17C-214 (18) ¢1ll/J-f P",
Rio � 0yti C!%if of �\To fljallt}lfoil
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S
DEPARTMENT OP BUILDING INSPEC1-101JS
Hia
212 Main Strcct ' Municipal Buddint,
Northampton, ?Hass. 01060
V,'OR.ICEWS COi\U ENSATION INSU_ ANCF AF'F11MV_T
(IJC scIl cJ(Y_iT131ttCc>
\Vlt11 a PI-mcipa1 pal"at-- ofbusiuess/residenc, at /f /y� �/ / y
11.1 (StTc--t/citf/natcIzip)
do hereby certify, under the pains sad pen'-hies of perjury, x_112!
( ) I gun an employe: providing the rollow11w wolkcf's colnotns_::Jon (or Iny
errlployccs wol_�ang on uhis job
---- (ljis)]_ ^C:� L.ot cI-Ev) -- -- (PcAic NLL' ,]bcij
( ) I am a sole propnetor, general contractor or horleovY-ner (tacit one) and L e hired
the consactors listed below who Ilave the foLlovrine •,vorkc�s coy��Der va orl uo'ucles�
(Namc 0. Con,,..!Clo:)
(Na Inc of Coutrzc,cr) --- Oi s-,lr-ancc ComDau""/Potic-" Numcsr) (—Ex-o,_m.;!o n Date)
(Name of Cownclor) (Insuranc Comp2-o)-/Police N;urbJ) (Expirrioo Datc)
(Nafflc of C0rt11c-,G0 (In uran Comr 17}�/I olio Nu17��t) (L��;u�tion Datc)
to�:>:_'wl-uifo(L-�i_i oc:f.•.3-tzvz:i;F to.11
,� I a1� a sole proprietor and have no one woi kdj)g for ❑1e-
( ) I am a hone owner performing all the wor k myself.
1401-E:plc Lr cw-act+,,. Jc bcaro„�_n Ibo cmplay pc:o to dD t�jZj ^ of
acx 2�o(c U,-;Larr uni'u in„iu:cb tb> lronrXn,vcr r�d�of oa the �uy!r zi- „,-rt�-rL.r'tbc-�..n c.-c r:x C�:Dv ccc.d_cd w[i
_Vlayc}ua Lx„ai d;c�_ ticct Act(GL152_-1(5)} zWGp _ocn try fcr c Lr ,_a pzrnu I c-,&mcc Lbc
1<g.1 0--*'-of cn cz�Ploy� undo-r do Wc,k_o (Cow al-ipa Ai_
1 underrtnnd t-e>copy of(b-z�m.y b-foc-w.ird.od to tbo of Icw viol At &__Jy Of -of I,-�fo(dx
oovm&c vrrifictioo aid th-1 w taurc-%-C�uridc scctioa 25 A of MGL 152 m foal to tba i.^q>-2ioa of t---i-t'n,l pcn-.Lka
.. oomittis of a floc of up to S 1,300 00 e N- of up to otx year c.�d o,il p�.,t;ia in t`.x f(,,of o Stop W o(k Order end o
rim o(S 100.00.da y t ea n x ar_
P
crini t N tun bcr
00("t—Az
----- 2� G Imol^
Sifnaturc of LIccj)_-c&PccIm1tcc -- 3Ce
f
` Version 1.7 Commercial Building Permit May 15,2000
SEC7ION;10-STRUCTURAL PEER REVIEW(7'$0 CMR 110:11)
dependent Structural Engineering Structural Peer Review Required Yes......❑ No.....16
SECTION!11-OWNER AUTHORIZATION -7013E COMPLETED WHEN
OWNERS°''AGENT OR CONTRACTORAPPLIESr FOR BUILDING PERMIT
'Dili Ace)(61,410k as Owner of the subject property
her 'by auth --� tK GZ`f'�G�''Y to act on
ml I matter i rk authorized by this building permit application.
Signature of Owner Date
.��
I ^�� Lt,�G _, 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 : --^��/C� ���L��x
05--Z "
,A,� License Number
Address , Expiration D to
Signature Telephone
SEC71C1N,1S:WORKERS',COMPEN"SATICN INSURANCE AFFIDAVIT(M.+G.L. c.152,§ SC(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...... ❑
f
` Version 1.7 Commercial Building Permit May 15,2000
S IQ 1, 9 PROFES,SI0WAL QESIGU AND'CONSTRtICTION'SERVICES -FOR,BUILDINGS AND STRUCTURES SUBJECT TO
C NS"t JC' ON G 3NTRCL PtJR I1ANT�t(�7 3t> CNII�R 116{CONTAINING M S IE THAN. S;�1C} C. , OF'ENDLfi3 l l Ph"t
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
nature 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
-- �4�'Z St ' Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Tb. HL11Y77 67-04
dress
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:
blic ❑ Private ❑ Zone: Outside Flood Zone Municipal X On 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
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 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: fi'm% of 'm-s-7,urmcr
D. Areithere 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
CE
S' TI N'�4»CONStRtlCfIC?N-SERVIS FOR PROJECTS LESS THAN 35,000
IC"FEET Off' CLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
°�� �!�'6°I�,l� �i � ��►S��db .� C.°9^d'�" �ECc.�.� i�'z3Frn�'� fN �'i��ts'�`.�' 4�
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 ❑
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:
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):
SECTI01 5 Bi 1 RING HEIGHT AND AREA,
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION �� s old ,N
w
Floor Area per Floor(sf) 1St /s k' '
AN
f
F
2nd f
1st Ni ' v
rd
AS-
2nd 3 �
4 th
3rd �F
4 th
H Y�
:/ 1p' SY ylf / E
Total Area (sf) Total Proposed New Construction (sf)
' i xw
y 2
............................ /.
_ 1 a
Total Height(ft) �' w
Total Height ft -------------------
oj,.
Versionl.7 Commercial Building Permit May 15,2000
x, ity�of rthampton
Z.�3 B '� partment
0
ain Street
Room 100
orthampton, MA 01060
r
one 413-587-1240 Fax 413-587-1272
s-
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 INFORMATI ON
This se i tt t beorh}l�ke` , I
1.1 Property Address: ,
Sxcc Nlap Lot
clay Digtri' 3
RoREIgCr' �l
..
elm
SECTi,'. N.2-PROPERTY OWNERSHIP/AUTHO,RIZED:AGENT
2.1 Owner of Record:
7
Nam (Print Current Mailing Address:
Sig ature Telephone
2.2 Authorized Agent:
441,
Name(Print) Current Mailing Address:
Signature Telephone
SECTION - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. &d0d#rg Fc6 Cl� (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
T:his.Section Fur Official Use Only
B uild.ing:;PermitNumber: Date Issued:
Signature:
Building Qommissiopep°/1nsppctor l3uitdings Date
99 MAIN ST BP-2001-0089
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-214 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_roofing BUILDING PERMIT
Permit# BP-2001-0089
Project# JS-2001-0140
Est.Cost:$3600.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: Jack Walton Construction 052591
Lot Size(sq.ft.): 18 120.96 Owner: ALEXANDER MAURICE&PAULINE F
Zoning:GB Applicant: Jack Walton Construction
AT. 99 MAIN ST
Applicant Address: Phone: Insurance:
130 County Road (413) 667-3358
HUNTINGTONMA01050-9727 ISSUED ON.7125100 0:00:00
TO PERFORM THE FOLLOWING WORK.-COVER EXISTING ROLLED ROOFING
W/RUBBER ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 7/25/00 0:00:00 1843 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo