31B-230 (7) 64 GOTHIC ST BP-2016-1513
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-230 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: HANDICAP RAMP BUILDING PERMIT
Permit# BP-2016-1513
Project JS-2016-002559
Est.Cost: $70000.00
Fee:$490.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BAYSTATE WINDOW& DOOR 089485
Lot Size(se.ft.): Owner: GOTHIC REALTY TRUST-BENJAMIN BARNES&ED ETHEREDGE
TRUSTEES
Zoning: CB(I00)/ Applicant: BAYSTATE WINDOW & DOOR
AT: 64 GOTHIC ST
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549-6824
HADLEYMA01035 ISSUED ON:6/17/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW WALK, WALL AND RAMP
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:
FeeTvpe: Date Paid: Amount:
Building 6/17/2016 0:00:00 $490.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
, 4
I VersionU Commercial Building Permit May 15,2000
.. -:--, Department use only
L - __
Cty of Northampton Status of Permit( 5 - Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Deur cur —
Room 100 Water/Well Availability
naf e n.ir 'cos Northampton, MA 01060 Two Sets of Structural Plans
phone 4'i 3-587-1240 Fax 413-587-1272
Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.11PProperty
/'Address. ..
C/ bo 'c JtL• Map Lot Unit
Zone Overlay District
-- - -- --- -- - Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C251- (6. Sr Cka /1S$dG,
Name(Print) //�O� Current Mailing Address
Signature �./ \ Telephone
2.2 Authorized genyjt�JA ( 1l
est'
og
Name(Pant) , F1/20(1-...W13/
Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildingt (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 _ jR� (((
6. Total=(1 +2+3+4+5) 1t/, / a 0 Check Number a15-4••• q
(This Section For Official Use Only
Building Permit Number Date
Issued
/ I
Signature: ®//' �G c/ — .7-&-/Z
Buil•m• Issioner/Inspector of B gs Date
D
Versionl.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 0 Repairs 0 Additions E Accessory Building 0
Exterior Alteration 0 Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief description here. j`/'�
Of Proposed Work NOG,/ ._6 /k / °Jo,/ii_.._ J1�idi19:-/ICS
_.. ...
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 ❑ A-3 0 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business 0 2A ❑
E Educational 0 2B 0
F Factory ❑ F-1 0 F-2 ❑ 2C 0
H High Hazard ❑ 3A 0
I Institutional ❑ -1 0 1-2 0 1-3 ❑ 3B 0
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 0 R-2 ❑ R-3 ❑ 5A ❑
s Storage ❑ 5-1 0 S-2 0 58 0
U Utility ❑ Specify
M Mixed Use 0 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 Roar(sf)
tsi
230
3 _ ..._.. 3,e
h ..
4m
Total Area(sf) Total Proposed New Cpnstructlon(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 0 Private ❑ Zone _ Outside Flood Zone Municipal 0 On site disposal system❑
4
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
Rear ._ _..—.
Building Height
Bldg. Square Footage -
Open Space Footage
(Lot area minus bldg&paved
narlcing)
;: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 b.I YES Q
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 elif DONT KNOW Q 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 0 NO 1ti
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. VII 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 p
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
S
Version]. 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 0
fig/ Pr,-.[„4.c vii
Name(Registrant)..rf /
6 &/ 60th' a S* Registration Number
Address _..._. _._. . ... _.
-- "-----""- ' Expiration Date
Signature Telephone
9.2 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 Reg strafion Number
Signature Telephone Expiration Date
......_..__.. ..._......
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
�/G�L ( WCt k— J _'r Not Applicable ❑
Company Na e
Responsible In Charge of Construction
676 Addir ga-lic . 04/14-) ciO-2C-
Address
Yild/F63sz _
Signature Telephone
•
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 Q No
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN /
OWNERS
��AA/G��ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
J Gi Lq Giy,T- ,asOwner of the subject property
hereby authorize. `IfraCcy _.. C't.✓xlG�i..-. - . ._ _. . to
act on my behalf,in all matters relative to/work authorized by this building permit application.
Signature of Owner/ nfres, -- 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
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: //'� ����yy
License Number(,//''S—0175V
ChM,' tusgNEj
Address Exp ietlon Date
Cerowallelrm
Telephone
SECTION 13-WORKERS'COM ENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance ffdavit 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 Q No Q
t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
_ - Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1 �JI I am a employer with _2 4. ❑ lam a general contactor and I
�y� 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ i am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ 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
3 ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees- [No workers' 13.F1 Other
comp.insurance required.]
',Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new afidevit indicating such.
(Contractors that check this box must attached an additional sheet showing the nave of the sub-contractors and state whether or not those entities have
employees- If the sub-connotors have employees,they must provide their workers'comppolicy number.
I an an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information // T
Insurance Company Name: .0,d oyl o C k- 7;760(ten o f
I
Policy n or Self-ins.L t
in d�11/(`� 1,( 6 /0 0 6� 62° �A
Expiration Date:
qq At5/14//6
4
Job Site Address: / 6c,§rei Q S7, City/State/Zip: ke, fen Z/1(4 Giceo
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 ran 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
Si nature: Date:
Phone
Official use Only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License K
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: 6 6/ 6-,/t .c_ '&T
The debris will be transported by: / I cc g_
The debris will be received by: MteAan 1nei `Coi s4r °ti
&/41/e7 Keetrh'f(�
Building permit number: _
Name of Permit Applicant
Date Signature of Permit Applicant
05/25/2016 10: 19 4132569354 PAGE 03/03
A�um CERTIFICATE OF LIABILITY INSURANCE DATE s�z4MEDM c 1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INF(T:AATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NECITIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder S an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights t0 the
certificate holder In lieu of such endorsemengs).
PRODUCER taw, Dean Paddock
NONE:
Paddock insurance Agency PRONE (413)253-555FAX
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_41LG,Na EN1
20 Gatehouse Road EgdAiL ddockenathanagenciea.com
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PO Box 48 INSURERS)AFFORDING COVERAGE _ _ NAICN
Amherst MA 01004-0048 INSUREe A:Travelers Insurance Cgm_panv 36131
INSURED INSURER as:Commerce Insurance 34.754
Hadley Concrete Services LLC INSURER c:
35 Middle St
INSURER o', _
INSURER E'
Hadley HDI 01035 INSURER P:
COVERAGES CERTIFICATE NUNBERMas ter 2016 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VIHIICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTMN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EYCLU510E1S AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADULT ELF
II TRTYPETYPE OG INSURANCE - AC I IWOO POLICY NUHDER MN�rrErn.I MMNOMYYYI UMrrs
X COMMERCIAL GENERAL UAWUTY
EACH OCCURRENCE E 1,000,000
A 11 CUNSMADE X OCCUR PREMISEA HEWED 300,000
NEDMISE3IE__._. ) ,3
fiB014<03«9 ID/9/2015 10!9/2036 one
IJ PERON ILA AOVI JURY 'S 0,000
PERSONId6 ADO INJURY S 1,000,000
GENL AGGREGATE LIMTAPPUES KR: GENERAL AGGREGATE E 2,000,000
X I POLICY�.. I PRO.
JEOT _a LOC _ PRODUCTS-COMPgP EGG 5 2,000,000
I OTHER I NOI 5
AUTOMOBILE wNLITY COMBINED SINGLE LIMIT AEELeraltErh
B _ ANY AUTO BODILY INJURY Mr Deur) 6 50,000
ALL OWNED I" AUTOS SCHEDULED
AUTOS WS/170 4/10/2015 4/10/Z016 BODILY INJURY Ter accident, 5 100.000
X MIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS PM,.ydt4) E 100,000
5
UMBRELLA we _ OCCUR EACH OCCURRENCE E
f— EXCESS LIAR '
CLAMS-MADE
AGGREGATE 6
DW RETENTIONS I S
WORKERS COMPENSATION PER OTH-
ANDEMPLOYERS'wBILRY 67AME fR _
ANY PROPRIETORMARTNER:EAEOU1WE v/N EL DISEASE
EACH ACCIDENT S
OFFICER/MEMBER EXCLUDEXCLUDE'? XIA
IMend.t yN NM A _ .. _
SA &Lemm.,EA. E-EA EMPLOYEES
DESURIPnoN OF OP A10NS below I EL DISEASE.
MOULT umn s
DESCRIPTION OP OPERATIONS/LOCATIONS I VEHICLES IACONO 101,AEOklmul Remnrte SWANN,may be attached N mere IAA Le required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
125 Locust St. ACCORDANCE WITH THE POLICY PROVISIONS.
Northampton, MA 01060
AUTAIRISED REPREBENTAT]E
Dean Paddock/D035 /---a �s;-=�
S11988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD
IN5026 tm14011