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38A-112 (3) VILLAGE HILL RD BP-2016-1238 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:38A- 112 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ZoningPermit BUILDING PERMIT Permit# BP-2016-1238 Project# JS-2016-002066 Est.Cost: $180000.00 Fee: $1260.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SALOOMEY CONSTRUCTION 018780 Lot Size(sq. ft.): 82371.96 Owner: HOSPITAL HILL DEVELOPMENT LLC C/O MASSDEVELOPMENT Zoning: PV(100)/SG b(81)/ Applicant. SALOOMEY CONSTRUCTION AT. VILLAGE HILL RD Applicant Address: Phone: Insurance: P O BOX 1203 (413)269-4360 Workers Compensation WESTFIELDMA01086 ISSUED ON.•412212 01 6 0:00:00 TO PERFORM THE FOLLOWING WORK.-INTERIOR DEMOLITION ONLY 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 4/22/2016 0:00:00 $1260.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Versionl.7 Commercial Building Permit May 15,2000 Department use only City of Northampton p Status of Permit: Building Department Curb Cut/Driveway Permit APR �O'� ' 212 Main Street Sewer/Septic Availability I Room 100 WaterM/ell Availability tAPPLI'ICATION Northampton, MA 01060 Two Sets of Structural Plans "`'pho e 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 Map Lot Unit VILLAGE HILL ROAD Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: OHS IIIJIIaMr do ME OMM @ MMM H", IX 77 Mal Sr, SUITE 310 Name(Print) Current Mailing Address:yEjFIE[[Dr MA 01085 J.R. ALIT 413-3481-7572 Signature Telephone 2.2 Authorized Agent: Z17M SAIAOME.'Y @ SAIIDOMEY CONSTRUCTICK P.O. BOX 1203, wEstFIErn, MA 01085 Name(Print) Current Mailing Address: ZITS SAIr00NlW 413-269-4360 or 413-531-0062 f Signature Telephone SECTION - TIMATED CONSTRUCTI C S Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) I 1 80,000 DFNDT•MON Check Number This Section For Official Use Onl Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Version 1.7 Commercial Building Permit M!X 15,2400 Department trse.orly City of Northampton Status of Permit: Building Department curb CUVDrvawSry Permit - 292 Main Street Sewer/Septic.Avolabillity Roam 100 Water/Well Avail O*bitty Northampton, MA 01060 Two Sets of Struc turel Plans phone 413-587-1240 Fax 413-587-1272 PkWSft PFans ,,,� Other Specify _ APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELUNG SECTION 1 -SITE INFORMATION 1.1 Property Address: This vection to be completed by office Map Lot unit VILLAGE HILL ROAD Zone Overlay District Elm 5t,piatfict ca District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 7 2.1 Owner of Record: WEMXWk1O;OWMW c/o W.WMV KIME L RAM = 77 K11A, ST, SUM 310 Name(Print) Current Mailing Address. ' r R �j��}� � 413-348-7572.nature —"�""" Telephone Amite w ZXM�WDOM. ,SAXOOM t k 3'E'Bi7CT`T i P.O. SICK 1243, WROWMD, M 01W5. Name(Print) Current Malting Address: zrm 413-269--4360 tar 413-531.-0%2 Signature Telephone SECTIONCONSTRU Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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) Check Number This Section For OfBclsl Use Onl Building Permit Number Date Issued Signature: Building Commissionerfinspector of Buildings Date Version 1.7 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 MDemolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs R Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work: DEVU=0N per, CtqLY _ PER ARCHIT & SQL ENGINE3MS PLANS 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 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 Floor Area per Floor(so 1st 1St 2"d 2"d 3rd 3`d 4th 4th Total Area(so Total Proposed New Construction(so 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 ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system E] Version 1.7 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 issued for/on the site? NO O DON'T KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 © NO 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 1.7 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 36,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect- 4 A.A�AS= Applicable 0 Name(Registrant): X21 F.�19T" S'iRE;F:L', I00ME,r I& 01020 Registration Number Address Expiration Date \� Signature Telephone 9.2 Registered Professional En lnee s): Name Area of ResponsibIfty ti_E&M IlVERE, AUBUM, .MA 01.581 `a— Address Registration Number .�-. 508 892 AM � �i, "1G —H>04 Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Respensibltity Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor .Si1ItJ [4L-� ICIIR Not Applicable 0 Company Name: ZIMS CXLT 413-531-0062 OBRIJIN CS--018780 EXP. 11/13/17 Responsible In Charge of Construction Hme 1t. #100978 :.P.Q. BM,1203, Z , M& 01086 EXP. 6/24/16 Address 413-269--4360 WCENE S CEI,: 413-537-9005 S naw Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J.R. ALLEN as Owner of the subject property hereby authorize Z17M SAID MEY to act on my behalf, in all matters relative to work authorized by this building permit application. 7 4/19/16 Signa a of caner Date I, ZIM SAID 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. Z NM SAIMMEY Print Name 4/19/16 Signa re of ner/Agent Date SECTIO 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ZITM SAIDIDNEY CS-018780 License Number P.O. BDX 1203, WLSRFI D, MA 01086 11/13/17 Address Expiration Date 413-531-0062 Sig ature Telephone SECTION 13-WORKERS'COMPENS N 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 XQk No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d I Congress Street, Suite 100 ,Wt Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SALOOPF:Y M)MCi, INC Address: P.O. BDx 1203 City/State/Zip: MA 01086 Phone #: 413-269-4360 Are you an employer? Check the appropriate box: Type of project(required): 1.a I am a employer with 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ji Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. No workers' com right of exemption per MGL y [ p• 12.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew aIidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of 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: MASS EM IDYER INSURANCE CXMPANY Policy#or Self-ins. Lic. #: MCC 200121012009 Expiration Date: Job Site Address: VIIJ" EDEM ROAD City/State/Zip:NoRTHAmpToN, MA 01060 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 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 coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Dat e: 4/19/16 Phone#: 413 269 4360 Official use only. 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: _3C) V;1t The debris will be transported by: The debris will be received by: TT Building permit number: Name of Permit Applicant Liv-&O n,�a Date Signature of Permit Applicant