38-063 Pip
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BtSEFCl�nSCtIE
e
m DEPARTMENT OF BUILDrhG INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
d1c, `/S le
with a principal place of bluiness/residence at-.
G y I'V , A Ae �-1417 4. 0e, 2 7( phone#) S.2 7 - $'77.S-
(streeflci ty/stal dzi p)
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-.
ffr L
(Insurance Company) (Police Nu-,nber) (Ex-piration 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) (ltlsurance Company/Policy Numbcr) (Expiration Date)
r
(Name of Contractor) (Insurancc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insztranc,� Company/Policy Number) (Expiration Date)
{, (Name of Contractor) (Insurance Company/Policy N1lrnber) (Expiration Date)
(attach addrtrooal shtct if nccUi to mchrdc information pc taiII °O all OG[JIraL�4fS�
( ) I am a sole proprietor and have no one waking for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while bomcowucrs who cmploy parrovs to do c xia-n•ace,con5tuc ioa or repair walk on s dwelling of
riot more than tht"units in w ffi r the hon»owner residca or on the grouad3 appiutecmd thtrao arc not morally ooasicicred to be
cmploycrs undcr the worirat saticn Act(GL152,ss 1(5)�appticalion by a homcowncr for a uccose or paean may cvidcooc the
legal statue of an employer under the Workers Conv-cl oa Act
I undastand that a copy of this stat==ai nuy be forwarded to the Dap u of District Ara&-&Oirioo of Inausnca for the
coverage vaification End that failure to sea=coverago under secdca 25A of MGL 152 can Iced to the imposition of ai niazl PenaW-
ooasisiing of a fine of up to S1,500.00 and/or uuptisonmeut of up to ooc year and civil paialtia in the form of a Stop Weft Ord--and a
fine of S 100.00 a day against try /
—GIGe'l! ux
only
Pm ber
rpm Lot#
Signab=of LicenseelPermittee
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject property
hereby authorize _ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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 perjur .
Print Name
/ G-C
Signature of Owner/Agent Date
SECTION 12 -;CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expira on to
7
Signature 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 the building permit. —
Signed Affidavit Attached Yes....... No...... ❑
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 ENCLOSED SPACE)
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
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
v
Version 1.7 Commercial Building Permit May I5,2000
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
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:
i
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC iFEET OF ENCLOSED SPACE'
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑ _
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ )
❑ Accessory Building[ ] Repairs [ ]
) rS �Pi✓ ! w-00j -So (Z/- S�/
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ lA ❑
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:
COMPLETE THIS 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) 15t
1st 2nd
2nd 3rd
3rd 4th
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft -------- -
t�-
Versionl.7 Commercial Building Permit May 15,2000
kit Lorthampton
i Department x
2 ain Street
7
2002 , m 100
1 0
North' mpt n, MA 01060
s e ka;"7-12 0 Fax 413-587-1272
Q, s t❑er d�"- ` �, `J.'CU
r C
APPOCXTION 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 b"'
completed by cs
Zone ' Overlay t)�str►c#� �� .��r�«
4r yr, ' aa � ;sAr
Ellin St:plstriGt' r �� CB,Drstrlct '- e
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone _
2.2 Authorized Agent:
Name(Print Current Mailing Address:
5 5A- Z y -7 i�r
Signature Telephone
SECTION 3 - ESTIMATED''CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
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 -q-7
This Section For Official Use Only
Building Permit Number: 6602—1067 Date Issued: _
Signature: - —
Building Commissioner/Inspector of Buildings Date
t Anli w BP 2002 1007
GIs#: COMMONWEALTH OF MASSACHUSETTS
u' •asp CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1007
Project# JS-2002-1619
Est.Cost: $12000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK DELISLE 074334
Lot Size(sq.ft.): 13634.28 Owner: SMITH COLLEGE TRUSTEES OF THE
Zoning URB Applicant: MARK D E L I S L E
AT. 182 EARLE ST
Applicant Address: Phone: Insurance:
3 GRANT ST (413) 527-4775 _ Workers
Compensation
EASTHAMPTON MAO 1027 ISSUED ON:5117102 0:00:00
TO PERFORM THE FOLLOWING WORK.ROOF: STRI P 3 LAYERS, NEW PLYWOOD,
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/17/02 0:00:00 547 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo