23B-044 (13) 41 LOCUST ST- 1ST FLOOR BP-2017-0762
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-044 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-0762
Project# JS-2017-001274
Est.Cost: $23400.00
Fee: $161.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL BISGROVE 085661
Lot Size(sq. ft.): 23435.28 Owner: DAVID GARDNER
Zoning:NB(1001/ Applicant: MICHAEL BISGROVE
AT: 41 LOCUST ST - 1ST FLOOR
Applicant Address: Phone: Insurance:
8 HERRICK RD (413) 241-1757
BLANDFORDMA01008 ISSUED ON:12/12/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATION OF EXISTING SPACE, NEW
DRYWALL & DOORS, NEW DROP CEILING, ELECTRICAL, NEW BATHROOM DOORWAY AND 15
REPLACEMENT WINDOWS
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 12/12/2016 0:00:00 $161.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0762
APPLICANT/CONTACT PERSON MICHAEL BISGROVE
ADDRESS/PHONE 8 HERRICK RD BLANDFORD (413)241-1757
PROPERTY LOCATION 41 LOCUST ST- 1ST FLOOR
MAP 23B PARCEL 044 OW ZONE NB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT +
Fee Paid /�1 ,,�
Il
Building Permit Filled out VVV
Fee Paid
Typeof Construction: RENOVATION FISTING SPACE,NEW DRYWALL&DOORS,NEW DROP
CEILING,ELECTRICAL,NEW BATHROOM DOORWAY AND 15 REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 085661
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O ATION 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
D lition D ay
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 40&Contact Office of
Planning&Development for more information.
Versionl.7 Commercial Building Permit May 15,2000
Department use only
DEC - 8 City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability_,
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-5871240 Fax 413-587-1272 Plot/Site Plans
l Other Speeify
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 4i Liao
This section to be completed by office
4i Lo'1ci4d ¶ j- - Ut.0`54.6,3 5 Map Lot Unit
3IUdr44' arntia 77Y1 t+ t. Zone Overlay District
---1 - - -- - - Elm St.District CE District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: .. f 0/076
pair /ftaATtt lAt. •! / // Ues11Qrn luc
Name(Print) Current Mailing Address/
> f 7 3 766`? 3/5—
Signature Atire4 - Telephone
2.2 Authorized Agent:
M1 rJ-c.,eJ 31st ccne_ _. 8 Herrick, ed. ` ala.cwnrd (!Mi of •g
Name{Pant} Current Marling Address
Signature :L `�Ce.C..naAAA: Telephone _
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building + 4200 co (a)Building Permit Fee
/ A
2. Electrical (b)Estimated'Total Cost at
Oy
IJ -C} Construction from e
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I8r f.d /q
J. Fire Protection (J(,)
6 Total=(1 +2+3+4+5) 60a Check Number •r -
This Section For Official Use Only
Building Permit Number Date
Issued
Signature.
Building Commissioner/inspector'of Buildings Date
ti CKyblsyovc, 3mco l . Lure
Le
V ersioi t.7 Commercial Building Panne May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 36,090
CUBIC FEET OF ENCLOSED SPACE
Intoner Alterations 0 Existing Wall Signs ❑ Demolition❑ Repairs L+J Additions ❑ Accessory Building
Exterior Alteration 0 Existing Ground Sign❑ New Signs 0 Roofing❑ Change of Use❑ Other❑
Brief Description S{,nUT1QtUn O -`3 S 't
tSknCj S (J(Lf;,vkc oz;rs >7ps.0
Of Proposed Work: a,§-73p t trn tie civ- LcL -'�. 4 ACt-af xd2ta!?ttiuX.,f,
t //
SECTION S-USE GROUP AND CONSTRUCTION TYPE #410 Acta /.W rxl(y+rc
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A..1 0 A-2 ❑ A-3 0 1A ❑
A-4 ❑ A-5 0 18 0
B Business 0 1 2A ❑
E Educational ❑ 28 ❑
F Factory ❑ F1 ❑ F-2 0 _ 2C 0
H High Hazard 0 3A { ❑
I Institutional ❑ I-1 p 1-2 0 I-a ❑ 3B 0 '�..
M Mercantile ❑ 4 ❑
R Resldenliat ❑ R-1 0 R-2 ❑ R-3 0 5A ❑
S Storage 0 S-1 0 5-2 ❑ 5B ❑
U (ARO ❑ Specify: :
M Mixed Use ❑ Speciry .. .... . . .
5 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 OMR 34)- Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE ONLY
BUILDING AREA EXIST7PIG PROPOSED NEW CONSTRUCTION
Floor Area per Floor(s0
arda
4m , 4^
Total Area(si) Total Proposed New Construction(s'p
Total Height(ft) _..
Total Height ft
7,Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: L3 Sewage Disposal System:
Public 0 Private ❑ Zone' _Outside Flood Zone I Municipal ❑ On site disposal system!:
Version] 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 -.: L R
Rear
Building Height
Bldg. Square Footage % - -- -
Open Space Footage
(Lot area minus bldg&paved
parking) -- --. -.-_ -
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ♦;9 DONT KNOW Q YES Q
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 4) NO Q
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 co
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES Q NO 0
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 ❑
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 1i
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
ISC`f(J 1t COns CL1iiC-1-iotn _. _.. Not Applicable 0
Company Nae
0'9 litAel r6 ,s141DJ
Responsible In Charge��off(C�ons ction y-/) /,/ ry
HFfrlck ed bl&nclC� iliA d/(1Dd '
Ad ss
LNCUCC 'Of') 9-132y1.1751
Signature Telephone
Vermont Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) pp^^��
Independent Structural Engtneenng Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTR44ACTOR APPLIES FOR BUILDING PERMIT
I...... A`!t G `,+-�fd-T1¢ ,as Owner f the subject property
hereby authorize. . V.tC1/1Ln A._ ) ALV• to
ac '.n my bete ) I• -tt relative authorized by this bolding penal!apphcattun
t Sp-na /n�ture of Owner Date
I, PA I C.�I(A i I,�I S Qv ,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
end belief.
Signed under the pains and penalties of perjury
I" IL.-11pd Becj rove _..
Pr Name
Signature of Ow rlAOent Data
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Constructi((o)�n/}}Supervisor: Not Applicable 0
Name of License Holder• Oil/! i } t �_ ... .. ... _
License Number
-c riot Cd BiCcoafiWj AA O)VO CS- e iFitc(cl
Pdpress Expiration Date
..� $�. Li/1,141 . 1161 - 30 ( 07
Signature / Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL.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 th(e building permit _
Signed Affidavit Attached Yes
e.
_ The Commonwealth of Massachusetts
Department ofIndusn-iat Ac idents
`,
, �_ re. Office of Investigations
16--1" - 600 Washington Street
Boston, M.4 02111
www.ma,ss.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual): ffi/l�y�4 131310
/-�) h l f 51)rt v tn-
Address: 1-1 .7 t _. e/
jn tpy
City/State/Zip: ._. _ A 'a. ... I 04'hone#: i , L-.,1, ) 7f. 7
Are you an employer?Check the appropriate box: Type of project(required);
I.❑ 1 am a emPIoYer with 4. ❑ 1 am a general contactor ands
o. ❑New construction
employees(full and/or part-timer have hired the sub-contractors
2.yo I am a sole proprietor or partner- listed on the attached sheet. 7. 12 Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in any capacity. employees and have workers'
9. 0 Building addition
[No workers' comp.insurance comp insm'auce
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MOL 12,11 Roof regatta
insurance required.]t H. 153,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#t must also en out the section below showing their workers'compensation policy information.
t Homeowners who submit tits affidavit indicating they are doing all work and then hire outside cuneacmrs mnstsuknit a new affidavit indicating such.
*Convectors that check this box nwstaetaclled an additional sheet showing the name orate sobcontra,ttors and state whether or not these entities have
employees. If the 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,
Insurance Company Name:
Policy#or Self-ms.Lie,#: 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 MOI,c. 152 can lead to the imposition of criminal penalties ofa
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 may be forwarded to the Office of 1
investigations of the DLA for insurance coverage verification
r do INrely ;tiff �'�he,,c 'us and penalties of perjury that the information provided above is true and correct
Phone ;tiff underIlii- Date: /3 . /6
Ltorch
S o
#: '7 4,1 / J 7
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License k ,..
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone k: __
The Commonwealth of Massachusetts
Department of Industrial Accidents
ll-=-—
= 1= "l
Office of Investigations
Y te ' 11
t=_i - I Congress Street, Suite 100
='•►_►_� Boston,MA 02114-2017
•�`''J www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant InformationPlease Print Leeibly
Name (Business/Organization/Individual): 'ndividual): ]Lint,.� D/1 rtvt,
I-
Address: k Cfr1co Pd
City/State/ZiplR}&y'r xp A' . DIOOS Phone#: I3, olgI , I -- 7
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.1p I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P ty 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.-
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12❑Roof repairs
insurance required.]' c. 152,§1(4),and we have no - '
employees. [No workers' 13.1]Other YerpIacipti to hnagOkb
comp. insurance required.] ..//
•Any applicant that checks box 01 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 suck
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.
/am an employer 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:
lob 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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do herebil
ertify under t t,ins and penalties of perjury that the information provided above is true and correct
Signature:: [ It . 'lit./' h/& Date:
}
Phone#: 413 , L[ I . 1lir
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#:
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: 41 L0 CSS S*
The debris will be transported by:
( �\SGC0V2 Con��rlAC�hun
V
The debris will be received by: Val e) R,Q c lel c ) i 1)c
J
Building permit number:
Name of Permit Applicant IN\ V ki,,e l 1:‘5(A r( v-e
gl � �J
Date Signature of Permit Applicant
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City of Northampton
Building Department •
Plan Review
212 Main Street /
Northampton, MA 01060
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