32A-186 (3) �
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WINTERBERRY, LLC
128 Federal Street
Springfield, Ma 01105
Phone: 413.237.5872
Louis Hasbrouck
Building Commissioner
City of Northampton, Ma 01060
I request that you grant a modification to waive the
requirement for construction control of the project at 5
Pomeroy Terr. 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 is considerable when compared to
the cost of the proposed work. Thank you for your
consideration.
Respectfully,
att ampa ari
Winterberry, LLC
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alal&j Ij a CX I e J- e
Office of Consumer Affairs and Business Regulation
0-1 10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 167628
Type: Individual
Expiration: 10/13/2016 Tr# 258813
MATTHEW CAMPAGNARI
MATTHEW CAMPAGNARI
128 FEDERIAL ST
SPRINGFIELD, MA 01105
Update Address and return card.Mark reason for change.
Address Renewal F-1 Employment Lost Card
SCA1 C 20NI-05/11
License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
�- iAOME IMPROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation
ion:
iRegistrati Type:
167628
%t�L Y._' 10 Park Plaza-Suite 5170
Expiration: 10/13/2016 Individual
Boston,MA 02116
MATTHEW CAMPAGNARI
MATTHEW CAMPAGNARI
128 FEDERIAL ST
SPRINGFIELD,MA 01105 Undersecretary Not va i without signature
fit Massachusetts -Department of Public Safety
Board of Budding Reguiations and Standards
License: CS-076047
MATTHEW D CAJOACURI
128 FEDERAL ST
SPRINGFIELD MA Oi 0-100T
ZZI
%, )I 1A Expiration
Commissioner 04116f2017
I
The Conmzonwealth Massachusetts
Department of Indu trialAccidents
— Off ce of Investigations
600 TYashington Street
Boston, MA;02111
www.mass.gpv/dia
Workers' Compensation Insurance Affidavit: Bttilders/Contractors/Electi-icians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): _
Address: �� S
City/State/Zip: D Phone#: 7•
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with � 6. New construction
employees (full and/or part-time).* have hired the s*b-contractors
2.❑ I am a sole proprietor or partner- listed on the attar-hed sheet. 7. ❑ Remodeling
ship and have no employees These sub-contraactors have S. emolition
employees and ave workers'
working for me in any capacity. 9. ❑ Building addition
[No workers' comp.insurance co . insurance]
required.] 5. z4e are a corporation and its 10.❑ Electrical repairs or additions
�.
officers have exercised their 11. Plumbing repairs or additions
I am a homeowner doing all work
right of exemptign per MGL
myself. [No workers' comp. 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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 off,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. 1,52 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 foverage verification.
I do hereby ce tr an penalties of perjury that the iftformation provided above is true and correct.
�� •Z j�/ /
Sit?nature: Date:
Phone#: P.2,37. 7 7�
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
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#:
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Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize ......_._ _ ........ to
act on my behalf, in all ma rs relative to work authorized by this building permit application
Signature of Owner Date
s Own /Authorized
Agent hereby declajthat tatements and infor mation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
n e palties_of perjury...._ ... _ __.... _ _. ...... ___. .. .._.._._
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
... _.. . ....................... .. . __. _ _
Name of License Holder: ../"4A_.�..1 }K ....C .�!1. l�.�?.NlA._Q,�. ..... ..__.. _�J o. _.. L4.._f
License Number
Address Expiration Date
Signatur 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
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Versionl.7 Commercial Builc ing Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICE -FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAININR MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable El.........
Name(Registrant):
Registration Number
Address ~-
Expiration Date
Signature ___., Tel*phone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address f / ~ 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
\ i .... . ..
Signature Tele hone Expiration Date
9.3 General Contractor
......... _......
.,_.........._ ,... ...,..,,__ ... .._ . _..__. _.,�._ _,.... Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
I
Signature Tele hone
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Versionl.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... .....,..: 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 iYEsued for/on the site?
NO DON'T KNOW O 13. S
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds
NO 0 DONT KNOW Q 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
_....................._.._ .,
Needs to be obtained 0 Obtained , Date,,Issued:
C. Do any signs exist on the property? YES NO 0
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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version l.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,' Repajrs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofiing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here (�'t,
Of Proposed Work:
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 ❑ 18 ❑
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 ❑ 5B x
U Utility El 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):1 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)
1
St _.........._.. 1st
nd
nd 2
2 ....... . f_..
.. .
3d 3d /
.
4m
4'h ....... ..... ......._......
...
Total Area(sf) Total Proposed New.Constructon(sf)y
__.... _ .._...._ ....._....
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone_I,nformation: ! 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system❑
I
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Version 1.7 Commercial Building Permit May 15,2000
Department use only.
City of Northampton Status of Permit:
� �� Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
2NIS Room 100 Water/Well Availability
G orthampton, MA 01060 Two Sets of Structural Plans
e 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans
DEr'.0!-.
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
T PQ(MG Map Lot Unit
N Q ZT RP,+M F TO 11, MA o t 66h 0 Zone Overlay District
.. __. _........... . .. ....___... _.._.._ _€ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner,of Record:
Y�t>�Tf FIfG0_ CA C F C�VAR
._t
Name(Print) Current Mailing Address
c
Signature Telephone
2.2 Authorized Agent:
Name(Print) �� �.J Current Mailing Address
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building f p (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 f)'60
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
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File 4 BP-2016-0823
APPLICANT/CONTACT PERSON MATTHEW CAMPAGNARI
ADDRESS/PHONE 128 FEDERAL ST SPRINGFIELD01105 (413)237-5872
PROPERTY LOCATION 5 POMEROY TER
MAP 32A PARCEL 186 001 ZONE URC000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: NON STRUCTURAL INTERIOR DEMOLITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 076047
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
1Cpproved 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
Demolition Delay
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.
5 POMEROY TER BP-2016-0823
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 186 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2016-0823
Project# JS-2016-001392
Est.Cost: $10000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MATTHEW CAMPAGNARI 076047
Lot Size(sq. ft.): 15986.52 Owner: MATTHEW CAMPAGNARI
zoning,: URC(100)/ Applicant: MATTHEW CAMPAGNARI
AT. 5 POMEROY TER
Applicant Address: Phone: Insurance:
128 FEDERAL ST (413) 237-5872
SPRINGFIELDMA01105 ISSUED ON.11412016 0:00:00
TO PERFORM THE FOLLOWING WORK.NON STRUCTURAL INTERIOR DEMOLITION
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 1/4/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner