32A-095 ��tt PT
Dues
a d Aasattchnsctti'
m DEPARTMENT OF BUILDI7,,JC INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFBIDAVIT
1, Pioneer Contractors
(IicenserJpermitLee}
«nth a principal place of business/residence at: `
P.O. BOX 1145 Nnrthamgton MA_01-061 (phonetr)
(s�.tJcl ty/stalelri p)
do hereby certify, under the pains and penalties of perjury, that:
(vf I am an employer providing the following vorker's couipens.-moD coverage for my
employees working on this job:
Wcc 500595701 20CIZ /��„y
Associated F.m=1 nv arc Tnsirrance Co-- ---
(Zasura.nce Company) (Polidy Number) (E.i-piration Dal ) ,
( ) 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:
(Na-me of Contractor) (Lnstnce Copany/Policy Ntn
ubcr) (E-\Tirntion Date)
a ttr tn
(Name of Contractor) Gasw-once Compamy/Poticy Number) (Expiradon Date)
(Name of Connector) (Insurance Compaoy/Pohcy Number) (F.i-pimbon Date)
(Name of Contractor) (Iasurauce Company/Policy Number) (ExTiradon Date)
(anach additional Shea ifneccmuy to iaclttdc infoctnatioa pcta;uins to nil 000tracWn)
( ) I am a sole proprietor and have no one worldug for me.
( ) I am a home owner performing all the work myself.
NOTE:plesse be aware that while homoownera who employ persona to do ami tca ocr,masuvcuoa or rcpair work on a dvelliog of
not moce tbau tbtoo units in tebich the honmovv reside or oa the Vvuods appurtonaot tba-do arc oot wally ooanxkmd to be
employ=under tbo wockc s ccap atatioa Ad(GL152,=1(5)),application by a homeowner for a tican3c oc permit may aidmee the
legar ct— of an employer uodertho Workoeg Comgomalion Act.
1 undcrsuad diA a copy of this ctatemcat may bo for worded to rho Dcparam ct of Indusa-ici Aaadcael offioo of lsausow for tbn
oovcrage vcnficxuoa and that fai1mc to scaue eovcngo under suction 25A of MGL 152 can Iead to the imposition of aimiatl pcnslb-
oomisting of a line of up to S1,500.00 and/or imprison.of up to one year and civil pmaltics in the form of a Stop Wort Order and a
fitm a(5100.00 a day Lpinst me
t For dcpattmcaW sic only
— 4. If Permit Number
Map-4 Lot#
Si tore ofLiaca Ipermi e
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 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Mary Yuri, Market9.5 LLC Manager
I, , as Owner of the subject property
Pioneer Contractors
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
2 2-11
Signature of Ow r Date
David Claxton
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.
Dav-td 0 Ctk-fon
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: David A. Claxton CS-017890
License Number
P.O. Box 1145,Northampton, MA 01061 01/19/2016
Address Expiration Date
(413) 626-7267
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 0
Version 1.7 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:
Lynn iQo5ner �, ck- Not Applicable ❑
Name(Registrant):
6 Crafts Avenue,Northampton, MA 01060 Registration Number
Address J 1
(413) 586-4483 Expiration DateZ C
Signat Telephone b `� 1 / 5
9.2 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
Pioneer Contractors Not Applicable ❑
Company Name:
David Claxton
Responsible In Charge of Construction
P.O. Box 1145, Northampton, MA 01061
Address 12�A lo (413) 626-7267
Signat Telephone
Versionl.7 Commercial Building Permit May 15, 2000
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 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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 0
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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 0 Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description Interior, non-structural demolition per plans dated 2/11/15
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 ❑ 1B ❑
B Business El 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B 0
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: B Proposed Use Group: B
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)
1 St 1 St
2nd 2nd
3rd 3 rd
4tn
4th
Total Area(sf) 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 Zoned Municipal On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:'`
D ilding Department Curb Cut/Driveway Permit
tJ ! 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
FEB
32015 hampton, MA 01060 Two Sets of Structural Plans
phone 587-1240 Fax 413-587-1272 Plot/Site Plans
C�ctric,PRIUM inNig$ as Ina Other Specify
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
9 1/2 Market Street Map Lot q Unit
Northampton, MA 01060
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
market9.5 LLC 20 Hampton Ave, Suite 150, Northampton, MA
Name(Print) �t
11�I ar i1 4un I M� er Current Mailing Address:
I 1 (413) 537-5793
Signature Telephone
2.2 Authorized Agent. �j
Pioneer Contractors P.O.Box 1155,Northampton, MA 01061
Name(Print) Current Mailing Address:
a�/ A C aXrL (413) 626-7267
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building $8,000.00 (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
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0792
APPLICANT/CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON01061 (413)586-5491
PROPERTY LOCATION 9 1/2 MARKET ST
MAP 32A PARCEL 095 001 ZONE CB(99)/
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: INTERIOR DEMOLITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinp,Plans Included:
Owner/Statement or License 017890
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
ion De y
SignatuMf uil m ffi ' 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.
91/2 MARKET ST BP-2015-0792
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-095 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2015-0792
Project# JS-2015-001539
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sa. ft.): 2700.72 Owner: MARKET9.5 LLC
Zoning: CB(99)/ Applicant: PIONEER CONTRACTORS
AT. 9 1/2 MARKET ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586-5491 Workers Compensation
NORTHAMPTONMA01061 ISSUED ON:211712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INTERIOR DEMOLITION
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 2/17/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner