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38-050 (5) TravelersPropertyCasu alt y ` 01140 -AM A-.Travr["Group rN\ 1000 LEGION PLACE ORLANDO FL 32801 CITY OF NORTHAMPTON DEPT OF BLDG AND INSPECTION 212 MAIN STREET NORTHAMPTON MA 01060 ACORD CERTIFICATE OF INSURANCE (On Reverse) x0411:11. C E RT II CAT E OF INSURANCE ! DATE(MNI\°D\Y1O __ .. .... 04-08-03 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE IRM INS AGCY INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO BOX 564 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EAST LONGMEADOW MA 01028 COMPANIES AFFORDING COVERAGE COMPANY 29MDM A THE TRAVELERS INDEMNITY COMPANY INSURED COMPANY COTTON, JOHN DBA B J W COTTON COMPANY PO BOX 921 NORTHAMPTON MA 01061 C COMPANY D COVERAM THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM\DD\YY) DATE(MM\DD\YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE=OCCUR. PERSONAL&ADV.INJURY $ OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per Accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-E4 ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ J — AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM A WORKER'S COMPENSATION AND STATUTORY LIMITS EMPLOYER'S LIABILITY (UB-973X409-7-02) 11-26-02 1 1—26-03 EACH ACCIDENT $ 500,000 THE PROPRIETOR/ NCL DISEASE—POLICY LIMIT $ 500,000 PARTNERS/EXECUTIVE OFFICERS ARE: L X I EXCL DISEASE—EACH EMPLOYEE g 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. C£RTIfICAT£H4LD£R CANCI"I kATION .... ... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL CITY OF NORTHAMPTON 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE DEPT OF BLDG AND INSPECTION LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR 2 1 2 MAIN STREET LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE ACf�RD 2S-$(3193] t� CARD COFCPORAI ION 1993 sz�;; MASSDEVELOPMENT Western Massachusetts Regional Office: April 1, 2003 1441 Ma-Street Springfield,Massachusetts C1103 Tel 4 3-T I-88 8 To Whom it may Concern: � Fax:4 3-755-1349 Cotello Dismantling is under contract to MassDevelopment for the demolition of house 31 at the State Hospital property in Northampton. Main Office: Please consider this letter as authorizing them to obtain all permits 75 Federal Street eoston Massachusetts necessary for the removal of this building. 0211C LL617-33C-2000 800-445-80 0 Sine Fax 617-330-200' Vincent Clerk of the Works, MassDevelopment co>e—n A; L C�: Ho(,,:, p,esicenNt-t0 - The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Mental Health 41M Svey`r Western Massachusetts Area P.O. Box 389 Northampton, Massachusetts 01061-0389 MITT ROMNEY Governor KERRY HEALEY Lieutenant Governor RONALD PRESTON TEL: (413)587-6200 Secretary TTY: (413)586-6592 KEN DUCKWORTH,M.D. FAX: (413)587-6205 Interim Commissioner Toll Free: 1-888-967-6622 ELIZABETH SULLIVAN www.state.ma.us/dmh Area Director April 1, 2003 To Whom It May Concern: I David Englehardt terminated the water line t o House 31 in October of 1993 due to the closing of Northampton State Hospital. David Englehardt Plumber/Steamfitter/Foreman CITY OF NORTHAMPTON, MASSACHUSETTS DEPARTMENT OF PUBLIC WORKS 125 LOCUST STREET NORTHAMPTON, MA 01060 a 413-587-1570 FAX 413-587-1576 George Andrikidis, P.E. Director,City Engineer March 31, 2003 � 4 Anthony Patillo, Building Inspector Municipal Office Annex 212 Main Street Northampton, Ma 01060 Dear Mr. Patillo: According to the Water Department records the water service to house#181 Prince Street (Building#31 State Hospital) was cut off at the main in the street June 10`", 1929. It is possible that this building was reconnected within State Hospital layout. It is our recommendation that the demolition contractor contact maintenance personal at the State Hospital to confirm any connections within Hospital property have been disconnected. Please contact me if you have any questions. Sinc Charles Borowski Superintendent of Water CB/dws Cc: George Andrikidis, Director of Public Works Ned Huntely, Assistant City Engineer MAR 31 2003 1 :06 PM FR TO 95871272 F.01 /01 Massachusetts Electric A Nallona)Grid Company o, nnn i March 31, 2003 Robert Holmes 2 Rocky timer Street Middleboro,MA 02346 Dear Mr.Holmes: This is t6 verify that Massaeht:setts Eleetrie Company removed the eleetti�service and meter at Building 31 at the former Northampton State Hospital grounds off Route 66 in Northampton, Massachusetts effective March 31,2003 for budding demolition Sincerely, Peter 1.Normandin Supervisor Operafions Overhead Lines cc: Tony Patillo,Buildiug.lnspeaor,City of Northampton PIN/jt PO Box 507 Northampton,MA 01061-0507 413.582.7200 ** Tt1TAL PAGE .01 ** 03/31/2003 12:50 14137327393 BAYSTATE GAS PAGE bl/01 r March 31,2003 Bob Holmes Mr. Holmes: RieWdhg Building 31, the Northampton State Hospital in Northamptorr, Mass, there is no gas at this property per our technician Rick Ross. Sincereiy, Terri Miner 03/27/2003 10:10 5089473093 COSTELLO DISMANTLING PAGE 03 83/25/2883 13:58 7917486369 W&T INSLIRANCE CERTIFICATE OF LIABILITY INSURANC +a!t os a mriT 7f . Conat nation D:.t. ONLY AND CONFAB NO RKWM t1PON TH9 cocrWICATE Construct*ors Division HOLDER THIS CMMFICAM OM NO7AIIIII01D.E rnWI OR 275 Darby Street 040 ALIM THE GOV■RAOE APPORDED BY THE POLICIES b[IMW HiJngh" HK 02043 Phase:791-740-6300 IN$I!�AFFORDING COKlRAOE N u mm a Vnited National Sasuranm Co. asotscilo�D� tia�tCa>�say, aa wyme, mmmzimn Iaternationsl Co. Middi Coro to 0 342 "cu"m D.- Casowrca Iasuree e cOVF.R14O6g THE PMX:WS OR IWUMV#C.R LLSTED MJMV KWI BEEN IMMI TO ng WURO NANEO ANOVC FOR THE POLICY PF.9100 WCATED,n1 rAffWANW4 ANY REQ%JWAMW.TIO N OR CON1mpa OF AMT C WRACY OR OrWM OocLW WT WITH REPECT To MMICH THIS CIRTFICATE MAY BE=UGp OR mAY VSRTAK rNE NK AANCCAfFORDMO K roc ocKioFg oaecPAEO mEmn M BuRJiCr TO ALL 7m TmPA 80AAw0NQ AND OONDRIMA OF SUCH POLIMS.AGGREGATE LINKS SHOWA MAY HAVE SEW REDUCED BY PAD CLAMS. LW rt"or INSURAW-9 FAY LRSITS OSNERAL UAMUTY SACH OCCURREIfCE S1,000,000 A x COMMERCMLOEIERALuAmmur 0=927202 12/06/02 12/06/03 FIREDANAGe(* owflm 13100,000 CLAMS MADE aX ocoAl MED GXP Ww arm pommy 3 10 000 ` X1 Pollutiou Iiab. PERSOMAL&A&4MLIURY fl 000 000 6&AVALAG0012OAT! s2,000,000 SEW AGGREGATE L"T APPLIES PNIC ram rd.CawA2r AQQ s 2 000 000 FOUCY Loa AUTOMOBILE LIABILITY R�OIE uflrl s I,000,000 D X A1wwtQ '1'8D 03/25j03 03/25/04 X ALL OWNED AUTOS 8001I.Y 3r.RRtY X 9CHWVLrMAUTCS IP-PWwn) f A NIR60Am& OOOLYINJURY R NON-0WED AM$ �' s PROPERTY DAWAM : IPw�oasN GARAGE UAMUTV I A=ONLY-EA ACCIDENT 3 ANY ALMO 1 pp��R EAAGC S AutOON�Y� AGO S OCfSSLIABILTIY _ EACH OCCURREACK 310,0004000 B OCCUR C CIA*amADE tlWIMS 12/06/02 12/06/03 AGVEdATR S10,000"000 s PEDUCTeIe s RETENTION s S WWMW CONP151SA IN ANC C WFLOYLWLIA urf MC2910171 11/05/02 7.1/05/03 F-L.EACHACCDENr 12500000 DISEASE-EAarPLOY2 3500000 6L,DISEASE-PMICV LN!t 500000 OL or OYiRA 11pN,yLOGA mms ADDED by a1OOR$EMaYTISPECIAL►1eDM9SIONS Dismantixnq and aealolitiQx% CERTIFICATE HOLDER ? ADDmoMAI INURED;mumm Lgwft CAN CuATION SHOUTA ANY OF 71111 ADO"DE9Cr4M POLICIn BE CAMGZII.� THE wmTIC OAY9 TM�OF,THE ISSINNO WILL SNOP�►YOR 10 NAIL 34_DAYS w>:m11N NOm 7n 71IB c8RI1RcATE HOLDER NAMED TD rw LEFT swr rmLIIIN TO DO sO SHALL For Informational Purposes Only W'C)SRNooeLQA7MaILI4f l7yorANYVJN*UPQNT"EINSu RQL IIS AGfNTSQR 1MDA7OJEMA71YHS. ATPM ACORa 7.s.5 ICACORD CORIIORATION 1S9A IIIIIIk- 03/2712003 10:,1.0 5089473093 — COSTELLO DISMANTLING PAGE 02 The Comonon wealth of MaSS9Ch USetts Departmnt of Industrial Accidents I awn S 600 Washington Street /i Boston,Mass 02111 Workers'Compenmtion Insurance A[fidavit name' BUILDING #31 location. NORTHAMPTON STATE HOSPITAL city NORTHAMPTON, MASS phone// 0 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. eompayname: COSTELLO DISMANTLING CO. , INC. addrela: 2 ROCKY GUTTER STREET CJJx. _MIDDLEBORO MASSACHUSETTS 02346 one#: 508 946-0880 insurance cn. AMERICAN INTERNATIONAL CO. nolievlt wc2910171 [] I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensarion polices: company-namS: addrsss- city phone on inSU gee_co, policy# company name: address; city. phone fi insurance co. nolEgy M _ Failure to secure coverage as required under Section 25A orMCL 1S2 can lead to the imposition or criminal penalties of a fine up to SI SOO.00 and/or One yearn imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a ring orsioll.00 4 day against me. 1 understand that a COPY 00 1115 statement may be forwarded to the Once of Investigations of the DIA for coverage verification. 1 do hereby ceryi the psi that the information provided above is true and correct Signature Date 3/o�7f43 Print name DANIEL T. COSTELLO \ Phone# 508 946-0880 olTieiat use only do not write in this area to be completed by city or town official city ar town: permitRlcense A i-lBuilding Department f C3LicenslnR Board C check if immediate response is required [)selecttnen•3 Office oHealth Department contact person: phone#: pother IMrkwd 795►1A> -CtiAArP�. C�iz# i of Nar;tljumptan , � � J�ta55ACltllB[tt8 jo - 5? DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street 9 Municipal Building \4 ¢ Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as !,is/her construction sup _ .*:sor. T he state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or hvo family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location .'O C a (rziu of rLiart 1allIPfnll ( _ B �S�i1E AChl16 C(1E =r F DEPARTMLNT OP LUILDP1 G INS PE'UI'ION'S — 212 Train Street ' Municipal BBuildinj, Northampton, Mnss. 0160 NVORIcLER'S COMPENSATION INSURANCE AFFIDAVIT - - ----------- (]i�nsczJ'��:rinittcc) with a principal place of businesshesidence ar. do hereby cuthy, 1111 ui Tu i,);,!ilS ;',Iiu pullai les of yinf1Unn i:Lti_ I am an einploy cr provkhng the IoHov✓II g %yoAcKs colllpC!1SaU")i1 COVC:�L's,C for in), clnployccs, walk lls." oil 1111$job) (La- `dS1G. Company) 1+ O:1C1�t11II1�C i� (�'�:r�'f::110(1 DmL) O I and a sole proonetor .general contractor or homeowner (circle onel and 'Have hued the contractors Red bdov nvho have the workers CO[P.i7eI1S2i'.OIl )Cl1C':eS (Name of Amami ousumncc Comcaal, 'olic; Nu�nb�;) -- -11 :�:;�:;��,;�:� : Date)- -.— - _ --- — - - - — '111O of Conga::y/P(-,, C, 'Nui-ii:,rf) (11tamc of Coni-mclor) {Ins�rallc� Comp2n}vPol;cy Num�r�r) Datc) (Name of Conliuctor) (IIISZ cane Como:_fly/Pohcy Numbs) .tia,: Date) (^fli.St td�t;;mi1 c7xct t.._-_.. _ _., ..�-.�.� .. .r:r:i:�:�- ,a luinF,'..,eli.,-C.:n Vic:•) i ( I auil it ,,Qlc pi op! 71:1;1 llave no oIle %vorki""", tol -me. .) I Gill i! llOIlle OA�;ilC.: !)C1or]i�lIl� all i!le. �'✓O',i: ili''rS:',lf. not:nCYC thrn diruo I!lilts CK-cxI t. c�tploy��v.�cr t}r_tv.:1_ri o.;:e_°.�tiar�t:(GL15o�s 1(S)l.zl lica;ic::by n homoo,N rr for e UPI ctanrc of an Mpwycc un.!c t::o Wa4cr Corn;xrLZitio t/ L I WA"amd On i arry of alh ct.0 w:t a:xy bo for�'—d-i to tl>o for tIw oovr rcgc vcrificaiioo and tllat f-ilurc to S_t7LTC coy'CT aSo uv--r section 2 5 A cd MO 1,152 can lad to tho iiiii mitim of ri:nm�l pct:slt:cs comr tmg of a frnc of up to S 1.500.00 aa"'cr of up to C'r. nag civil p> ltia in tic fixIn of n firIc o(S 100M E dsy i r.in l t r Fur Wtir"W u-—1) Pcrrnit Tlumtr�r ___ I - - - - I Signature of i IT ' ,c:J1 c n t.cc SECTION 8-=hCON$TRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number r Address Expiration Date Signature Telephone �9" ReisteredFiime mprbuement Con actor _ Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellinys of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780 Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work to-which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION�5 DESCRIPTION OF3 PROPOSED WORK(6h6ek4all applicable) .TI W New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolitions New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: // Pim,2Ls5; .5eote,-7 JfQie Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ sa If New house antl or addition°fo�ezi'sting Fiousrng .con p16te thi.f61I'win ; a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves_ Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? _Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? _ Yes _ No . I. Septic Tank City Sewer Private well City water Supply SECTION;7a OWNERAUTHORIZATION-TOBECOMPLETED WHEN OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT l as Owner of the subject property hereby authorize cUS76(-i0 611a+,q (C"'fah'v 'v to act on my behalf, in all matters relative to work authorized by this building perrAt 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 perjury. Print Name Signature of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION 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 Zv Fi Bldg. Square Footage Itoc,sg % Sr. .3_ Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location) 500 Lv 4,t A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW �� YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW '/0 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: D. Are there any proposed changes to or additions of signs intended for the property ?YES Nom IF--YES, describe size, type and location: City of Northampton Building Department C. r 212 Main Street e rlSe s I. Room 100 Wa er We va Northampton, MA 01060 ph7ode 4f -587-1240 Fax 413-587-1272 PIo Sete p a . Qv Y .. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION T is secttontobecompleted�by_office 1.1 Property Address: E � Map Lot 'a "Unit 11/L71A.�110Zvv (f17r f/05�'?��9L _ Y ry Zone- Overlay District Elm St. District „ CB Disfr�ct SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ass 43 ��,�,�,� U�s�.� 5��. ��vd c�s AM Name(Print) Current MailinP�Address: 01132 _ qW. 332. Telephone Signature 2.2 Authorized Agent: 91A5) &ye Name(Print) Current Mailing Address: `f 3 Y 4; 34c,> Signature Telephone SECTION'S - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only .completed by ermit applicant I. Building (a) Building Permit Fee 2 Elecirical (b) E stimated Total Cost of _ Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (l + 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-2003-0804 APPLICANT/CONTACT PERSON COSTELLO DISMANTLING CO INC ADDRESS/PHONE 2 ROCKY GUTTER ST (508)946-0880 PROPERTY LOCATION BLDG#31 - 181 PRINCE ST MAP 38 PARCEL 050 001 ZONE PV THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinsz Permit Filled out Fee Paid Typeof Construction: DEMOLISH PRINCIPAL BUILDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildinp,Plans Included• Owner/Statement or License 043330 3 sets of Plans/Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IT AT ION 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 Commis si r 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. BP-2003-0804 GIS#: COMMONWEALTH OF MASSACHUSETTS momalm - CITY OF NORTHAMPTON - . Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0804 Project# JS-2003-1320 Est.Cost: $51300.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: COSTELLO DISMANTLING CO INC 043330 Lot Size(sq.ft.): 2265 12.00 Owner: NORTHAMPTON STATE HOSPITAL Zoning:PV_ Applicant. DISMANTLING CO INC AT. BLDG #31 - 181 PRINCE ST Applicant Address: Phone: Insurance: 2 ROCKY GUTTER ST (508) 946-0880 Workers Compensation MIDDLEBOROMA02346 ISSUED ON:413103 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMOLISH PRINCIPAL 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• Receipt No: Date Paid: Check No: Amount: Building 4/3/03 0:00:00 44771 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo