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17C-129 (10)
i ' l J i j t I . c I j 1� C �d 5A Aj FR --------- i y i' C, p i �o�esp�yb Ei4 4 P r� I I � 1 C'oNC R� �Nr�zY �F I i Lo { NO i`"a�2 Sr9 N Dc R AP T7S, E�0 RCyr!e o��1tiAM p�O 9� ��: Wmrf I1alllpf fail Bas%itchnsrtta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFAMA.VIT (ii ce nser�permi tzec) with a principal place of business/residence at: (phoneri) (St7Z�.I�C1 ty/stalrlIl p) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following xork-cr`s compensation coverage for my employees working on this job. (Insurance Company) (Policy Numbcr) (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 Comgany/Poticy Number) (Expiration Date) F , (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) Qnsurance Comp my/Policy Number) (Hxpiration Dale) (Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date) (mach additional thcct ifno—Lry to include inf«mafio.pctaiaing to all oo�radot�) ( ) I am a sole proprietor and have no one working for me. ( ) 1 am a lrome owner performing all the work myself. NOTE:please be aware that while hocnoowm a who employ pasom to do m,mim*^;co¢stu oa or repair worst oo a dwelling of not mote than tbree units in which tba honmwncr reside oc on the grounds appurtensrd thereto arc not&coerally ooandcred to be employaa under the worker's oompcnatioa Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may evidmoc the legal clubs of an employee under the Worker's C.ompomatioa Aa- I understand that a copy of this rtattlncni may ba forwarded to tho Dct�of Indzrstrial Acad.:,&offioa of Iusurinco for the covaxge verification and that failure to acatre coverago under section 25A of MGL 152 can lead to tbo imporitioa of criminal penalties oomisting of a Sne of up to S1,500-00 and/or k4 isonnxtu of up to one year and civil penalties in the form_of a Stop Work Ord--and a fins of S 100.00 a day against me For dq tme W use only Permit Number Map# Lot# Signa -Ire of Licm see/Perm.it#ce e Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURALR''11ER OE, IEW"(780 CMR 110:11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No......Cii/ SECTION 11-OWN ER;AUTHORIZATION,-,TO BE,COMPLETED WHEN OWNERS AGENT OR'CONTRACTOR APPLIES FOR BUILDING PERMIT - 1, �.� V'11A 0 c d �¢ ,\-� 04-_�C1.1 as Owner of the subject property hereby authorize D=we_- to act on my behalf n all matters relative to work authorized by this building permit application.Lic;��_ i I 0 Sig a e 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 perjury. �J ova. " Print Name Signatur of ner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder 'bgn0,Q'.a G.c:'�)T- CS 03ao5'3 License Number (c S /Ae�14Nf- w.- P.-1 �, /..o v�cw.eo.do�.J t s Ile) �0,3 Address Expiration Date �ji3- SaS-��zz.. 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....... 121 No...... ❑ Version 1.7 Commercial Building Permit May 15,2000 SECTION 9 PROFESSIONALi DESIGN ANQ'CONSTRUCTION SERVICES -.FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUC;TI'ON 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 Company Name: Not Applicable Q� Responsible In Charge of Construction Address Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 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 t here any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: Version 1.7 Commercial Building Permit May 15,2000 SECTION';:4 'CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35;000 CUBIC"FEET Off'ENCLOSED SPACE Interior Alterations Existing Wall Signs Existing Ground Signs Additions d Roofing ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] Accessory Building[ ] Repairs [ ] SECTi, N,51'"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 ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential d 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``I Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SEC TION'6"BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY, Floor Area per Floor(sf) � ' � � y 1St P � � 7S 2nd a , 1st— � n i rd ,a s ry th ,R,4 3 rd 4 4th Total Area (sf) Total Proposed New Construction (sf) ,wts Total Height(ft) Total Height ft ----- ----"------ N �; } Versionl.7 Commercial Building Permit May 15,2000 l3 City of Northampton �e Building Department 212 Main Street ,, a- Room 100 Northampton, MA 01060 . j ph �- 3-587-1240 Fax 413.587.1272 APPLICATION TO<dNS7 �C' ;,REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING �1 \ OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-klT,E INFORMATION 1.1 Property Address: This section to be completed by office M �u �c�wQ —�l`SQv� S /'-�( _ Map .Lot Unit } 3 7 , Zone Overlay District :Elm St. District CB District SECTION 2 -'`PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: G SSW-Ll030 Signat r Telephone 2.2 Authorized Agent: \-fir `�7 O J - Soo Name(Print Current Mailing Address: S—( — 7'0 7)0 Signat 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 00 C) 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) .9 ;too0 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-0496 APPLICANT/CONTACT PERSON DAVID GOUR ADDRESS/PHONE 68 MEADOWBROOK RD (413)525-4622 PROPERTY LOCATION 137 HIGH ST-FORSANDER APTS MAP 17C PARCEL 129 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT HANDICAP RAMP New Construction Non Structural interior renovations Addition to Existin¢ Accessory Structure - Building Plans Included• Owner/Statement or License 032053 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,,MM ATION PRESENTED: Approved 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 Co ssion 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. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 9 NORTHAMPTON HOUSI�Au A JTIIuRiTY `F, \0t1 I S P 15' RECEIVED i 4 �l i I !I 14 f I r� i f 137 HIGH ST-FORSANDER APTS BP-2003-0496 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 129 CITY OF NORTHAMPTON Lot: -001 Permit: B U l l d i Z Category BUILDING PERMIT Permit# BP-2003-0496 Project# JS-2003-0824 Est. Cost: $2000.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID GOUR 032053 Lot Size(sq.ft.): 125452.80 Owner: NORTHAMPTON CITY OF 7onir2:_URB Applicant: DAVID GOUR AT. 137 HIGH ST - FORSANDER APTS Applicant Address: Phone: Insurance: 68 MEADOWBROOK RD (413) 525-4622 EAST LONGMEADOWMA01028 ISSUED ON:11114102 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT HANDICAP RAMP 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: P-0 L 5S O k Driveway Final: f l—'�D•O a Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: ©k - $ -O j THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATI K ANY OF ITS RULES AND REGULATION Certificate of Occu anc 2 Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 11/14/02 0:00:00 0 $0.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo