31B-225 (12) DAWES HOUSE -8 BEDFORD TER BP-2016-1548
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:318 -225 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: SPRINKLER SYSTEM BUILDING PERMIT
Permit# BP-2016-1548
Project# JS-2016-002348
Est. Cost: $15000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group FIRE SERVICE GROUP LLC 145974
Lot Size(sq. ft.): 9583.20 Owner: SMITH COLLEGE OFFICE OF THE TREASURER
Zonin°:EU(100)/URC(I00)/ Applicant: FIRE SERVICE GROUP LLC
AT: DAWES HOUSE - 8 BEDFORD TER
Applicant Address: Phone: Insurance:
PO BOX 1244 WC
BELCHERTOWNMA01007 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:MODIFY EXISTING SPRINKLER SYSTEM
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: //a04
Building $105.00 P
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
Filed BP-2016-1548
APPLICANT/CONTACT PERSON FIRE SERVICE GROUP LLC
ADDRESS/PHONE PO BOX 1244 BELCHERTOWN
PROPERTY LOCATION DAWES HOUSE-8 BEDFORD TER
MAP 318 PARCEL 225 001 ZONE EU(100)/URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid (t a"1.1�{
—41175.
Building Permit Filled out /9
Fee Paid
Typeof Construction: MODIFY EXISTING SPRINKLER SYSTEM
New Construction
Non Structural interior renovations A
Addition to Existing Cr
Accessory Structure
Building Plans Included:
Owner/Statement or License 145974
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO R�S4TION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Pennit 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
D lit' D v
IFVC
Signa ding Of is 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.
Versionl.7 Commercial Building Pcrmit May IS,2000
Department use only
City of Northampton Status of Permit:
Building Department Ctxb Gut/Driveway Folmd
212 Main Street Sewer/SepticAvagabdity
Room 100 Water/ Well Avaitabirity
Northampton, MA 01060 Two Sets of Stmptmal Plans
phone 413-587-1240 Fax 413-587-1272 Ptot4 to 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
Map Lot Unit
f� ! Zone Overlay District R€c Fonc T'c�-Ac& Elm St Ci•,bict CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Simi 414 Colle c
Name(Print) Curreit Mailing Address.
Signature __ Telophone
2.2 Authorized Agent:
Name(Pont) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED 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 I 'O bO ._ .
6. Total=(1 +2+3 +4+5) Check Number -2/y3 1t/UFj'
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
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 Repairs Additions 0 Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign❑ New Signs 0 Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: m a1,,;
Fy QYiSkiY.N Sre.iw\Uetc Sy,{}ew.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 0 A-3 0 1A 0
A-4 ❑ A-5 0 113 0
B Business 0 2A ❑
E Educational 0 2B 0
F Factory ❑ F-1 0 F-2 ❑ _ 2C 0
H High Hazard 0 3A ❑
I Institutional 0 1-1 ❑ 1-2 0 1-3 0 38 ❑
M Mercantile 0 4 0
R Residential 0 R-1 ❑ R-2 0 R-3 ❑ 5A 0
S Storage 0 S-1 0 S-2 0 58 0
U Utility ❑ Specify'. ... . _..
M Mixed Use ❑ Specify:
S Special Use 0 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"
2 ` 2nd _.
3rd 3d
44m
N
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 [i. Private ❑ Zone Outside Rood Zane❑ Municipal 0 On site disposal system❑_
Version!.7 Commercial Building Permit May 15.2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be fined in by
Building Department
Lot Size
Frontage
Setbacks Front
Side I.: R: L: R:
Rear
BuildHg Height
Bldg. Square Footage io
Open Space Footage
(I.at area minus bldg&paved
parking)
of Parking Spaces
Fill:
(volume&tacaian) - -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document It
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained o , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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 O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,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
1111.11111.1
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:,p Not Applicable ❑
Name of License Holders D(r�rc ISi L 5+3112
License Number
1010 Tl4v(LP AuF 54- Sc - 'Y,sf75'
Address Expiration Date
413- ,(4-9Na
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 v No Q
." The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
el iQ 1 Congress Street, Suite 100
,i,! •=4:4E Boston, MA 02114-2017
�+—r�
a 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):
I.Q-1 am a employer with as 4. ❑ I am a general contractor and 1
employees (full and/or part-time).' have hired the sub-contractors 6. ID New construction
listed on the attached sheet. 7. ❑ Remodeling
2.D I am a sole proprietor or partner-
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 I1.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §I(4),and we have no
employees. [No workers' 13.0 Other S IZaIVt t
comp. insurance required.]
*Any applicant that checks box PI must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they arc 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 1
Insurance Company Name: 13 on Aw0 {-1U1]So>J n
Policy# or Self-ins. Lic. #: X 14 U 1 - 41 13 YTS &.-1 S Expiration Date: 9-1 IA
Job Site Address: 'Pr a GAFOILO "re RACC City/State/Zip: 1k)OR4!i444t..704. sJ
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
tine 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.
1 do hereby certify nder the pains and penalties of perjury that the information provided above is true and correct.
Signature: (11--W4---. _ — Date: I U - 1(p
Phone#: fit 2- (!moo'j /0
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: