31B-240 (4) TENNEY HOUST- 156 ELM ST BP-2016-1333
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map Block: 3 1 B-240 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-1333
Project# JS-2016-002299
Est.Cost:
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SCAPES BUILDERS & EXCAVATION LLCO21087
Lot Size(sq. ft.): 7971.48 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: URC(100)/EU(62)/ Applicant: SCAPES BUILDERS & EXCAVATION LLC
AT. TENNEY HOUST - 156 ELM ST
Applicant Address: Phone: Insurance:
P O BOX 469 (413) 665-0185 O WC
DEERFIELDMA01373 ISSUED ON.512012016 0:00:00
TO PERFORM THE FOLLOWING WORK.-LIGHT DEMOLITION, FIT & FINISH
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 5/20/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1333
APPLICANT/CONTACT PERSON SCAPES BUILDERS&EXCAVATION LLC
ADDRESS/PHONE P O BOX 469 DEERFIELD01373 (413)665-0185 Q
PROPERTY LOCATION TENNEY HOUST- 156 ELM ST
MAP 31B PARCEL 240 001 ZONE URC(100)/EU(62)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: LIGHT DEMOLITION FIT&FINISH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildiny,Plans Included:
Owner/Statement or License 021087
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQ MATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
. /
s-
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.
Version 1.7 Commercial Building Permit May 15,2000 +
Department use only
C City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
MAY 16 ZOIs 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
°RTMM
F1° n 13-587-1240 Fax 413-587-1272 Plot/Site Plans
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
.SG Map 31'5 Lot qq0 Unit
I (,-n r Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�uL ' �d�
Name(Pant) J/ S 4 ,PAT j� ep`�E'� Current Mailing Address: �
Signature Telephone
2.2 Authorized Agent:
.0 t.e. Cu
Name(Print rrent Mailing Address D( 7
YSignature Telephone
SECTION 3 STIMA ED CONSTRUCTION COSTS
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 14 1001d
— T_his_Section_.For_Official_Use-Onl
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
yTwly
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 .
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Buildi
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
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 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 213 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 4 ❑
R Residential R-1 ❑ R-2 R-3 ❑ 5A ❑ j
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(sf)
1 sc
2nd
2nd
3rd
3rd
_.
4m 4m
.
__.._..........__.._...._........__................................................._.._............
......__
Total Area(sf) Total Proposed New Construction(sf)
..
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❑
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Version 1.7 Commercial Building Permit May 15,2000
S.-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:'
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 0 DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
g
IF YES: enter Book Pae and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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:
w..., _.... _..,, Not Applicable ❑
Name(Registrant)
Registration Number
Address
Expiration Date
Signature
Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
...._.. .... ._........ ..
... __. .... _ _. ._... ...
AddressRegistration Number
__.
Signature Telephone Expiration Date
. . . . ..._...........
...................... . ........ ..
NameArea 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 Teleph.ne Expiration Date
9.3 General Contractor
Not Applicable ❑
--Company-Name: —
Responsible In Charge of Construction
_.._.....
Address
Signature Telephone
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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 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
P.
,as Owner of the subject property
hereby authorize
� o
act on my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner Date
V.�'Ct I Z�.'t w..�,.. . _.._. ._,. ...._. ._.. .___..._ 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 p ' _ nd pen. los of perjury._.. __....
Print Nam
�C 1.
Signa rg of 0 er/A ent Date
SEC } N 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
_ .............
nn p
Name of License Holder. .....J GL s ... ..[,.�lw_
License Number
leo /Va>'A
Address Expiration Date
Sign,atur 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 b 'ding permit.
Signed Affidavit Attached Yes No O
-0—
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 TVashington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information > Please Print Leaibl)
Name (Business/Organization/Individual): ( S aj Fk e'7
Address: Jl D
City/State/Zip: S (e ld 111# L'IM Phone#: 02—665--
Are you an employer? Check the appropriate bog: Type of project(required):
1.[�( I am a employer with 15 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
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. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp.insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
❑ officers have exercised their 11.7 Plumbing repairs or additions
�. I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurequired.]]rance re t c. 152, §1(4), and we have no �7
employees. [No workers' 13.[f+ Other
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 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: ���� hd rI
u�'`�
Policy#or Self-ins.Lie. #: I�� �b 6`I Lyj�/1 A6
Expiration Date: '125116
Job Site Address: /J - �f`tl S�if� /" TY ,&-.�'b /�rCity/State/Zip: ,0�- 01 d b 3
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.her•eby certify un er the pains and penalties of peijuiy that the information provided above is true and correct.
Signature: _ Date:
Phone#:
Official use onlh. Do not write in this area, to be completed by ci07 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#:
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