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17C-183 (4)
' l i �t l LL- - --- - - - r ------ - - - LF V'a�a�1h4Yt'�v 1 GO�.PIA�� f I oLAI � 1 I I �y 1 °Q xxf wart 11amptoll g6 �lasat:chasrtts' U, DEPARTMENT OF BUILDITLG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT with a principal place of business/residence at: 16.9`-/t'Lt�d e LP�i (mss.=' c,� � 04- 6,�- � J- (phone#) 7Q 121,,;7 (str ci-Ucity/statelap) do hereby certify, under the pains and penalties of perjury, that: ( ) I aal an employer providing the following workers compensation coverage for my employees working on this job. (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole r rietor, 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 Company/PoLicy Nu.mbcr) (Expiration Date) �f. (Name of Contractor) G-n-s ance Company/PoLicy Number) (ExTLmuon Date) K • ` (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach a kiVLoml sheet ifn6OC =ry to i CWC iafOnntaon pe7tnining to nli ooa meters) ((I Z�m a sole proprietor and have no one workin�_for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while hocaco a who ernploy persons to do mxinr'„*,,or,caffitr%=oa or repair work on a dwelling of not more taw throe units in winch the homeowner resides or oa the grounds appurtenant thereto arc not generally ooandcred to be employrra under the worker's ooaptsation Act(GL152,Ts 1(5)),application by a homeowner for a liccwt or permit may evidence the legal status of an employer under the Workeet Compomation Act. I undcntand tad a copy of this mtcrocni may bo forwarded to the Dcpart.,nd of In&.tial Ac6dm&Offroo of tn;vrwco far the coverage vcriflactioa and that fa' to acatre coverage under sce ion 25A of MGL 152 can lead to the imposition of criminal pcnal - oomistittg of a fine of up to S 00.00 andVor imprisoama of up to one year and civil pcaaltics in the form of a Stop Work Ord and It fine of 5100.00 a dax/ me— For dcpartnr�al tr,e only Permit Number _ Lot t✓ __ Map# — Signature of Licensee/Pt:rmittce---- - e Versionl.7 Commercial Building Permit May 15,2000 SECTION 10=STRUCTURAL PEER REVIEW(7130 CMR 1l'O.11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑ SECTION 11 -OWNER!AUTHORIZATION -t0 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 1, 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 — --�--i----—�------- Signature of Owner/Agent Date SECTION 12 -CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ 1 Name of License Holder : CAE t1_1 e,4 CS f^ 7 f License Number le)l kke Xolrl �o� r 4), &w 4 Addres O Expiration Date _ 17S 12 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. L/ Signed Affidavit Attached Yes....... ❑ No...... ❑ Lev lr. %ovtuk-% 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 35,00'6 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 ❑ Responsible In Charge of Construction Address Signature Telephone w 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 ❑ 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 1'S-7140.0 c0 '%)>f Frontage q l� $ l Setbacks Front y Side L:L) 10 R: L: R:_ :} Rear `3 p t Building Height ,.>0,1 Z0 ti Bldg. Square Footage n Open Space Footage i' % (Lot area minus bldg&paved parking) C J #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW V YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW V/ 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: ' Version 1.7 Commercial Building Permit May 15,2000 SECTION-4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35;000 CUBIC;FEET 9 tNCLOSED SPACE Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] 1A Accessory Building[ ] Repairs [ ] DESC2 Per : c-1fAQ4 o r t>t-CLA Casa- (FT) -tor S SECTION,,• USE GROUP AND'CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ A-4 ❑ A-5 ❑ 1B El B Business ❑ 2A El Educational ❑ 213 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 El 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) St 1st 2nd f ,G 2nd 3'd 6 3rd 4tn y , 4th �. •, Total Area (sf) Total Proposed New Construction (sf) Total Height(ft) W', Total Height ft --- -- --- -------- ; r; H N'ersionl.7 Commercial Building Permit May 15,2000 City of Northampton ; Building Department 212 Main Street S t Room 100W3 L ;t v _ 21,10jgorthampton, MA 01060 '- phone 413-587.1240 Fax 413-587-1272 APPLICATION 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 This section to be,compl.etedby office 1.1 Property Address: ' IN t� 1 t 4 - -1 �t�Srfl tj+ Sl. Map Lot Unit I Zone O�rerlay_District D I©6o El rn.St:,District" CB°Dlstrtct SECTION 2- PROPERTY'OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t'SCA-1 yl .e- _ .Z�$ W. ��, co).5�u tt'A�u rr y� tti l d i z Name(P Current Mailing Address: (y t3) � fG- �SGS Signature C/ Telephone 2 2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com leted 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) 5700 ! Check Number This Section For Official Use Only Building'Permit Number:T �`� Date Issued: Signature: — Building Commissioner/Inspector of Buildings Date File#BP-2003-0973 APPLICANT/CONTACT PERSON LEV SIMKHOVICH ADDRESS/PHONE 109 MORELAND GREEN ST (508)752-1270 PROPERTY LOCATION 57-59 CHESTNUT ST MAP 17C PARCEL 183 001 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 EXTERIOR STAIRCASE FOR 2ND EGRESS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 071814 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 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 ui ding 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. 57-59 CHESTNZPr sr 6P-2Ci13-Oc?i 3 GIS#: COMMONWEALTH OF MASSA `HUS TTS Map:I31ock: 17C- 183 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2003-0973 Project# ]S-2003-1568 Est. Cost: $500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LEV SIMKHOVICH 071814 Lot Size(sq. ft.): 15725.1°6 Owner: KIRSCHNER DOROTHY B TRUSTEE Zoning:URB Applicant: LEV SIMKHOVICH AT. 57 - 59 CHESTNUT ST Applicant Address: Phone: Insurance: 109 -IMORELAND GREEN ST (508) 752-1270 WORCESTERMA ISSUED ON:5116103 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT EXTERIOR STAIRCASE FOR 2ND EGRESS 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: ffDcLc�S' U k Dri, l5 """- Z Final: Final: Rough Frame. Gas: Fire Deuartment Rough: Oil: Ynsulatifbr•r Final: Smoke• 1'ival: Q� 7 0 THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. x/ J Certificate of Occu anc Signature: FeeType: Receipt No• Date Paid: Check No: Amount: Building 5/16/03 0:00:00 639 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo