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16B-003 (12) File APPLICANT/CONTACT /CCONON ATACT PENEON JOSEPH M GILLETTE ADDRESS/PHONE 30 HAYNES CIRCLE CHICOPEE01020(413)592-2772 r, 1/ ,/, PROPERTY LOCATION 100 BRIDGE RD-JFK �lY"-v„I/I MAP 16B PARCEL 003 001 ZONE URA(100)/RI(81)/WSP(44)/SR(0)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid BuildingPermit Filled out CA, _U — Fee Paid Typeof Construction: REPAIR DAMAGE IN BOYS ROOM&REPLACE WILES HALLWAYS& CLASSROOMS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 103014 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 ••• :n delay 77/6 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 ,LT, ' ___ .. Department use only p r� City of Northampton Status of Permit: 0. 28 2015 Building Department 212 Main Street Curb Cut/Driveway Permit Sewer/Septic Availability Flea c,Plumbing&Gas icsi:T ne. Room 100 Water/Well Availability Northampton,MA Okra Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PloVSite 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 Jf,t.. m/AC/A 41 p C.yk-0/ Map Lot Unit /00 7�etnefrc l� Zone Overlay District �('jl ©r -etc" #n/ a 47 __ am SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C._ ,,j /5 of/logy/4lnvo / Name(Print) Current Mating Address: Signature Telephone 2.2 Authorized Agent: .� //) i ig-,+ -tZ Name(Pri Current Mailing Address: Jt q / Lf/3 - 5')U7-/?‘e cit-L'� Signature ` � , .\ Teteghone SECTION - STIMATE t Cc NSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant _ 1 Building 37( oo — (a)Building Permit Fee 2. Electrical 3�G>a (b)Estimated Total Cost of Construction from(6) 3. Plumbing I 300 ._ Building Permit Fee /j 4. Mechanical (HVAC) 14 a Fee 5.Fire Protection e 6. Total=(1 +2+3+4+5) -T/ !!! c eroZ)— Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspectorof Buildings I 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 CIlF9 Existing Wall Signs ❑ Demolition Repairs/Additions 0 Accessory Building❑ Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use❑ Other 0 Brief Description Ente• brief description here. Of Proposed Work: rile / /lam evef Pry c-e_ z) /4.- in SECTION 5 USE GROUP AND CONSTRUCTION TYPE r(/f //r✓+PyS t Cr/4 if t ni, S USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 0 A-2 0 A-3 0 1A I ❑ A-4 0 A-5 0 1B 0 B Business ❑ 2A 0 E Educational 2B ( 0 F Factory 0 F-1 0 F-2 0 2C 0 H High Hazard 0 3A 0 I Institutional 0 I-1 El 1-2 0 I-3 ❑ 3B 0 M Mercantile 0 .... �....- 4 0 R Residential 0 R-1 ❑ R-2 0 R-3 0 5A 0 $ Storage 0 8-1 0 —..S-2 0 I 58 I 0 U Utility ❑ Specify: M Mixed Use ❑ Specify: $ 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 1 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sg 1 1 sr :, 2"' 2 301 3`O 4n, 4m Total Area(st) 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 0 Private 0 Zone Outside Flood Zone[) Municipal 0 On site disposal system[ Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING FRequired by Existing Proposed Zoning This column to be filled inby Building Dep nincnt Lot Size Frontage Setbacks Front (Side L: le: L: R: Rear Building Height Bldg.Square Footage ro Open Space Footage (Lot area minim bldg&paved parking) • N of Parking Spaces Fill: tloume&I ovation) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW © YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO fl IF YES, describe size, type and location: 0. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q IF YES, describe size, type and location: E. WUI the construction activity disturb(clearing,grading,excavation,or filling)over i acre or is it part of a common plan that will disturb over t acre? YES Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version l.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 Name(Registrant) Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional En.ineer(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 or Responsibility Address Registration Number .�...._....._...— Sgnature Telephone Expiration Date 9.3 General Contractor Not Applicable 0 Company Name: Responsible In Charge of Construction Address Signature Telephone Version/.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 0 SECTION 11 -OWNER AUTHORIZATION-TO RE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMITr I. CC ITc/{/rbc eLlo-F �' /*24^(4 s1 lit--IC lci{i/X L ren { as Owner of the subject prpped) hereby authorize ( 07Mp/IT MGS,4. ,f12nr Joh 70n4 "LH I act on my behalf, in all matters relative to work authorized by this building permit application. Signnaattuuurrreee1.��lgoff Owner r'yt�`t O{'/♦ /� }y(� � �.(/}�� Date -+„"1�� �) W1( �1Y2- ( fJ\1NW” Q'p/.t1^fciss � , .S Owned .uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the b- .1 my knowledge and belief. '�gned under the pains and penalties of perjury. 'moo tV-teMt7— me 01.171 [C-- e o'Owner/Age Date S= • 12-CONS - CTION SERVICES 10.1 et}Construction Supervisor n �j Not Applicable 0 Name of License Holder v/�Se/OO /4• " //C7(£,. License Number 2 (e.f.e (LA o* SA., SGlin.4rZ .,s e 5 - fo30/ q Address Expiration lk i1/1341/ Date yf 3-x%1 -777'2- LI1/3a J/ ?0/ 7 Signature � Telephone !11 // _.. Jill ._...- p Illr V/ SECTION 1 • 0‘' RS'-OMPENSATION 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 rest in the denial of the issuance of the building permit. 0 Signed Affidavit Attached Yes No 0 ^ `_'R" CERTIFICATE OF LIABILITY INSURANCE 1 9„ 2914"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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 is an ADDITIONAL INSURED,the poticyjies)most be endorsed. II SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A staterneM on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODlcER I dIail Croats Alexander W Borowski Inc �PIINEEA5 a (513)586 5011 �,,„o ^Isl ee •.88 King Street, Suite B Atc,,,,q roak eborawskiins cee.COM AP1 Pls)WORDING ER041- ."'AICs Northampton MA 01060-3257 NSURER*Nautilus Insurance Company 1NSUPYD suPE Asps Specialty Insurance Complete Restoration. Solutions Inc instayn a LUDerty.Mutual 30 Haynes Circle IMSURERO Hanover 22292 INSURER E Cn_copee MA 01020 LNnuRER E: COVERAGES CERTIFICATE NUMBER;14/i5 REVISION NUMBER: THIS'S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PCLICv PERI as ',NDIC:ATED NOTWITHSTANDING ANY REDD REMENT, TERM OR CONDITION or ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA1t MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED ST THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. £X LUSIONv AND CONDW ONS OF SUCH FOhOESLIIMITS SHOWN MA?HAVE BEN REDUCED EY PAID CLAIMS Imv _._ __...._ D3t01firkr. _ ._ •v o NL PANCL P�WVO Po4CYNVmOCM MMIPnrf^"f4F I t MMNOP"r`nl, L .T¢ AAL. Hq , GENERAL ur.9ltm ( '. I=fC ncia-a, ' .'dC.OP.t. -_R E X o M E P_ 7 PRt £ 3a 300,000 I A ....1 % ..._ I I ECP190fi11212 8/29/SPld L/2B/Tp]5 � S,OOi'. , .r ' FtELPHN 44 AN.m..;PR 1.000 0 A00 2,000,000' GIRL 6 Emic et,ea _o aC C. Pm_.,. _ 2,030 0001 X7jI. e :dO U oeu.ELIABILITY bY_!iT NO Es : FH +ALA L5 TU6 _._..� X uaeRExw LIAe dcc..a evwcc .. S DC B u XCEssns yt;_A S.00.DO pratacte4 aMit/Tore Iv MS42015 C Fa ON 1 ,'t 1 000 DOC' u M 3rC2w315-324 704-0$4 3/1/ROiC Y 1201` _ S I 1,000 000. 1,_000000' D Ballnant Coverage AIm96595-02 V/2B/2014 A/Ta/2015 ;. ., . v# A CPI. I X2206642212 vicerc011 IL/2s/2015 H 44 , a, newer-on Or CIERATIOAS:LaoCAtIONS/VEHICLES poach ACORM51.AIWnanal R arAa Sthn1se.a mare apace we4m,re, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN For Insurance Purposes Only ACCORDANCE wag THE POLICY PROVI51ON5. AUTNORI]EDREPRESEHTATIE R Borawaki/BORGCS 7_ ACORD 25(20101051 D1968,2010 ACORD CORPORATION. All eights reserved INSC2S:-o c'a o The ACORD name and logo are registered marks of ACORD