnat e- Telephone
SECTION 13-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 of th building permit.
Signed Affidavit Attached Yes No �j
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF Eq.,CLOSED:SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant): _ __...... ... ... ........... .
Registration Number
Address '
_. Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
i
. ..... .......... ...... ......_. .. _....:.......... ._ ._ F ..
Address Registration Number
Signature Telephone Expiration Date
.. _ .:....__ __._._ _....
Name Area of Responsibility
Address Re istration
' 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
_Z _.
Address
�!l z�6 771
Si nature Telephone
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON.ZONING
Existing Proposed Required by,Zoning .
This column to 5e filled in by
Building Department
Lot Size _. ...... ...__.... _µ
Frontage
Setbacks Front _.....w..
Side L:_.__..._J R.3 .. L__.....__. R. ... ...__ _.. _ _._.....
Rear
Building Height _...._ ...:.__,
Bldg. Square Footage % ----1
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 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 mYES 0
IF YES: enter Book Page and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
MW
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 �
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Ex' ting Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other F-1 Brief Description E e rl hi� T&
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A
A-4 ❑ A-5 El 1 g ❑
B Business E] 2A ❑
EEducational ❑ ZB I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 11 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:
COMPLETETHIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group
Existing Hazard Index 780 CMR 34):' Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
151 _ _ .. 1St
2nd 2
nd
.. .. ....._ ..._....._._ ..........__....._._,i
3 d 3rd
4th
4th .
Total Area(so Total Proposed New Construction(sf)
Total Height(ft)
-- - - Total Height ft
7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone„Information: 7.3 Sewage Disposal System:
Public ❑ Private [] Zone Outside Flood Zone E] Municipal ❑ On site disposal system❑
- Versionl.7 Commercial Building Permit May 15,2000
Departure t use,on)V
City of Northampton status at PerrrtEt
Building Department Curb Of/Dnveuvay Perrrct
.i � 222014 212 Main Street Sewer/Septtc YZI
I ROOM 100 Water/Well Availability
e ,6 F �N pection orthampton, MA 01060 Two Sets of 5tructuraE-Plans
e 3-587-1240 Fax 413-587-1272 Plot/Site Plans
Other`Specify
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
1.1 Property Address: This section to be completed by office
�! �1AW Map Lot Unit
.y ✓� -
1 Zone Overlay District
-_- Elm St:District' C13 District
SECTION 2 'PROPERTY OWNERSHIP/AUTHbRIZED+AGENT
2.1 Owner of Record
Name(Print) �� Current Mailing Address
Signature Telephone
714 J1.
2 2 Auth ize ent
e� :�
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3-ESTIMATk/11 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official'Use Only
completed by ermit applicant
1. Building J (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6 _ .......... ..... ....
3. Plumbing G� v Building Permit.Fee
A-pop
4. Mechanical(HVAC) _.._......... _„ -
5. Fire Protection _...
6. Total=(1 +2+3+4+5) d Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings i Date
File#BP-2015-0682
APPLICANT/CONTACT PERSON KEITH GRAHAM CONSTRUCTION
ADDRESS/PHONE 16 CORTICELLI ST NORTHAMPTON (413)582-6890 Q
PROPERTY LOCATION 71 KING ST
MAP 32A PARCEL 121 000 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out o n .a I �
Fee Paid
Tyl2eof Construction: REMODEL 2ND FLR BATH
New Construction
Non Structural interior renovations
Addition to Existingti
AccessoU Structure
Building Plans Included:
Owner/Statement or License 075895
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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 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 Commission Permit DPW Storm Water Management
e it' Delay
Si re of uil mg O cial 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.
71 KING ST BP-2015-0682
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 121 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0682
Project# JS-2015-001308
Est. Cost: $5500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITH GRAHAM CONSTRUCTION 075895
Lot Size(sa. ft.): Owner: J W INC C/O WHALEN INSURANCE
zoning: CB(100)/ Applicant: KEITH GRAHAM CONSTRUCTION
AT. 71 KING ST
Applicant Address: Phone: Insurance:
16 CORTICELLI ST (413) 582-6890 O
NORTHAMPTON MAO 1060 ISSUED ON:1212212014 0:00:00
TO PERFORM THE FOLLOWING WORK.REMODEL 2ND FLR BATH
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:
FeeType• Date Paid: Amount:
Building 12/22/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner