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24B-034 (3) Page No. of Pages PROPOSAL SUBMITTED T PHONE DATE STREET JOB N CITY,STATE and ZIP C DE 1 JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: o t 1-�•° C,6 �✓ J� G-G y�'J` S�v�24 [31- A '��fG�l// G✓(L!/'+'1 s /r'7 r`i''�'1� (,�. �`J c'/s�/7�/�� cal/ �fr�� 5 t� `� �i�'/�'-"�/l� sRa5,;:5 P'2,ep Inc 1. 1 i CG I:creby to fUi'ni8i paterial and labor —Complete in vJl'h above specifications, for the SUITI Of: ejU rl i� !ll `—, cJH �i2G<'----- — dollars($ Payment to be mad as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature r charge over and above the estimate. All agreements contingent upon strikes, accidents Note:This r posal maybe or delays beyond our control.Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if n ccepted within days. / fa�n rreptance of Proposal —The above prices,specifications d conditions are satisfactory and are hereby accepted. You are authorized Signature do the work as specified. Payment will b made as outlined above. Date of Acceptance: ` Signa L " The Commonwealth of Massachusetts + Department of Industrial Accidents 7. 7z Y Office of Investigations - 600 Nl'ashingtorz Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeaibIv Name (Business/Organization/Individual): GcJVYI/f)V5 !l" S �t (/C 4z`•v Address: ,2G� City/State/Zip: a Q r©,6 G Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 7 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. 0 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.❑ Electrical repairs or additions q ] 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.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. r 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. 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 perju7y that the information provided above is true and correct. Sienature: Date: Phone#: Of use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# I Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Yin _ . . �Poe as Owner of the subject property .,...,._. ........ .... ..,,..., ....... `..... n ..._ hereby authorize � � - � � �►c. .. _. __ to act on 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.perlqY.... __ Print Na e Signature of Owne ent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor Not Applicable ❑ _....... .. VVI Name of License Holder: ..... _...LV. .. ... ._...... License Number Address Expiration 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. Signed Affidavit Attached Yes 0 No 0 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 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 9.2 Registered Professional Engineer(s): Name Area of Responsibifity 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 I Expiration Date 9.3 General Contractor _.. . ...._., _. .._. ..:._ ., ...... Not Applicable ❑ Company Name: Responsible In Charge of Construction _._........ _ ... ...... ....... Address Signature Telephone i I Version 1.7 Commercial Building Permit May 15,2000 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:----,-- 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 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regist f Deeds? NO 0 DONT KNOW 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 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES I—A NO IF YES, describe size, type and locationr`� D. Are there any proposed changes to or additions of signs intended for the pro erty? 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 ``°`~ ••,W.,..."•.•.,.r..,: .,,, Y SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Acce .413uilding❑ ..` Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing , Change of Use❑ Othet❑ Brief Description Enter a brief description here. Of Proposed Work:.. CO it w O V L re ___.. 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 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I 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 ❑ 58 ❑ 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) Ist 2nd .._ 2nd .__ _.... ................._ .._................ ..........._.._..._. . ....... _... .._.__.. ..._..... 3rd 3rd 4m .. __._ .._.. .r._.M 4 th Total Area (sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft .._ 7.Water Supply(M.G.L.c.40, §54) 7.1 Flood'% Information: 7.3 Sewage Disposal System: Public Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑ i I - ' Versionl.7 Commercial Building Permit May 15,2000 RECE1 L) Department use only it of Northampton Status of Permit: + 6 2�� uil in Department Curb Cut/Driveway Permit - OCT 2 Main Street Sewer/Septic Availability oom 100 Water/Well Availability eAUOr+Q01 ha pton, MA 01060 Two Sets of Structural,Plans e - 7-1240 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 1.1 Property Address: This section to be completed by office L ��,V 1� S i Map Lot Unit Zone Overlay District .......... _ ___...._. .-._......... ._... ._......_..._ .__..._.. ._ . Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: K7 Name Name(Print) Current Mailing Address oldba Signature Telephone — // ) 2.2 Authorized Agent: .6-9.7 �.n . -�... ... C� ,/- ' Name(Print) Current Mailing Address Signature Telephone SECTION 3-E MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be /Q eo Official Use Only completed by ermit applicant �G 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) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date 324 KING ST-STORAGE BUILDING BP-2016-0515 GIs#: COMMONWEALTH OF MASSACHUSETTS M R Block:24B-034 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2016-0515 Project# JS-2016-000859 Est.Cost:$10500.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: CYRUS NEWMAN 064690 Lot Size(sq.1): 87991.20 Owner: BLUEBONNET LLC Zoning: HB(100)/ Applicant: CYRUS NEWMAN AT. 324 KING ST - STORAGE BUILDING Applicant Address: Phone: Insurance: 697 Bridge Road (413), 586-1093 NORTHAMPTONMA01060 ISSUED ON:1011612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER - STORAGE BUILDING 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 10/16/2015 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner