18-005 (11) • 4-(1��1 p�.
i�O OF
8 a C-iW laf wartIjampupil L
B f,�a3aACt(ItSrtla
c
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 �,~ 'J•y
WORKER'S COMTENSATION INSURANCE A-FM' AVTT
(li censerJpermi ties)
with a principal place�ofQbusiness/residence at: Ax 30 t�kCC o �.f� 1 � (phone#) ��3 �¢�cs ��
(stmeUci ty/stafrl'ri p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following -worker's compensation coverage for my
employees working on this job:
(IIlSllSaIlCe Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
�r
(Name of Contractor) (lasurance Company/PoL cy Number) (Expiration Date)
(Name of Contractor) (Insurance Comi-any/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shed ifnearsuycv inc}ude infixmaiioa peon;^;^�In all oorrtractors)
(x) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware dhai while homcow=-3 who auploy pci-ow to do m&mice construction or repair work on a dwcUing of
not more than throe units in which the homeowner resides oc oa the gcouzds appurtemai thereto arc not gcommIly eoosidered to be
employ=uncr thS works" comQez 4ca Act(GL152,ss 1(5)),appticatioo by a homcow=for a liocwe or pcm may evidence the
legll status of an omployec coder the Wor$oet compematioa Act
I understand that a copy of this 2W=cat may bo forwarded to the Dq{ Aaroi of lodudr d Aeade&Offioe of Irrnrraaoe for the
coverage vaificatioa and that failure to severe covcmp under socUoa 25A of MGL 152 can Icad to tho imposition of aiminal pen LWCS
coatisting of a ftnc of up to S1,500.00 and/or i nplisonnxni of up to one yrw and civil penalties in the form of a Stop Work Ord--and a
firm of S 100.00 a day against mc.
/ For iqutmtaW tsac only
G _ Permit Number
Map#----Lot ----
: Si t of s /Pcnnittcc 1�3EC
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR i`10.'1%)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 -OWNER AUTHORIZATION -TO,B.E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUIL''DING'PERMIT
I, GJG�v► l'�vNjYi as Owner of the subject property
hereby authorize )<'Q VIA f} 1.0!1 S v ti (6 r"y to act on
my behalf, ' . matters relative to work authorized by this building permit application.
z �
Signature o wner Date (�S
I, , 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
WI SE.C, IO N'12 -CONSTRUCTION SERVICES
Licensed Construction Supervisor: Not Applicable �Q
Name of License Holder
License Number
Address Expiration Date
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....... 5d No...... ❑
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
92 Registered Professional Engineer(s):
m��c � . �c�arvc��a c,v,� Fo.�.►,,,,f�.a�ti,�
Name Area of Responsibility
14 f� ()2N1-1 >, MPt- 32 AS5
Addre Registration Number
�7�6&
q�3-SE32-'?cx�v & -moo -04
ignature 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 Expiration Date
9.3 General Contractor /�
1CGvI us 0,,r,I-(ryO, SON Not Applicable ❑
Co mpa y Name:
Responsible In Charge of Construction \
Cl/l
Address 7���
�arar�`-!`ter,?�l-
Signatu Telephone
Version 1.7 Commercial Building Permit May 15,2000
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
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size N C
-Frontage �� "/ C'
Setbacks Front S3
Side L: Z;-7 R: 3 L: R:
Rear '� I
Building Height
(''o ti_�PS>� ��dV c
Bldg. Square Footage 350 %
Open Space Footage %
(Lot area minus bldg&paved 2) too S 1,
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
IF YES, date issued: �I1Z16 3
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book 712-g' Page rt/ `� 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 ueed to be obtained fro the Conservation Commission?
Needs to be obtained Obtained Date Issued: Arm.
C. Do any signs exist on the property? YES NO _
IF YES, describe size, type and location:
D. re there any proposed changes to or additions of signs intended for the property ?YES
Noy
IF YES, describe size, type and location:
Version 1.7 Commercial Building Permit May 15,2000
R
l
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations DemolitioPl New Signs [ ] Change of Use [ ] Other [ ]
❑ /� Accessory Building[ ] Repairs [ ] r
e►.o,v�e. VoLL (�StD RVtL-7)�tit f-ae , Pr-RtM-r s'GS (KID V T-(L t 1
SECTION 5 - USE GROUP ANb 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 ❑
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 ❑
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'
14 kOR,
Floor Area per Floor(sf) 1 5t
r
1st 2nd
3rd d
2nd s
4th v
3 �
rd
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft) °,6 x ''v
Total Height ft -- - ---
E! Versionl.7 Commercial Building Permit May 15,2000
1, City of Northampton
Building Department R3
212 Main Street Se r r-
{titil Room 100
w - =��Northampton, MA 01060 T�fl Sets P 7
►`3 harts 13-587-1240 Fax 413-587-1272- PIotlSite PtSr . w�-=
p
CD
APP41Cb710N TQ COA� JQ 1CT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, O EMOLIS NY BUILDING
_-) OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION=.1 - SITE INFORMATION
This section to b6,(. offrcet,
1.1 Property Address:
2 _ / Map Lots Unit
-7- �
r <
.._
Zone Overlay brs#rrct
Elm St. District CB`Dstrrct"
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I--�-vN��'►.. 17 14 L/(7 ll&QInl 1217 A,,,,,42z 610 r
Name Print) Current Mailing Address:
/04-7
Signature Telephone
2 2 Authorized Agent:
Name(Print) 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 (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) d(f) .p0 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1001
APPLICANT/CONTACT PERSON Mark Darnold
ADDRESS/PHONE 4 Allen Place
PROPERTY LOCATION 245 NORTH KING ST
MAP 18 PARCEL 005 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid L ss
T_ypeof Construction: REMOVE COLLAPSED BUILDING(NO UTILITIES)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 ssion
i
Signature ofl5uilding 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-2003-1001
245 NORTH KING ST
COMMONWEALTH OF MASSACHUSETTS
GIs#:
Map:Block: 18-005 CITY OF NORTHAMPTON
Lot: -001
Permit Buildina
BUILDING PERMIT
Category:
Permit# BP-2003-1001
Project# JS-2003-1604
Est Cost: $$5000.00
Fee: PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const.Class:
Homeowner as Contractor
Use Group:
Lot Size(sa. ft.): 57934_80 OWnPr:_ HLTNTER.JC?H`1&SNEiL
Zoning:HB Applicant• Mark Darnold
AT: 245 NORTH KING ST Insurance:
,4n�licant Address:
Phone:
4 Allen Place
NORTHAMPTONMA01060 ISSUED ON:5 115103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE COLLAPSED BUILDING (NO UTILITIES)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W.
Service: Meter:
Underground: Footings:
Rough: House# Foundation:
Rough: g
Driveway Final:
Final: Final: Rough Frame:
Gas:
Fire Department Fireplace/Chimney:
insulatior:
P.ouRh: G1;
Final: 0 K le • 6 3-�'L�
Final: Smoke:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
J
Certificate of Occu anc si nature:
Check No: t:
Feel e: Recei t No: Date Paid:
Amoun
5/15/03 0:00:00 178 $35.00
Building
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo