31A-069 (8) 206 ELM ST BP-2017-0641
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-069 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Egress$[airs BUILDING PERMIT
Permit# BP-2017-0641
Project# JS-2017-001041
Est.Cost:$2500.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN C CLARKE 106082
Lot Size(sa.ft.): 8058.60 Owner: SALLOOM SIMON
Zoning:URB(I00)/ Applicant: JOHN C CLARKE
AT: 206 ELM ST
Applicant Address: Phone: Insurance:
92 JANUARY HILLS RD (413) 335-3644 SOLE
PROPRIETOR
AM H E RSTMA01002 ISSUED ON:I1/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:BUILD DECKING & FIRE ESCAPE LADDER
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 it 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 11/7/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0641
APPLICANT/CONTACT PERSON JOHN C CLARKE
ADDRESS/PHONE 92 JANUARY HILLS RD AMHERST (413)335-3644
PROPERTY LOCATION 206 ELM ST
MAP 3IA PARCEL 069 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid st 1
Building Permit Filled out ID* `
Fee Paid ✓
Tvpeof Construction: BUILD DECKING&FIRE ESCAPE LADDER
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106082
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
Demolition Delay
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.
p7 Versionl.7 Commercial Building Permit May IS,2000
" r Department use only
�c , .''City of Northampton Status of Permit
Building Department cum Cut/Driveway Permit
/ 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 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. 1 This section to be completed by office
706 1(AN S/ - Map Lot Unit
/Jo / /� rn N�•/o .. /4/4JTqq CIOC D Zone Overlay District
-- --- -- _.- Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
206 ('I-, .T/ AZ// fie . 414
Name(Print) Current Mailing Address'
3/a 7y9 anfl
Signature Telephone
2.2 Authorized Agent
?06.7 C. Cla/ke q.2. 0-aft,...-7 1 rI& H4
Name(Print) Current Mailing Address / 0/cot
(1/1-335-36Y y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building 12 S00Oo (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
6 Total= (1 +2+3+4+5) Check Number /05
This Section For Official Use Only
Building Permit Number Date
OC_ Issued 1/ /7//6
Signature:
Building Commissioner/Inspector of Buildings Date
Versonl.7 Commercial Budding Permit May IS,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition 0 Repairs Additions 0 Accessory Building
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other 0
Brief Description Enter a brief desert tion here. arc k,4 + j
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A4 ❑ A-2 p A-3 0 IA ❑
A-4 0 A-5 0 1B ❑
B Business ❑ 2A ❑
E Educational 0 28 0
F Factory 0 F-1 0 F-2 0 2C ❑
H High Hazard 0 3A O
IIns
Ntitutional 0 I-1 0 1-2 0 -3 35
❑
Mercantile ❑ E 4 0
R Residential ❑ R-t 0 R-2 ❑ R-3 0 5A ❑
5 Storage 0 S-1 ❑ 5-2 0 SB I ❑
.___. '.._.. c....._
U Utility ❑ Specify:
M Mixed Use ❑ Specify.
S Special Use ❑ Specify. __-
COMPLETE THIS SECTION;F EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDfOR CHANGE IN USE
Existing Use Group: ._.. ._ _.. ._. Proposed Use Group:
Existing Hazard index 780 GMR 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)
End
3°
Total Area(st) That Proposed New Constructionist)._
Total Height(ft)
Total Height H -
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❑
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 L R.
Rear
Building Height - -
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
narking) ._.
#of Parking Spaces - ----
Fill.
(volume&Location)
A. Has a(�{Special Permit/Variance/Finding ever been issued for/on the site?
lam
NO ' DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 43' DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO a�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO red
IF YES, describe size, type and location:
E. Willl 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Vet sionl 7 Commercial Building Permit May 5,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 750 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) _
9.1 Registered Architect:
__.. . _._.. __. Not Applicable ❑
Name(Registrant) __ __ .. .._. .. _...._ ...
_. __.. . .
_. _....... Reyis,2tion Number
Address ..... _. _ _. .. _.
Expiration Date
Signature Telephone
92 Registered Professional Engineerts)c
Name --- Area of Respanelbflity
address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
5ddress HeSstraton Number
Signature Telephone Exp ration Date
Name Area of Responsibility
Atldres, Registration Number
Signature Telephone
gn' Execration Date
Name Area of Responsibility
Atldresv Registration Number
Signature Telephone Expiration Date
9.3 General Contractor]
30Ari C. (/a'I*C Not Applicable 0
Company Name_
C4Rrfr (1p.c 2 !,,,reale. S _
Responsible In Charge of Constmction ll
Jokn Cc Clarke 92nzr J. g. //t .f . ",L•57-
Addressf (4A
T�1-�j�'�� // ,l� 41t3-33S4Gyy
Signature " Telephone
•
Version1.7 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 Q
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
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 penury.
Print Name
Signature of Ovmer/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder 3s!„7 C. Caree
p / // y n License Number
(Z. JPA G.. /'d`S K6..eT /4C✓v7 /tt c,4Q7/.. C5-fob QV-
Expiration Date
Y13- 335-36Y `/ (/I7Jo/$
5 tore Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§250(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 No 0
The Commonwealth of Massachusetts
Department ofIndustr•id Accidents
Office of Investigations
600 Washington Street
.lioston,MA 02111
r 'u-
www.n¢ass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E.'.kkctt'IciansJPlamhers
Applicant information C L Please Print Legibly
Name (Busmness/OrganizadioMndividual);^�-Sthn .. C('cua bo
Address: 7esy.Z tOana.�y 11: S Pam{
City/State/Zip:j4i»L+✓ T!S /1.4 too a. Phone#: /?^-33 f
Areou an employer?Check the y p appropriate box: Type of project(required):
i.❑ I am a employer with 4. I am a general contractor and I 5 ❑New constriction
employees(full and/or part-dine).* have hired the sub-contactors
2$ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contactors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
(No workers'camp,insurance comp. insurance.'
required.) 5. I r We are a corporatiot and its 10.❑Eketical repairs or additions
3. El I am a homeowner doingall walk officers have exercised their I1
_❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
112.❑ Roof repairs
insurance required.]t c. _1.52, §1(4),and we have no
employees, [No workers' 13.❑Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit new affidavit indiva Ong such.
Contractors that check this box must attached an additional sheet showing the name of the sub-connacrors and state whether or not those entities haat
embryos". If the sub-contractors have employes,they must provide their workers'comp.mlicy number.
I i n an eneployer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip: •
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 Iead 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 of the DIA for insurance coverage verification_
I do hereby certify an the a- d penalties of perjury that the information provided above is true and correct.
SSi nature: Date: 0772 9/ a
Phone#: `/f 3- 33C- ,3(. <j y
nOjficiad use only. Do not write in this area, to be completed by do'or town official.
City or Town: Permit/License f
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspecfor
6.Other_
Contact Person: Phone#: _, y
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: 9206 F(ri 5-Peen No.rtia 7t ,, !`//J
The debris will be transported by: M. 54/dc,,,, 1 e, c_
The debris will be received by: /4- Q,//c,„4, 1h c
Building permit number:
Name of Permit Applicant John
///77/6
Date v Signature of Permit Applicant
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