18-013 WALL MART (5) • r
't:1iAMpj. c
�aSl Rr}lrt5f the
s
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mess. 01060 �4
WORT EwS COMTENSATION INSURANCE AFFIDAVTr
L7I— S— OTC TZonrI t-,) NCa
With a principal place of business/residence at:
S$ �21�1N Klrl t,.� ST•l U��Nt=tt�NboN � �`�� .f {Zi1�-(Phone#} cj��-2-�11-31��d
___^J� {st7eei/rity/sea eJziP)
do hereby certify, under the pains and penalties of penury, that:
()� I am an employer providing the following uForker's compensation coverage for my
employees working on this job:
C N I)' 11)Y 309 CD
__ (Insuu m Cornpaz y) {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 foilovrillg worker's compensadon policies:
(Name of Contractor) Omsuranct Company/Policy Number) (Expiration Date)
(Name of Contractor) Comtpany(Policy Dumber) (Expiration Daft)
(Name of co=a(nor) v (Imumacc CoExpany/Folicy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Bate)
(attaeh additional a:hcct ifnecesa.ary to isx-.ludc icfor=AfLoa pcxiaiuing to a13 ooc radors)
( ) I am a sole proprietor and have no one working for me.
{ } I am a home owner performing all the work myself.
NOTE:ptease be to do=bn c,a am coasfta oa or rrpair wort:on a dwcUmg of
not more then throe units is which the hoar ooaacr residw or oaa the grouads appurttnaai tbcrcw ant not gcauv y oaasidered to be
cWtoyers undcr tba warkcex c=p=ssdao Act application by a homrowncr fora Uccwc a pcmit may evidence the
hest atrwm of an oaaplcyar uadcr too worivex caaYpaandiw Arx.
I uodcssund that a oopy of this r tatrmad may be famftrded to the Drgaartrnas of 1,o&L,,triai Aoadom&Offioe of L==—for tho
covcxtge vtsiClcaiioa twd that failtse io aeaue oovetsgo ratdar section 25A of MdL S 52 tart lead to the imposikioa of criminal ptnalsirs
oomistixrg of a rme of up to S1,500.00 arwar impaiso ofup to one year and civil pc=Wes is the form of a Slop Wore Ord_—and a
fine of S 104.04 a Oay agaitut tne.
For dqmtamw uac-t
Permit Number
i
'l C i lit#
Si of Licensee/Ye �ttee e
L •d eaa :ol TO La unr
.j
Version l.7 Commercial Building Permit May 15,2000
IT
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
s EC r�rr�l au tfGRJ9,A r r r r y
as Owner of the subject property
hereby authorize _ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
. b
J� y 7
Print Name
Si ure of owner/Agent Date
101 Licensed Construction Su ervisor: Not Applicable ❑
Name fL'ecenseHolder: ROQe—r l"`• �e�pfd CS oaLoq C1
License Number
15g LQ1r(16-en Un, M�! 0114-15 10122-101
Address Expiration Date
ql" --2a 6 y
Sign ure Telephone
Xm
tt _ aF
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....... tA No...... ❑
g •d eTF :OT 10 L2 unC
Versioni.7 Commercial Building Permit May 15,2004
Ctt > 7�" �
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
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
Name Area of Responsibility T
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
MUI+t - S+G�� "�C�C9 <l'1G< (Y1 C • _ Nat Applicable ❑
Company Name:
�er- R
Responsible .-bes�res �tresiclei��
In Charge of Cons uction
6'8- Franklin 5 �e�k; 11��nch dcnll"I o����
Address
Sigrofure Telephone
S •d e12 =01 10 1..2 unC
Versionl.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 0 Zone: Outside Flood Zone ❑ � Municipal ❑ On site disposal system ❑
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column io 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
ark'
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 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 X
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_
No
IF YES, describe size, type and location:
{, •d eoa :01 t0 LZ unr
Version 1.7 Commercial Building Permit May 15,2000
.RFi.. as .- t rz...., s,�.e.... z.° s,.rwc. v��a�e^ •hu.;�„�s @°w.� �� .",�-:._.,l V..4 ..a. r �-..�.�uzs�a�:i';.-,
. „
.a,w..� .:'.���mwss;ro.A"' y
n2 f a
Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing
❑ ❑
Exterior Alterations Dernol€tion❑ New Signs [ ] Change of Use [ ] Other [ ]
0 Accessory Building[ ] Repairs [ ]
zp-7r e 2,ernwL exis' ill rood s s--ei)5 ancX rep lave with rleo aloo�e.
4
Ar � W Gr Wc11-YYlart S biz ZRoI �Jot�Fi-yam {an M.�4
o.a�� f r P {
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 ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1.2 ❑ 1-3 ❑ 38 ❑
M Mercantile 9 4 ❑
R Residential ❑ R-1 ❑ R•2 ❑ R-3 ❑ 5A ❑
S Storage O S-1 ❑ S-2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
l
clrl rir��
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
il ?1�1Cx HE1T Ari1Q �
c a
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION %
rz 1 Ito 4) M EFrf
Floor Area per Floor(sf) st
n 7
Ist 2 nd
3rd b yb kcI
2nd
4th
3rd
4th A3 N.
11
Total Area(sf) _ Total Proposed New Construction (sf) ° � Z,
--------- ---- -.........--.--- t P b
Total Height(ft)
Total Height ft--- 1
3q j wt
E •d eBT :OT TO L2 unr
lc
rJUL Versionl.7 Commercial Building Permit May 15,2000
ity of Northampton
17 2001 uilding Department
212 Main Street
Room 100
DEPT OF BUILDING INSPECTIONS No thampton, MA 01060
NORTHAMPTON,MA 87.1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
1.1 Pro erty Address:
I$>J North KinQ Siree�
`y-` �/y� +},�y� M J^.�
W o ck 1 •a ' Q 1 V 1 \ f 1 I \ i{EY d h ft�
sw Tio�lr arP li TTIOW �W"
2�1 O ner of Record:' Cl i6fl_TJIt ` X4AA) bEM ,r, &sSFr
Name(Print) Current Mailing Address: �C)� �
Signature Telephone
2.2 Authorized ,gent: L j p f /
Name{Print} Current Mailing Address: 727 r l
`Z7-7 Z-lN
Sign ce Telephone
�
Item Estimated Cost(Dollars)to be �c# �GJs OtE'•
completed by ermit applicant `'
L Buil ing C �°;> iling nJte
by &(5z 0o
�a
2. Electrical ft pd T 51,�
n Q1 >�9nu��Y71 ala`
3. Plumbing K�u1i Ian er I '
rl
4_ Mechanical (HVAQ
5. Fire Protection n a
b. Total = (1 +2 + 3 r4+ O0 ?4
n h
FurSfti Gial'is, . 111
l'6 g Perm,j
®ai Qate Issued
Signaure
'StlLldlr�g�omttiiSS'Fa�>wr/Inspectg��'f il�ngs E7�t:�:
z •d etj :OT TO La unr
4
; S_WAL FART BP-2002-0079
GIs#: COMMONWEALTH OF MASSACHUSETTS
00 1
., .
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0079
Project# JS-2002-0119
Est.Cost: $344652.00
Fee: $1725.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MULTI STATE ROOFING 026919
Lot Size(sq.ft.): 452588.40 Owner: GIBRALTAR MANAGEMENT CO
Zoning:HB Applicant. MULTI STATE ROOFING
AT. 180 NORTH KING ST - WALMART
Applicant Address: Phone: Insurance:
158 FRANKLIN ST (978) 297-3660 Workers
Compensation
WINCHENDONMA01475 ISSUED ON.71201010:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE EXISTING ROOF SYSTMES &
REPLACE WITH NEW ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 Sisnature:
Fee Tyne: Receipt No: Date Paid: Check No: Amount:
Building 7/20/010:00:00 5103 $1725.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo