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31B-286 (9)
129 MAIN ST BP-2017-0271 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 31B-286 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: WATER DAMAGE BUILDING PERMIT Permit# BP-2017-0271 Project# JS-2017-000141 Est.Cost:$4714.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THOMAS DOLAN 039281 Lot Size(sa,h.): 31755.24 Owner: FIRST CONGREGATIONAL CHURCH OF NORTHAMPTON Zoning:CB(I001/ Applicant: THOMAS DOLAN AT: 129 MAIN ST Applicant Address: Phone: Insurance: P O BOX 297 (413) 585-0612 () CHESTERFI ELDMA01012 ISSUED ON:8/3I/20I6 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE DROP CEILING TILES & GRID WORK FROM WATER DAMAGE WITH FIRE RATED TILE & GRIDS - 500SQ FT - ADDED - REPLACE FLOORING IN KITCHEN & REMOVE 4X6 ASBESTOS AREA 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 $100.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Versionl 7 Commercial Building Permit May 15, 2000 Department use only thiol ' - City of Northampton Status of Permit• : 5 I I Building Department Curb Cut/Driveway Permit _ - >_r' r 212 Main Street SewertSeptic Availability, Room 100 Water(Well Availability__„ of Torvs Northampton, MA 01060 Two Sets of Structural Plans rc .,i r ro.orhone 413-587-1240 Fax 413-587-1272 Plot/Site Plans _ Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This section to be completed by office /of- L,(oa.'v IP /✓bva .�,,d.,_ Map Lot Unit ec,c2�1 /0Mshoz Sr Zone Overlay District ,c4'Jetaysiert me4 •d/06d Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i/�iljto•m ©. PtcQhee 429 10010 et . s#4,4„ N. Name(Pm / Current Mailing Address: CM •to �t,O,. j is/ r's, , 9/3 -sere-2- ilt/2— , n� Telephone 2.2 Autho ze• Agent: /o On baAm.✓ •o I 8c?r 0197 Name(Print) Current Staging Address; Noshes A 0/•4, ma la, Signature �........... Telephone I-//$ c2,7-576 V SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost{Dollars)to be Official Use Only completed by permit applicant _ 1. Building (r' •+e 141 I (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Building on Feee Construct 3. PlumbingPermit Fee 4- Mechanical(HVAC) — — 5 Fire Protection �//-,, /� 6 Total=(1 +2 +3+4+5) 718?. ••7 Check Number g This Section For Official Use Only Building Permit Number Date Issued f¢/�/ Signatureer F / fJ ,;_ Building :mmissionerlins/pector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 ISECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 • CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wall Signs 0 Demolition]] Repairs Additions D Accessory Building 0 Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing El Change of Use Other 0 Brief Description Enter a brief description here. Of Proposed Work: Orp�7 •/uCe. petorrt5 fit, .Gycil'n.i- lrwi yx 4seP.J�O� .-/t SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 0 A-2 0 A-3 ❑ IA ❑ A-4 ❑ A-5 ❑ 1B 0 B Business 0 ............ 2A ....... ❑ E Educational 0 28 ❑ F Factory ❑ F-1 0 F-2 0 2C ❑ H High Hazard 0 32‘ ❑ I losttutionai 0 I-1 0 I-2 0 i-3 ❑ , 38 M Mercantile 0 i 4 ❑ R Residential 0 R-1 0 R-2 ❑ R-3 0 5A 0 S Storage 0 5-1 0 5-2 ❑ 5B ❑ U Utility ❑ Speciry:. 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(s(} 1a '. .. 4" Total Area (sfl Total Proposed New Construction(st) Total Height(fl) . I Total Height It _. 7.Water Supply(MG'. c.40,§54] 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Vermont Commercial Budding Permit May I5,2000 8. NORTHAMPTON ZONING 1 Existing Proposed Required by Zoning This column to be filled in by Building Depanmeat Lot Slab _.. . . _ Frontage .. . Setbacks Front Side G.. . R L R: Rear Building Height --_ Bldg Square Footage Open Space Footage (Lot area minus bldg&paged parking) #of Parking Spaces - -- Fill: _. (volume&Location) A. Has a Special PermittVariance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES O 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 wafer or wettands? NO 0 DON'T KNOW (3 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date issued: C. De any signs exist on the property? YES Q NO \J IF YES, describe size, type and location: - - - . -- D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 0 Name(Registrant): _ _... 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 _. . Signa:ure 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 AI(ihil I(ihieftiy [ 44110/01 Not Applicable 0 Company Name. .._.._ .. . . .. Responsible In Charge of Construction 8 RO 00t .0177 41. SeOlki Address Signature Telephone • Versioni.7 Commercial Building Permit May IS,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 119.11) ((�� tndependent Structural Engineering Structural Peer Review Required Yes 0 No V SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .as Owner of the subject property hereby authorize 1 ' 4.. e%, s ktl _.. _ to act on mybehalf,in/{ /� /u x matters relative ttoowork�ae,uthorizay this building permit application. eota : • Signature of Own- Date /emVlJfy - _: 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 beliet. under the ems and penalties of penury Signeda��snl Parr, ame lS /6 Signatt e f Owner/Aden( Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: ,q Not Applicable ID Name of License Hot der __/„j®��test /{'� _65N 0. 70"4 License Number Q Q 7 hetks ^� Mitis (work A2- a oi/7 ATelephone Expiration 08te gd TQ9971.576Y _ Sign SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must he completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the h Mina perma Signed Affidavit Attached Yes No 0 The Commonwealth of Massachusetts - - Department of Industrial Accidents • Office of Investigations } r;s 600 Yf'ashinnYon Sheet Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information /� /' (Please Print Leaibv Name (Boniness/Organization/utdividual): rfttrf��. -1,2 'J�b` 40, Seole IL��/////jy YJr&'626I� _.�._ Address:_ — j ,9Q? ehg 4'. City/State/Zip:_„ Phone 4`: ,1'//3 di lir _..-57 6 `/ Are you an employer?Check the appropriate box: Type of project{requited): 1.�t am a employer wztt t 4. [� S am a general contractor and 1 b w 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. IVRemodeling These sub contractors have ship and have no employees &. 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers'comp.insurance camp. insurances required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.Ti Lam a homeowner doing all work officers have exercised their I1.f7 Plumbing rep}hs or additions myself. [No workers'comp. right of exemption per MGL. 12.0 Roof repairs insurance re abed- c_152, §1(4),and we have no q employees. [No workers' t'},0 Other comp.insurance required.] 'Any applicant that checks box d1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- iConvacfors that cheek this boa must attached an additional sheet showing thenen of the subcontractors and state whether or not those entities hem employees. lithe 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. J Insurance Company Name: j __ y.,j_ $. am_, t s)o�aL- fist ] ).-^� Policy#or Self-ins.Lie.#: /n 6+M - �C6/'r 1. t,P V Expiration Date: Q- ,, /6 '/ Job Site Address„ / t f ttin d City/State/Zip: Ate, Mw 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 MCL,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 maybe forwarded to the Office of investigations ofthe ..��DR for insurance coverage verification. Ihereby terf under the pains an enables of pepedal),that the information provided above is trueand correct. S'enalure' Date: 1 PhnneN: 1/13a17en)/Jl Official use Only. Do not write in this area,to be completed by cm'o'town official City or Tomo; Permtt[License N Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other 1 Contact Person: ___ Phone#: ._ City of Northampton 212 Main Street, Northampton, MA 01 060 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: /07y an of The debris will be transported by: n- 2.-G- - MA,4 The debris will be received by: fit Building permit number: Name of Permit Applicant tint V 4 44/ Date Signature of Permit Applicant