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DEPARTMENT OF BUII1DING INSPECTIONS -_
212 Mailr Street ' Municipal Building
Northampton, Mass. 01060
WORiCI W,') COMPYNSATI.ON INSURANCE AFNI)A'G IT
(l 1 CeI1SCtf pCTII]1ttC�)
with a principal place of busMcss/resideuce at:
(El C�Cdlcity/stni c1-rip) ---
do hereby certil}r, under the pains and penalties ol'perjtll-, that:
V) I am an employer provicillig tlrc following ��,�or�:cr�s compensation coverinr. for Intl'
employees working oil this job:
L,-,V� C kW--, /�3 j W
--- — -- ------ _-
p,. ) (Polio Number) (ExTiration Late)
( ) 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:
A 11
r (Name of Contractor) Qctsvrarice Cornpmy/Policy Number) (Expiration Date)
(Name of contractor) 0-r surancc Company/Policy Number) (Expiration Date)
(Name of Contractor) �(Insurancz Company/Policy Number) (Expiration Date)
(Name of Contractor) --- (I11surmce coullmny/Policy Numbb-r)— (Expiration Date)
(auach additiooil sh cci ifnco�to inchude infortnatioa putnining to all ooatrectors)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that«iii I wiio anploy pxrsom W cio maurtcaance,axntrudioa ar repair wori:on a dwc-tting of
not moce than throe unit/in wiridi tlx homooc redder or ou the pro uy-b appurtcnarrt thereto an not Ccnerally eocnidcrrd to be
amPloyert under the Worker's maipatsation Act(GLI application by a homeowner for a liccnsa a permit may evidence the
legal status of an employee under tho Workeet Componution Act
I unduttuWd thai a copy of this rtatcniart may bo forwnrdnd to tbo Dqt rtnro2 of rr%&L-An l Atadm&Offioc of tnausnce for the
oovaage Ve ificatioo and that failure to seater:covcragn trttda section 15A of biGl,152 can iced to tbo imlwaitioa of criminal penalties
ooasisting of a fine of uP to S 1,500.00 attdlor'[�a of UP to one year and civil pmaltia in the form of a Stop Wort`Ord-and a
fism of 5104.00 a day tgunst me
For dq=tnt A use ooly
1 f Permit Number
IL _ ---------- �1'Imo' Map# Lot#
Signature ofLia� mittcc TSTe
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......IR
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the stihjecl proper lv
hereby authorize _ _ _ _ to act of
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 perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Richard Young _ 011878
License Number
P.O. Box 56 Florence, MA. 01062 8/14/03
Address / Expiration Date
413-584-1367
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 affidavi
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... K1 No...... ❑
Versiont.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 i 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
Young Roofing Co., Inc. Not Applicable P7
Company Name:
Richard Young President
Responsible In Charge of Construction
P.O. Box 56 Florence, MA. 01062
Address --7 1 1
584-1367
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 colmnn to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: 1,: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
Il of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding Bever 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 t,/"" 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:
Vcrsionl.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 Existing Ground Signs Additions ❑ Roofing MI
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs ( ]
TP-IZA7
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
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 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)
1st
2nd
1st
3rd
2nd
13
4th j, s
rd
E k Z x t
Total Area (sf) Total Proposed New Construction (sf)
........ ....... ................ _ t.
Total Height(ft) x� tti °
,E
- --
Total Height ft ---------------- ---
Version 1.7 Commercial Building Permit May 15,2000
y of Northampton
0 �2:ampton,100 i.ildng Department
12 Main Street S
Room
JUN 1 3 2002 MA 01060
L_— phone 13 87.1240 Fax 413-587-1272 j
OFPT OF S L LINUI INSPEC-1 IONS �
_ ELI-C7IT , EPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
I�
SECTION'1'=SITE INFORMATION
4' This section,to be completed bY,,off!,," a
1.1 Property Address: .a � a � r
(Pq0' +� i
Map g 0-
`Zone Overlaybistn
1,,,,,Elm St District
SECTION 2`- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
I
f
Signature Telephone
2.2 Authorized Agent:
Young Roofing Co., Inc. P.O. Box 56 Florence, MA. 01062-0056
Name(P�rot)' / Current Mailing Address:
��C�LL 413-584-1367 I
Signature Telephone
SECTION 3-- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 'OfficiaLUse Oniy� '
completed by ermit applicant
1. Building (a) Building Permit Fees
`�o
2. Electrical (b) Estimated Total Cos't Df; �
Corstruction,from: 6 .
p
3. Plumbing Building Permit Fee ' ,
,
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number R Mot
This Section for.Official°Use Onl '
Bulldmg Perms#`#Number Date Issued;
, a ,k
1 X i z a
K M�N
5lgna t ure ' �a
` :Building Commissioner/Inspector of Buildings, Date`
it
i
w
, z ' BP-2002-1115
GIS#: COMMONWEALTH OF MASSACHUSETTS
ft ;04�010 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1115
Project# JS-2002-1786
Est.Cost: $5850.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin: Young Roofing Co Inc 011878
Lot Size(ss .ft.): 483080.40 Owner: AQUADRO RICHARD C&MARIE E
zoning:RR Applicant: Young Roofing Co Inc
AT: 640 KENNEDY RD
Applicant Address: Phone: Insurance:
P O Box 56 (413) 584-1367 Workers Compensation
FLORENCEMA01062 ISSUED ON.6113102 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 6/13/02 0:00:00 13381 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo