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DEPARTMEIrT OP DUTLDD\'C rNSPECT101.'S
212 Main Street ' Municipal Building
Northampton, Mass. 01060
'NORICER'S CON'TENSATION MSURANCE AfFM-AVIT
0j omiscrJpc mi ttcc)
V.qt-b a pruicipal plac; of business/residence at:
� t�}. atoi'Z
(sac/a ty/sta.tc�p p)
do hereby ccrn.f),, under the pains and penalties of pef7w-y, .hat `
O I am an employer providing die follo%vine worker's comnenS-nJon cove MJe For my
etuplovees wor�jng on 'Ons job_
(Lnsur:�� Conr„c}-) fPelic: i;u.-ter) --- (�=,.pirvar Pzu.)
( ) I am a sole proprictor, general contractor or homeowner (ci cie one) and have hired
the cone actors listed below v`rho have the following worker's cocoensanon policies:
(Name of Co:,.t:acwr) (In2ranc Colnpari)-!Pob; -, Numscr) frz�i;lco� Datc)
- (Name of Coocraetor) Ms,uanc:, Compaavi?obc, N=bcr) (Lxpimuoa Date)
(Name of Conn-aeto,) (LaFw-anc;. Compan)•/Pol;cy Number) (Exair-"600 Date)
(Name of Conaaczor) (Iunuran= Comcany/PoLcy Numbs) (Ex-pi.r-ajo❑ Date).
(attieb riioczl 6,---if aoc- .-N•w melu<3a iaformaaoa pcnainia6 to eu oo=r.,,—n)
( I am a sole proprietor and have no one worLzing for me.
( ) I am..a home owner performing all the work myself.
NOTE:plea be aw-ut thu utjo 6omcv aocr�µ'bo empray pcz.om w cti e--;.-+.--,,..•. cc. .rjao c repair wurK oa a d-X L.z of
aoe most ih= ' _--Iru in u$ieb the bocmawne rmda or oa the V-ou zpputtcn rl thcr eo a-c o c alty oee dmi to be
-rploy—unCC Lhe•�Q}rr�a= -, ..'cQ Ac'(C,LI52.=1(S)�apptia.600 try a bomma-ocr fca-6c=x—or p=mu r=y c-rd=cc the
lc-g l rc-n.,of an axployx uodor rbn Woriccic C.C,,; ition Act
I UDdcwLa d thy.a oopy of thin cmlcmcnI m.y be r,,,,ded to tbo Dcpartmcra of lnduuicl AmdooI'oTjoe or 1,=. nco for the -
oovmtse veriCesioo bad Ihet Ld=r-to iwuc bovcr-4o uadr Icc:G n 25A of M01-152 on load to the impas ioa of eia i peaaw=
ooasismg of a fioc or up to S 1-500.00 artdlor of up to one yc and ci%it pcaatio io be form of a Siop Wort Order and a
Gm 0(s 100.00 a d:y Lpiau me
For dqur=-=-j u,c only -
�� Permit Numbcr
, t.�p —_ Lot
Si�naturc of Lic=iscc/Pcm-iucc ,::
` Versionl.7 Commercial Building Permit May 15,2000
SfCTlON 10!STRUCTURAL.PEER REVIEW(780 CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11-= OWNER AUTHORIZATION TO BE COMP:LfTED WHEN
OWN ERS'AGENT'OWCONTRACTO :A, PUES fOR'BUfLDING"PERMIT"
as Owner of the subject property
hereby authorize � c to act on
my behalf, in all atter rel iv to work u z by this building permit application. r
Signature of Owner Date
t
At/ as Own /Authorized Ag_a�-
hereby declare that the statements and information on the foregoing application are true and accurate, to f my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Na e
Signature of Owner/Agent Date
SECTION42;.-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: LEA LEA Noott�Applicable ❑
Name of License Holder : 'I C C'&0 �
License Number
�-t 4 "C eWSl 706e
dr ss O t 0 'Z_ Expiration Date
, '_0'_ ,4 i 3_
Signature Telephone
SECTION 13!WORKERS°COML'Et!ISATlON INSU,RANCEAFFIDAV1T.(M G L e 152;§25C(6)) m
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...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 PROFESS{ONAL DESIGN;AND CC3NSTRUCTiON SERVICES - FOR BtJ1LDiNGS AND STRUCTURES SllBJEC7 TO
CONSTR,t1CT10N CONTROL PllRSUANT TD 780 CMR�116{CQNTAtNlNG MORE THAN';3 ,CtflO C f Ot :Et�1CLOSED SRA CE)
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
Versionl.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 0,, Private ❑ 1 Zone: Outside Flood Zone Municipal AS-00 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
arlcin
#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 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 , Date Issued:
C. Do any signs exist on the property? YES 17` NO
IF YES, describe size, type and location:
D. Ar there any proposed changes to or additions of signs intended for the property?YES_
Nor
IF YES, describe size, type and location:
R
Versionl.7 Commercial Building Permit May 15,2000
SEflN4' (:Oi.N�S +fNf�1�y.�jlSRQECLfSS1 �►ifl5,3Dt1
r ._ .:_:., r"S,. ..iz.., .:. ;#. ,+*,:ys 4....., t. � ... .at'✓ r t,.x.er +' X3''°.'1
. er
Interior Iterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [�
❑ Accessory Building [ ] Repairs [ ]
BRIEF DESCRIPTION: .1, �� ,t 30"� 4 004 t-g
SECTION 5-:-USE tROUP:AND CONSTRU!CTIOTI TYPE'>_
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business nk 2A ❑
E Educational ❑ 2B 0
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:
CAMP,LC 1S E Al I I111 IMF GOI IG,RENO AflONS'AOO CANS Nt OR,CHANGE IN USEt
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 786 CMR 34):"
SECTION_6$UILDING.HEIG AND AREAx
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTIONM
Floor Area per Floor(sf) st 71
ist 2nd
2nd 3rd
3"d —
th
th
c ab a
Total Area (sf) Total Proposed New Construction (s17
Total Height(ft)
Total Height ft
• Versionl.7 Commercial Building Permit May 15,2000
City of Northampton
Building Department
�., ,tiV
212 Main Street x`
Room 100
.0 ` Northampton, MA 01060
- 2
phone 413-587-1240 Fax 413-587-1272
APPLIQN jTgNS,TRITrRP �NQVpT�,CHEIN6E_ liE U O. OCCr�JPANC�f�E f.Oii,DEMOLISH ANY BUILDING
A�R YHAN A ov%E1bw!WO F t�U1FEL ING.
SECTTON,1 SITT��IFORMAT30N __
1.1 Pro perty Address.
v RN
SECTION Z ,PROPEiiL7Y OWNERSHIP�AUTHOiRIZf D AGENT ,
2.1 Owner of Record:
Na a(Print) Current Mailing Address:
16 ,6
Signatu Telephone
2.2 Authorized Agent:
U C=f a
Name n t) Current Mailing Address:
L.t 3--'2-9,6-,y S
Signature Telephone
:SECTItIN3' fSTIMATED'tONSTRIIfCTItDN
Item Estimated Cost(Dollars)to be Official Use Oh 1y
completed by rmit applicant
1. Building (a Building Permit Fee
1>
2. Electrical (#�J�stibiAW Total Cost of
'r .Cor�stix9etion'"„fiora<%b.4'�`,
3. Plumbing �wtdmg eru��f fee
as Y
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3+4+ 5)
"Cljec)C NuM, ber,
Titiiis Section:F it 0f n
"�llsetn!_
Building;Permit(Number x gate issued:
Signature:
Building Commissioner/Inspector of Buiidings Date
File#BP-2006-0999
APPLICANT/CONTACT PERSON Pamela LeBeau
ADDRESS/PHONE 248 Bryant St CHESTERFIELD (413)296-4506
PROPERTY LOCATION 24 HAYDENVILLE RD
MAP 11C PARCEL 034 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: FRAME&INSTALL 30"X 60"COOLER W/DOOR&SHELVING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 064756
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Pen-nit 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 S Commission
2 �a►
Signature of Building 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.
BP-2006-0999
GIS#: COMMONWEALTH OF MASSACHUSETTS
w� 1 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0999
Project# JS-2006-1484
Est.Cost: $1800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Pamela LeBeau 064756
Lot Size(sq. ft.): 18730.80 Owner: ASHTON JOSEPH D
Zoning: HB Applicant: Pamela LeBeau
AT. 24 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
248 Bryant St (413) 296-4506
CHESTERFIELDMA01012 ISSUED ON:312812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-FRAME & INSTALL 30" X 60" COOLER W/DOOR
& SHELVING
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 Siiinature:
FeeType• Date Paid: Amount:
Building 3/28/2006 0:00:00 $50.004673
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo