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17C-224 (4) s - a oR� PTO � c y (riff of �,Torfl}U))tPtoll - — A � E �Ra�lachnsclta' _ co DEPARTMENT OP DUILD0\10 fNSPECT)ONS — 212 Alain Street ' Municipal Budding Northampton, Mass. OIOGO WOMCER'S CONUENSA TON LNSURANCE AFFMAVIT (Iiccas Pc-rmittcc) v,rlth a piincipaI place of business residence at- bA (phone') (Srrc tuaty/state/Zi p) do hereby certify, under the pains and penalties of perJury:, -hat O I an an employer providing die following Nvorkcr's cotnnensado11 covervgc For my CI ployecs worUng on'dais job: 4(LkAnCorer ) (Pclic: ?cur) (T_:pirtior Dztc) O I am a sole proprietor, general contractor or homeowner (ci c?e one) and have hired the conc-a(nors listed 'below wbo have the following workers raMpenSabon pe!icies: (Name of Cont^cwr) On_-L zloC Cornpan)'/Pobcr NIu_m -_-) (Ex)timuo-, Date) (Name of Conrraaor) (lnsttrancc Comoazw?oIjm, Numinr) (Lx-Dir.ation Date) (Name of Coluraeto,) (tasw-ancc CompanyfPoke)' Nambu) (E\pirooa Date) (Name of Contractor) gn uranc–c Company/PoUcy Numbs) (Expindon Date) (anscb aC•1it:t 1 s3ca ifooa.-u�-w c>c'u�'6 infocm�zoo p�taiaiag to.0 oosnc.. n) O I am a sole proprietor and bave no one wor�dng for me. ( ) I am,.a home owner performing all L6e work myself. NOTE:Plc be awvt tic wt`Je bcmcoumcnµ-bb cmp toy peru=to 0.i Cam=ocr.—,acloo t:repay woric oa a d,,el -g of twe tnor<tb:o ` oc—,,to wt ich the boc�reach oc oa the p ouoccs zppurten r_tbcC. e. ox C=>.---.Uy 00=6- d to be carploy—un c the wu r4 rr=*--.=Iim Act(GL]52-=1(5)x-wLicaDoo by a bomcoavc for c liar oc pcmh rn_y c,-r&=the Icv-1 c xu of an cs.Ployer wo&o tho wockcet C,o=p.om.lioo Aa- t-d.esaiad tb-a oopy of this eatemcra o y tx for—,ded to Rho Departseoa of 1-6.,;a]Aaea.&Ohio.or(e>r—for Lb. eoverasc vcri[tmioo and Uu L•;]tae to secure teovrraSe under soetioa 23A of MOIL 152 an Ied to the Lq*a on of air; P.­ oocaisi t of a fine of up to S 1500.00 uidroc i>mqxj� of up to ooc yur end cvi]Pcx tJc is the form of a Slop W oric Order and a ftm of S 100.00 1 day IpuC31 tree For dcy.rtav-, use only permit NuIDbcJ Jl 1,.(np» L•ot S;pzattrrotL;croscrJPcri cc e j Versionl.7 Commercial Building Permit May 15,2000 SECTd�N 30 STRUCTiIRAL PEE#2 REVIEW(78D CMR`110 11)' Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION 11 OWNER A>�THORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR B11;1CDING PERMIT as Owner f L o the subject property hereby authorize C�T CDVts-EYfcc17y1 to act on m behalf, in all matters relative to work authorized by this building permit application. Sig ture Owner �, EXeC-L -ivy i Date l' 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 Signature of Owner/Agent Date SECTION 12- CO NSTRlC VICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number ess Expiration Date Signature Telephone SECTION 13 WORKERS°COIVPEiJSA710N lyStlRAiVCE Al fiDAVIT"{M G t X52, 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...... ❑ J a Version 1.7 Commercial Building Permit May 15,2000 SECTION 9 PROFESSIONAL DESIGN AND CQNSTRUCTI0N SERVICES FOR BUILDINGS,�AND RUCTU,RES SUBJECT T0=° C©NSTRU,CTION=CONTROL PURSUANT TO 7OQ�CMR,116(CQNTAINING MORE THAN 3ar,ODO C F .OF=EIJCLO"SEfl Sl?ACE) 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 r 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 Versionl.7 Commercial Building Permit May 15,2000 ti 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 ❑ Municipal ❑On site disposal system ❑ 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department i Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved arlin #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO `' DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained j , Date Issued: C. Do any signs exist on the property? YES V 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 n - SECTIrON tl- NS� O��lll eE.R�CI�R�I� CI� SSA�I��,�i�411��`�_ Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building L ] Repairs [ l BRIEF DESCRIPTION: - \ S O r SECT1614°3-USE'GROU,I AND.CONS RU N 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 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ I-2 ❑ I-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: C MPLEfFT IS�C N iI E tG l�I iG t flEltGt�II G C��ATIflNS DIII flNS AND�OR:CHA�tGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): Mull SEL'l<SON:fi$UICDINGlitE3GH�'�1ND.AREAx - BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION i 11 .. _ka Floor Area per Floor(sf) ist ` l 2"d � ��� 1St 2nd yw k 3`d 3.d 4h' 4th , H Total Area (sf) Total Proposed New Construction(sf) "z Total Height(ft) Im � b Total Height ft n Versionl.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 SECTION l �SIT�3NlF.OR1vJATION'S � `" 1.1 Property Address: f T I✓�S-fy-a t s �SEC'1�ON.`� -P,RO�ERTYO�fItNERSF1i���1JT##OR7ZEDiAGENT ' 2.1 Owner of Record: Va ImmuV% J)e VV-(RP► '`fLer 3 ar�.eJf- eQ -, Vr'+trt�v» NApe(Print) Current Mailing Address: 4(2,) --Sass I9 Sig Lure r Ir' Tel' one 2.2 Authorized Agent: a (Print) Current Mailing Address: Signature Telephone SECTION MATED CONST121ICTION STS Item Estimated Cost(Dollars)to be 'O�icial��v on,y completed by rmit applicant 1. Building ( Building Pe -Fee 2. Electrical ((b� sbrrated Total Costc�f s ion°sraiction ,rn 6 3. Plumbing $wld�ngPerm�t fee 4. Mechanical(HVAC) 5. Fire Protection w 6. Total = (1+ 2+ 3+4+ 5) This Section,Fbtf'cial Use±On1 Buidiag Permit Number ' Bate Issued x : - Signature: Building Commissioner'/Inspector of Buildings Date 1-3 NORTH MAIN ST BP-2004-0478 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-Block: 17C-2241 CITY OF NORTHAMPTON Lot: -001 Permit: BUiidinQ Category: BUILDING PERMIT Permit# BP-2004-0478 Project# JS-2004-0681 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin CDT CONSTRUCTION 003666 Lot Size(sq. ft.): 7187.40 Owner: VALLEY CDC Zoning: GB Applicant: CDT CONSTRUCTION AT.• 1-3 NORTH MAIN ST Applicant Address: Phone: Insurance: 158 NORTH MAPLE ST (413) 585-8677 Workers Compensation FLORENCEMA01062 ISSUED ON.10123103 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE ROLLED ROOFING W/SHINGLES 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: Receipt No: Date Paid: Check No: Amount: Building 10/23/03 0:00:00 5547 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo