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VACANT 72 sf ]VACA VACANT --XEA E HALLWAY 341 345 sf r KITCHEN
43 sf
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CLOSET Projed North
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168 sf 45'-11" CLOSET
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17'-0" 4'-5" ATTIC 1 sf _ DOOR REQUIRED
`o 2 HOUR FIRE RATING REQUIRED
STAIRS 400 sf
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o VACANT
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SECOND
FLOOR PLAN
Drawing No.
A-2.3
City of Northampton 212 Main Street, Northampton, 1\4-A 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
,address of the work: �-t '? r-P')N3:> N�
The debris will be transported by:
The debris will be received by:
Building permit number:
Dame of Permit Applicant
Gate rpature of Permit Applicant
4
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
Inspector Hasbrouck,
In accordance with the Massachusetts State Building Code, 780 CMR § 107.6.1 (5), 1 request that
you grant a modification to waive the requirement for construction control of the renovations at 48
Round Hill Road in Northampton.The work is of a minor nature, will not affect accessibility, life and fire
safety, or structural requirements and can be done in accordance with the prescriptive requirements of
the code. Construction control is impractical for this project because the cost of control construction is
considerable when compared to the cost of the proposed work.Thank you for your consideration.
Respectfully,
Max Hebert
Project Manager
Historic Round Hill Summit
Ow
i
S
The Commonwealth of Massachusetts
Department ofludustrial Accidents
—' Office of Investigations ,
t-r 600 Washington Street
-_ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): —
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.El I am a employer with � 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
___2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
–-- These sub-contractors have
ship and have no employees 8. Demolition
d have workers'
working for me in any capacity. employees an 9 E]Building addition
[No workers' comp.insurance comp. insurance.$
5. 7 We are a corporation and its 10.0 Electrical repairs or additions
required.]3.❑ I qu a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.7 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the nacre of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: —
Policy#or Self--ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: VL1111 Date: Z
- - G6 5
Phone#:
Of use azlV. Do not write in this area,to be completed by city or town official
___--
—City-or Town: _ .___ __- _ -- Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#:
J
•
X
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-;STRUCTURAL.:PEER REVIEW 1780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION-TO BR COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR'APPLIES FOR BUILDING PERMIT
as Owner of the subject property
herebyauthorize .. .,....__. ................. _..,__ _.... ............._. ..... ... _. __... ..__ ...
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, _ . . �.....___... .�._.._._�._. ._.._..,....._. _.,.___,....,_.._,._ ..._....___.__._...__._,._.__._.... ....................: ,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 penaltiesofperjury x.
Print Name
Signature Owner/Agent Date
SECTI N 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder:i_ .�� ' .����"' !�� ..
License Number
Address Expiration Date
Signature Telephone
SECTION 13-WORK S'COMPENSATIOPI INSURANCE AFFIDAVIT
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 0 No 0
s
Versionl.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 1,16(CONTAINING MORE THAN 35,000 C.F.OF EKLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature elephone
9.2 Registered Professions ngineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
.. .......__........... P
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature lephone 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
ti
Version 1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by honing ,
This column to 6e filled in by
Building Department
Lot Size
FrontageM. .._.._. ... .... .._.". .. _ .._,_".._.. _,...__. ....._... _ _.._,w.... ..........
Setbacks Front
Side L:.--, R:'
Rear
Building Height
Bldg. Square Footage %
Open Space Footage % -
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Varia rice/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Zettands?
IF YES: ter Book ' and/or Document#e
B. Does the site con in a brook, body of wat0 DONT KNOW 0 YES IF YES, has a permi t en or need to be ervation Commission?
Needs to be obtained Obtained , Date Issued:_
C. Do any signs exist on the prope ? 0 NO
IF YES, describe size, ty and location:
D. Are there any propos changes to or additions of ns intended for the property ? YES 0 NO 0
IF YES, describe ize, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or i 'ng)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN,35,OOD
CUBIC FEET OF ENCLOSED
SPACE-�-
Interior Alterations Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description :Enter a brief description here.
Of Proposed Work Re Nov ATs E3-A.7 H r2z a N. A P AP:T W
SECTION 5-USE GROUP AND CONSTRUCTION TYPE' .
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 El A-2 El 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 ❑ I-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 F-1 Specify:
COMPLETETHIS SECTION IF EXISTING BUILDING.UNDERGOING-RENOVATIONS,ADDITIONS ANDIOR CHANGE IN USE
Existing Use Group: _.__ ____.._._ _._ ___... ..__. __.._ ,._ .__ Proposed Use Group: .r,.. ___ ___. ..._...._. _.... _.., ...__,....
Existing Hazard Index 780 CM 4): . __ .__...._ 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(so
4.
w
St
1 St _. .. .
....,._ 2nd .._
2nd
rd
3rd 3
th
Total Area(so Total Proposed New Construction
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 Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building.Permit May 15,2000
Department use,only
-- —�; ity of Northampton Status of Permit
U Department Cuit Cut/Driveway Perm
`i Y 2'015 212 Main Street Sew'6tis6pti&Avaaiiifity
Room 100 WaterlWell availability
hampton, MA 01060 Two Sets of Structural Plaris
..:
- - 87-1240 Fax 413-587-1272 Plot/Site.Plans
Other Specify
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 completed by office
1.1 Property Address:
_ ............. _.. _. ..._.._._ _.
8 � tAk 0- Map Lot Unit
t—f11 Zone Overlay District
'Elm SDi--------- strict CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�1L1 Cj��n�n1�r LIL �17r� �l >t i T l = �?1,�i' CriLL tLIAA-
Name(Print) Current Mailing Address ` \C
r`
Z L �
Signature �` .` '– Telephone
2.2 Authorized pent:
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION!COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ��'7T (a)"Building'Permit.Fee
2. Electrical S •1100 (b)`Estimated Total Cost of
Construction from 6' _..... .. ,_ .__
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) __. .. _... _.,..._.
5. Fire Protection . .. _........,
6. Total=0 +2+3+4+5) ct t Z``, Check Number
This Section For'Official'Use Only
Building Permit Number Date
Issued
Signaature:_
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1159
APPLICANT/CONTACT PERSON GARI BOURASSA
ADDRESS/PHONE P O BOX 821 WESTFIELD01090(413)237-6631
PROPERTY LOCATION 48 ROUND HILL RD
MAP 3 1 B PARCEL 004 001 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1., L,
Fee Paid
Typeof Construction: RENOVATE BATHROOM UNIT#211
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildiny Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
TH FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I RMATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
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.
48 ROUND HILL RD BP-2015-1159
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-1159
Project# JS-2015-002036
Est. Cost: $14400.00
Fee: $240.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GARI BOURASSA
Lot Size(sa.ft.): 311018.40 Owner: HISTORIC ROUND HILL SUMMITT
Zoning: URC(100)/ Applicant: GARI BOURASSA
AT: 48 ROUND HILL RD
Applicant Address: Phone: Insurance:
P O BOX 821 (413) 237-6631
WESTFIELDMA01090 ISSUED ON.512812015 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE BATHROOM UNIT#211
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 5/28/2015 0:00:00 $240.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner