24A-042 (3) Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL,PEER REVIEW(780i`CMR110.11,)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION-':TO::.BE.COMPLETED..WHEN
OWNERS AGENT OR CONTRACTOR:APPLIE,S:FOk BUILDING PERMIT
................. the subject property
hereby authorize A-A
Lill to
6 ) - -
�Mhalf, in all matters relative to work authorized by this building permit application
T
Ilijnzrt�re of 0 n Date
a �n /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
an belief.
Sig ms and penalties of Pe
..........
Print ame
V-1
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Ad s Expiration Date
SY nYure Telephone
SECTION 13-WORKERS.I COMPENSATION i.INSURANCE;AFFIDAVIT(MIG6L.:!c.1 62j§i 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.
Signed Affidavit Attached Yes 0 No 0
The Commonwealth of Massachusetts
Department oflndustrialAccidents
-- 3
u Office of Investigations
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): (,i k6V IN Sbyr - OM11)6 %rZ
Address: CN, L"' . q Wl ST
City/State/Zip: r-A k- 616 Phone#: Lk P7> 3 4-AiS S
Are you an employer?CheckAhe appropriate box: Type of project(required):
1.❑ I am a.employer with 4. E] I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp. insurance.$
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 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
employees. [No workers' 13.0 Other
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 name 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. f
Insurance Company Name: 'fLlti \�
Policy#or Self-ins.Lic.#: j�j ��1�j` � Z. Expiration Date: S 16
�,..
Job Site Address: A City/State/Zip: Pbfi6q
Attach a copy of the workers' compensation policy declaration page(showing the policy number and a iration 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 thepains and4enylties of perjury that the information provided above is true and correct.
Siizna ture: Date: N�
Phone#: ,
F e only. Do not write in this area, to be completed by city or town officiaL
wn: Permit/License thority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 CMR116(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
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
_, Go••rig _4 o Y `l SO.
Address Registration Number
. nature Telephone Expiration Date
i
_.. .
Name Area of Responsibility
i
3
Address Rqistration Number
Signature Telephone Expiration Date
}
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
......... _ .._.............._. .. .. _.._ _... .,.__._W..................__-........,,...
._...._....._.._ _..__.. .._..__.
Name Area of Responsibility
i
Address Registration Number
Signature Telephone I Expiration Date
9.g-Zeneral Contractor
('\ 1u Not Applicable ❑
Company Name:
Responsible in Charge of Construction
_.
dd
r _
S ature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to 6e filled in by
Building Department
LotSize _,.._._ "_, .. _ _ ._. .__._:".• . ,.,,, _ I __ . ..,,. • _ ._._,_., _._._.
Frontage _ , _.._._.,,_ _•,•._„•.x ... _,._. M_. .....__. . ..._.; .:,.. , _ _ ._.. ._ .
Setbacks Front
Side L R.:. .__"_ L . _.. R: .
Rear i
Building Height ....... "
Bldg. Square Footage % "
Open Space Footage _ , %
, w-x
- -- (Lot area minus bldg&paved
parking)
#of Parking Spaces ' •• €_ i.
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
=LF,YES, date issued: � �"_.•.._..,__.�_...,_
IF YES: Was the permit recorded at the Registry of Deeds?
NO C DONT KNOW 0 YES 0
IF YES: enter Book ' Page. and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C 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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 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 35,000
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-11 N Q,,\ m 1
SECTION 5-USE GROUP AND:CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ 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 Cl - - 3A ❑
Institutional ❑ 1-1 ❑ 1-2 Cl 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:�'___w,...._........��_..._.._�_.._...._..�........,w,T _...-.__..._ � W._. ._. ,
S Special Use El 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 '.
2nd
....._.-..........__.. ......_.__.,._...�.__._._..�._,.
_..... . __ _.... __.. .. 3rd
3rd
4th , I 4th 1
Total Area (so Total Proposed New Construction(sf)
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[]
0 Versionl.7 Commercial Building Permit May 15 2000
D�parfine"t useFort}�
ity of Northampton Status o1 Penn►t ...
r '
x �
ilding Department Curb C"ut/DhV,6 /Pep'mt� '
lions 212 Main Street Sewer/SepbaA0iI`abt[ity
ROOM 100 Water/Well Avatlability� ;
Northampton, MA 01060 Two'Sets of StructurahPIans
phone 413-587-1240 Fax 413-587-1272 Plot/Ste Plans
Outer 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
�
,tCIL&r�
� t Map Lot Unit
0 ,t 6 � � Zone Overlay District
- Oc �W►� i Elm'St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) yj Current Mailing Address
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Q )y4j k/,Y, S- - %
Signature �H Telephone
SECTION 3-€STIMATED CONSTRUCTION!COSTS'
Item Estimated Cost(Dollars)to be Official Use.Only
completed by e.rmit applicant
-
1. Building (a)Building'Permit:Fee
2. Electrical (b)Estimated Total.Cost of
Construction from 6 _.._._...,
3. Plumbing i Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number ��
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0373
APPLICANT/CONTACT PERSON NORTHAMPTON CITY OF JACKSON STREET SCHOOL
ADDRESS/PHONE 120 JACKSON ST NORTHAMPTON01060
PROPERTY LOCATION 120 JACKSON ST
MAP 24A PARCEL 042 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out U rr
Fee Paid
Typeof Construction: CONSTRUCT NEW CONCRETE LANDINGS&RAMP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 013977
3 sets of Plans/Plot Plan - /.►''(
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF, QANATION 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
Volition Delay
Si ure of Bui din fficial 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.
120 JACKSON ST BP-2016-0373
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-042 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-2016-0373
Project# JS-2016-000607
Est. Cost: $43000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GALVIN & SONS MASONRY 013977
Lot Size(sg. 8.): 274428.00 Owner: NORTHAMPTON CITY OF JACKSON STREET SCHOOL
Zoning.URB(100)/ Applicant: NORTHAMPTON CITY OF JACKSON STREET SCHOOL
AT: 120 JACKSON ST
Applicant Address: Phone: Insurance:
120 JACKSON ST WC
NORTHAMPTON MAO 1060 ISSUED ON:912512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT NEW CONCRETE LANDINGS &
RAMP
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 9/25/2015 0:00:00 $0.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner