31B-145 (13) 44
112 B KING ST BP-2004-0811
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B- 145 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0811
Project# JS-2004-1200
Est.Cost: $10800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Jeffrey Dome 043099
Lot Size(sq. ft.): 8058.60 Owner: YENNER WILLIAM
7unin : Iv:.? Apolica : Jeffrey Mme
AT: 112 B KING ST
Applicant Address: Phone: Insurance:
2 Fiske Mill Rd (413) 625-9244
SHELBURNEMA01370 ISSUED ON:2/24/04 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR APARTMENT REPAIRS, CABINETS,
CEILING TILES
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:
0 4 ,'Sj� Driveway Final:
Final: 7-1S'Q1--af Final: ;(30)C-1244, a)( 'V /y Rough Frame: ' ,gyp
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: ,P,�
Final:ti--/b--.0.1 a, moke: Final:O/f y-/�-B4f/�L(.,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT OF
ANY OF ITS RULES AND REGULATIONS.7Certificate of Occupancy ---- � ------ se# r .. ,---Zite
Signature:
FeeTvpe: Receipt No: Date Paid: Check No: Amount:
Building 2124/04 0:00:00 267 S50.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
ffA r 771
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•
112 B KING ST BP-2004-0811
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B- 145 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0811
Project# JS-2004-1200
Est. Cost:$10800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Jeffrey Dome 043099
Lot Size(sq. ft.): 8058.60 Owner: YENNER WILLIAM
Zoning: NB Applicant: Jeffrey Dome
AT: 112 B KING ST
Applicant Address: Phone: Insurance:
2 Fiske Mill Rd (413) 625-9244
SH ELBU RN EMA01370 ISSUED ON:2/24/04 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR APARTMENT REPAIRS, CABINETS,
CEILING TILES
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:
Dri%eway 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: Receipt No: Date Paid: Check No: Amount:
Building 2124/04 0:00:00 267 $50.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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File#BP-2004-0811
APPLICANT/CONTACT PERSON Jeffrey Dome
ADDRESS/PHONE 2 Fiske Mill Rd SHELBURNE (413)625-9244
PROPERTY LOCATION 112 B KING ST
MAP 31B PARCEL 145 001 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 9 AO
Fee Paid
Typeof Construction: INTERIOR APARTMENT REPAIRS,CABINETS,CEILING TILES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 043099
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 .' 'ssion
,P -I' 2_4/-COY
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.
a �
•
a Versionl.7 Commercial Building Permit May 15,2000
--- Department use only
City of Northampton Status of Permit:.
r -Building Department Curb Cut,'Driveway-Permit -
E �r, r �L E i . 212 Main Street Sewer/Septic Availability
1' r`.=-= Room 100 Water/Well Availability
Vit..,,° :-- ------
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Northampton, MA 01060 Two Sets of Strticturat Macs_-_
FEB phone 413-587-1240 Fax 413-587-1272 Plot/Site Pians
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
A . ' OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: G .5This section to be completed by office
11 , 5 K /N1 map 3' !J Lot I t5 Unit
Not i N AM PToi) Zone NIB Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l, Y!2 - / - f o y6=?x -7/7 4,..„ k/5
Name(PrintCurrent Mailing Address: ,,f'idit O/3-7a
I4t —liki r./ 62 92411
Signator• Apr Telephone
2.2 Authorized Ape
TE FFRENI Dot-1E Z FiSke rt uc (. AD. 5MELI3QRNt tlA.
Name(Pint) Current Mailing Address: Of 370
cry-A-- y 1 3 6 ?S - 5 2 Li y
Signatu 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
c c)00
2. Electrical 3 DO I (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
( 500
4. Mechanical (HVAC)
5. Fre Protection
6. Total = (1 + 2 + 3 + 4 + 5) I Check Number 13-6
{ This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
IF
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Iterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing C
❑ 0
Exterior Arations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
Accessory Building [ ] Repairs [N,4
BRIEF DESCRIPTION: APARTI-1J) T RMPA/R51 CARPET , PAINT CA,4&NETS , CEICMNGTILF5
SECTION 5- USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) I CONSTRUCTION TYPE
A Assembly 1❑ A-1 0 A-2 E A-3 C 1A j 0
A-4 ❑ A-5 0 16 I 0
B Business 0 2A 0
E Educational 0 26 I 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 - I-2 0 I-3 ❑ 3B 0
M Mercantile I❑ 4 ❑
R Residential 3(/ R-1 ❑ R-2 0 R-3 ❑ 5A =
S Storage 0 S-1 ❑ S-2 0 53 I C
U Utility 0 Specify:
M Mixed Use C Specify:
S Special Use C 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 Roor(sf) 1st -
845iMG'xer S ZS — _
2nd
1st
2"d 3rd
3rd —
4th
4th
•
Total Area (sf) Total Proposed New Construction (sf)
---------------
Total Height(ft)
Total Height ft-------------
Versionl.7 Commercial Building Permit May 15,2000
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 Rood Zone 0 Municipal 0 On site disposal system 0
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
IA Setbacks Front
t� 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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:
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 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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 Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor—
✓ CFFR E'l Dc fr1k Not Applicable 0
Company Name:
TE FFKE y Dor1E
Responsible In Charge of Construction
FISKE tint AO. S H EL, )I A dE 1 PIA . 01 370
Airs
' p
S0 y � 3 6ZS -5z�l4
. Teiephone
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 "es 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i
i/t/iitot_erwki.c.e_ as Owner of the subject property
hereby authorize �e )D0Yke— to act on
my behalf n all matte relative authorized by this building permit application.
Sign a of 0 er Date
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I, 7E FFREDo tic , as Owner/Authorized Agent
hereby declare that thestatements 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.
5EFFAEy QoriE
Print Name
.i
Z
.i a O
Signature of a :� Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable
0
Name of License Holder • j C O I' D 9
2 cl
� %faXpa ' License Number
ea�w�►r�
S� ice\ 01 70 S/ s-/
20
ess Expiran Date
JDA_ y l 3 CO25- 91-44
10 • • Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted witn this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes Il No 0
. . .
O�SIWip2,O
F, `.`e (Lii-i of 1rrf17ampfon ►-
A• Jab ^EtssRchntells ^ �._ • t=
T f =
—..s� —
DEPARTMENT OP BUILDING INSPECTIONS I4 —'
fiC z .
212 Main Street ' Municipal Building
?Northampton, Mass. 01060 r
WORK:ER' CO?vE ENSATION CISURANCE aI-FED AV1T
-- 7EFFRc y — Dori -- '
(li ccascrJpermi t1ec)
with a pnncipai place of business/residence at:
2 POKE H/L ( R D. 514EL ANE) MA, (phone'.) 411 6, 2,5- 1 Z `l'(
(s rrwth_•i ty/sta.tc i p) O/37O
do hereby certify, under the pains and penalties of perjury, tai • . •
( ) [ am an employer providing the followine worker's compensation coverage for my •
employees working on this jobi
acs,.r- Con? ') • (Potic:Number) .(:::pi:cion Dale)
Sp I am a sole proprietor, c ��or 5oneowner (cce one) and have hires
the cooter aciors listed ''Delo% w i• 'e the following worker's comoensz6on policies:
. (Nomc of Contmczo-) (;ns+rance Company/Polk-1. t )tom . - Irz?Irduon Dau)
1.:aJl p ' Si
tt0 RIZ!
(Name of Cootraaor) (l.nsuranc Company/Policy Nuclb:r) (Exi i,zition Date)
(Name of Cooaacio) (lntsura.ac:. Company/policy Na > ) (Expirr000 Datc)
(Name of Cootracior) (Insuranc Company/Poticy Number) (-xpuatioo Daly).
(saacla.doz=e.!bca if 000cz.r).to inetwSc informs-ion pertaiaias to all oo.:=-..con) ,
( ) I am a sole proprietor and have no one worm for me. •
P g
( ) I am.a home owner performing all the work myself.
NOTE:Pic=sc bc awue Lb=,a''.ie boeaoo.aacra Sabo cm{a:oy pe-.oes to do r-,i.-.n,...-• a :e.aoo a rgair work on a dws1=g of
not ta=r:th_c L`71,e twits io,Atida the bomoow,a raid=or oo th.c I-ourxia zppurteo.zrr dare.=t c Dot eco raft'pec-d=ad to bc
aMployes u.G-the watch co=peasztioa Ara(GL152,,1(5)),appt;a000 by a bcrr.aow-oc far c uc:=:or pcmit cr-ty n idc3oc the
Ie s.1 r..ou of en.mploy.r under ciao woriror.Compeo,a:ion Ant
1 undo-maxi ttza a copy of tlai,mrocum may b.rorrwrd.d to ch.Doq.nmeee of Iodutrict Acode..s'OCGo.of 410t+n00e for th.
'Dove tee veiGtsioo mad th1 Lilt=to swum boverabz under sociion 25A of MOL 151 me lead to the i,.Gaositioo of eicaiatl perlabies
oonsiairtg of a Calc atm to S1_500.00 andfa Co2prisocsoocca of up to ooc yv cod coil pcma io io c ram of a Slop Wort Ordc and a
flan of Z100.00 a day actiast cc
. For d�.rwti-�v.e only
/ r I Permit Hl1IDt)c'
Er .' •c rani ucc / ( t1�ce 1