Loading...
31B-230 (6) Kris Renkowic Carpentry 24 Cross St Florence, Ma 01062 1 request that you grant a modification to waive the requirement for control construction for the installation of four new windows at 64 Gothic St in Northampton because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction when compared to the cost of the proposed work. Thank you for your consideration. "Mass Amendments, section 107.1 allows for an exclusion from control construction for this project" Respectfully, r The Commonwealth of Massachusetts Department of Lidustrial Accidents a Office of Ir vestigations , 600 Washi baton Street Boston,I L4 02111 a www.ma*s.gov/dia Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: a� Cru S S City/State/Zip: f (ac VICe- a. Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer 4. F-1 I am a general contractor and I mP Y er with 6. F-1 New construction employees(full and/or part-time).* have hired tlQe sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.X I am a sole proprietor or partner-� , 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.insuraince.$-- required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions g J.El I am a homeowner doin all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.Q Other^/2U c✓,h S comp.insurance required.] *Any applicant that checks box#1 must also fill outthe section below showingftir 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 nar�e of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workets'comp.policy number. I am an employer that isproviding workers'compensation insurjance for my employees. Below is thepolicy 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 civi,11 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 copyl 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: Date: Phone# Official use onrlr. 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 Clak 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: I Version 1.7 Commercial Building Permit May 15,2000 ,o 4 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 1;1 10i.1-1. Independent Structural Engineering Structural Peer Review Required Yes 0 r No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Re>�Yactit, .� ca�` ..._.___. ., _,.,k, ..__ ._._ _..,.__.. _ ... as Owner of the s7property hereby authorize to act on my behalf, in all matte relative to ork horized b is building permit application. Signature of Owner L t' r - I, ©1�CC - 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 d � w_..-. ._ v�v0...w_._ Print Name m4- Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder �5'�_5. !!� ✓,.� License Number Address , _ Exp ra iot n Date Signature Telephone �KK 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 Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION''SERVIC S-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAININP MARE THAN 35,000 C.F.OF ENCLOSE©SPACE) 9.1 Registered Architect: f' Not Applicable ❑ �._ .. Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility . Address Registration Number Signature Teliephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility i } Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Tel phone Expiration Date 9.3 General Contractor _...... . .. . ...... .._...__.,.__.,. _._ _.._. _.._._. ___._' _.... __ Not Applicable ❑ Company Name: Responsible In Charge of Construction _ .,,r.... _ ....v.._... _,.._. _. _.._.,-_.._ .._._. Address___ _ Signature Tele'hone E Version 1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON,ZONING Existing Proposed Required by Zoning This column to 9-e filled in by Building Department Lot Size Frontage _._ .. ...._ __.._.... _:._.._. _..._...,__.:. _ ...,..._.. ....... ..... _.. . Setbacks Front Side Rear Building Height Bldg. Square Footage _.__...... .__...• % Open,Space Footage _ _ _._ _. % --- (Lot area minus bldg&paved #of Parkin Spaces `._.._. w _ ...._........... Fill: (volume&Location) A. Has a Special Permit/Variance/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 0 YES IF YES: enter Book ' Page _ and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 0 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. k Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAI 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing.Wall Signs ❑ Demolition❑ Reppirs❑ 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: �kc^ov%vl `-08 Sn 'fir ivj 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 ❑ I -_ - 3A ❑� I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 1 1 4 ❑ R Residential ❑ I R-1 ❑ R-2 m R-3 ❑ 5A El S Storage El IS-1 F-1 S-2 ❑ 5B ❑ U Utility F-1 Specify: M Mixed Use ❑ Specify S Special Use ❑ Specify:�rvM COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING OENOVATIO NS,ADDITIONS ANDIOR CHANGE IN USE Existing Use Group. Proposed Use Group: Existing Hazard Index 780 CMR 34) Proposed Hazard Index 780 CMR SECTION 6 BUILDING HEIGHT AND AREA r BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf7 1St St _.._�_�-.,....._.._..�..M._,. nd , 2nd ,.......,_.__ � 2 3rd 3rd 4th 4m Total Area(so Total Proposed New,Construct on s 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 E] Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[] k a Versionl.7 Commercial Building Permit May 15,2000 Departtne t use an1Y City of Northampton Status of Pen►t� g �1 Building Department Curb Gt,t/Q 6w,ay, Perrxtt 212 Main Street NOV 2 Room 100 WaWAW ll Avalla lfity 1 Y x 4 CnQj 1 rthampton, MA 01060 T+ t gofi'uuctutaPlas ° `: , pho e 4 3-587-1240 fax 413-587-1272 PIaUSi#e Plans -=� .�,,P, Other Specify APPLICATION TO R CT,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 Map Lot Unit e� N\o YN '��1��CYl(��C c-.c�`C�- C G d Zone Overlay District u- .a� M _ _ w. .i Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address:©1QQt� Signature Telephone 1203 ,.53— <j-S7 2.2 Authorized Agent: Name(Print) Current Mailing dress " 6�, ©Lem /I S5 Iv.i r'ec --IT Signature,C- c Telephone S// 5 SECTION 3`-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building M (a)'Building'Permit;.Fee 00 on 2. Electrical " (b);Estimated Total Cost of Construction from 6 _ _.... .... ..... 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection _... _. . ... ,,.v.__.... 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0724 APPLICANT/CONTACT PERSON KRIS RENKOWIC ADDRESSIPHONE 24 CROSS ST FLORENCE ,01062(413)455-8838 PROPERTY LOCATION 64 GOTHIC ST MAP 31B PARCEL 230 000 ZONE CB(100)/ 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: INSTALL 4 REAR REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108864 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO$MATION 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 1' 'on Delay ature o uil ing 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. 64 GOTHIC ST BP-2016-0724 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B -230 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP-2016-0724 Project# JS-2016-001214 Est. Cost: $5000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KRIS RENKOWIC 108864 Lot Size(sa.ft.): Owner: GOTHIC STREET CONDOMINIUM TRUST Zoning: CB(100)/ Applicant: KRIS RENKOWIC AT. 64 GOTHIC ST Applicant Address: Phone: Insurance: 24 CROSS ST (413) 455-8838 FLORENCE ,MA01062 ISSUED ON.1113012015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 4 REAR REPLACEMENT WINDOWS 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 11/30/2015 0:00:00 $100.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner