31C-015 (4) 137 WEST ST-FIELD GARAGE BP-2017-0919
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 3 IC-015 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:INSULATION BUILDING PERMIT
Permit d BP-2017-0919
Project le JS-2017-001570
Est. Cost: $13000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group; SCAPES BUILDERS & EXCAVATION LLC 021087
Lot Size(s4. ft.): 936540.00 Owner: SMITH COLLEGE OFFICE OF TREASURER
zoning-1'FR{I 22''RR t122 'WP t4871 Applicant: SCAPES BUILDERS & EXCAVATION LLC
AT: 137 WEST ST- FIELD GARAGE
Applicant Address: Phone: Insurance:
P O BOX 469 (413) 665-0185 O WC
D E E R F I E L D MA01373 ISSUED ON:21612017 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK AND INSULATE EXISTING
PESTICIDE ENCLOSURE IN METAL BUILDING *PLAN VIEW REQUIRED
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: 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 2'6/2017 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587.1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0919
APPLICANT/CONTACT PERSON SCAPES BUILDERS&EXCAVATION LLC
ADDRESS/PHONE P 0 BOX 469 DEERFIELD (413)665-0185 0
PROPERTY LOCATION 137 WEST ST-FIELD GARAGE
MAP 3IC PARCELOI5 001 ZONE FFR(1221/RR(122)/WP(48)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: SHEETROCK AND INSULATE EXISTING PESTICIDE ENCLOSURE IN METAL
BUILDING
New Construction
Non Structuralinterior
or renovations
Addition to Existing 0 p G /
( Q
L () N
Accessory Structure d U(
Building Plans Included:
Owner/Statement or License 021087 9 &bu IJ
3 sets of Plans/Plot Plan Y ddd
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO/ORATION 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
% p -3 - /7
SifBuilding 0 n:ia 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.
3.0
Version1.7 Commercial Buildin: Permit May I5,2_000
Department use only
\ City of Northampton Status of Permit
OJ \Building Department Curb Cut/Driveway Permit
e �z" 212 Main Street Sewer/Septic Availability
( Room 100 Water/Well Avatlabdity
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans_,—
Other Specify
APPCATIONTO 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 Addres4'. This section to be completed by office
/ ._ M1
37 et ed5-74t (A/oh-lw, 714 Map Lot Unit
Fr.�a�e Zone Overlay District
e(€'
-- - Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Ownecef R5Qf& //,- t p ,/ ;�y
/IFI 5 �f.•-7/447-4. (&/e/ � /LL wz S f s-F� N617JVlaPP Il in
Name(Pont) At Current Mati ng Address
Lmcrncy3 +�)"�� zf T 3 -J'-6S -zti-2y
Signature Telephone
2.2 Authorized Agent: _ ' --
Maine(Print) Current Mailing Address
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS r"
item Estimated Cost(Dollars)to be Official Use Only
com.ieted bypermit applicant
I. Building AO 44126 (a)Building Permit Fee
2. Electrical 6100
(b)Estimated Total Cost of
t/C Construction from 16) _
3. Plumbing Building Permit Fee
4. Mechanical(NVAC) -- - -' -
5. Fire Protection
6. Total=(1 +2+3+4+5) It 3 6M Check Number ,(0) lieCl
This Section For Official Use O� C/ �—
Building Permit Number Date
Issued
Signature_
Building Commissionerrinspector of Buildings Date
Versfonl.7 Commercial Building Permit May 15,2000
ON 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
FEET OF ENCLOSED SPACE ]'
x Alterations 0 Existing Wall Signs 0 Demolition Repairs(L�j Additions 0 Accessory Building 0
for Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use Other 0
Description •Enter a brief description here SAS-frvz/C c..-d r )'t S Le letie exrfi�y.�
roposed Work: 7 .--517 Ci de eh t f D J it t-e A"i ft 1E-1-/ Iou� l��tf r
TION 5-USE GROUP AND CONSTRUCTION TYPE I
USE GROUP(Check as applicable) _ CONSTRUCTION TYPE
3mem* ❑ A-t ❑ A-2 0 A-3 ❑ i IA Ri ❑
A-4 0 A-5 0 18 0
usine_s 2A
uc
dational 0 2B [Q
actory_ 0 F-1 ❑ F-2 0 2C ❑
sigh Hazard 0 3A ❑
Istitutiional 0 I-1 0 42 O ( 3 0 3B ❑ _ 1
0
Residential 0 R-1 0 R-2 0 R-3 0 SA
Storage 0 S-1 0 8-2 0 5B ❑
Utility 0 Speciy
Mixed Use ❑ Specify.
Special Use 0 Specify 1 — _ - . -_- _.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
ixisting Use Group: ....._ ... Proposed Use Group 7 -_... _
Existing Hazard Index 780 CMR 34) _. _. Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA I ^`
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
_ . . 1s
1R'
2w.
3'
. 1 3" ... ..
4m _ - - 4 -. __
Total Area(if) Total Proposed New Construction(sf) _.,.
Total Height(ft) _..
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Fined Bone Information: 7.1 Sewage Disposal System:
I Pitt C3 Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Fi
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed I Required by Zoning
This column to be filled in by
Building Depamnem
Lot Size ....
Frontage _..
—__
Setbacks Front a '
Side
Rear ... ,.
Building Height
Bldg. Square Footage I %
Open Space Footage
(Jot area minus bldg&pvcd
padcinpJ
#of Parkin_Spaces _„
(volume&Localon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW p YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 DONT KNOW 0 YES (3
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained (J Obtained O , Date Issued: ,
C. Do any signs exist on the property? YES Q NO ;►!4
IF YES, describe size, type and location:
0, Are there any proposed changes to or additions of signs intended for the property ? YES Q NO GI
IF YES, describe size, type and location:
E. Wi11 the construotlon activity disturb(clearing,grading,excavafon,or Ming)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northnmpioo storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CTION CONTROL PURSUANT TO 790 CMR 116 CONTAINING MORE TI-IAN 36,000 C.F.OF ENCLOSED SPACE)
erect Architect
... . .. .. ... . - - Not Applicable ❑
_. _. .. Regrsiration Number
Expiration Date
Telephone
tistered Professional Engineer(s):
—_ .._.. Area of Responsbdily . . _.
Registration Number
Nre Telephone Expre4un Date
e Area of Responsibltity
rens _.._ Registraton Number
nature Telephone Expiration Date
Joie _._ -- Area of Responsbily
dtlress Regtsha6on Number
$gnaNra Telephone Expiration Date
Name Area of Resoonstbillty
Address Registration Number
•
Signature Telephone Expiration Dale
9.3 General Contractor
�cCc eS LL3N7c4ij .e,+- Ave'{,b n-
Company Nam •
Responsible l arae of Conutmci on
Address cud /3
Managing
Member,Lie 03-66510n's`
Signature Telephone _
Versionl.7 Commercial Building Permit May G5,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 1 pp^^}}
Independent Structural Engineering Structural Peer Review Required Yes 0 N 4J
SECTION 11 -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L ` /({{
/Ok e /Y- ( Ady. i/ 5>dit/f, i/ddr!S�, : as Owner of the subject property
hereby authorize. . L"LG f1C„S _ to
act O:+e behalf,in all matters relative/to work authorized by this budding permit application.
/i/ th717/ /� , �4 _
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
Rini Name . ... _. __.
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 licensed Constructionj}Supervisor Not Applicable El
Name of License Holden {/31{. Ljex,S eirrwe-rs o20.07
License Number
I/O Aint th. { //3 r eA `7
4 0 `/3 '7 _ _WS/2-ors
Address Expiration Date
O—`—~ Managing 71/3>- 5 18
signature / mombeiLWTelephone
SECTION 13-WORKERS`COMPENSATION 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 result
in the denial of the issuance of the building pernittt.
Signed Affidavit Attached Yes 0 No 0 _ __,J
The Commonwealth of Massactricsetts
Department of Industrial Accidents
Office of Investigations
t coin
I !: 600 Washing on Street
Boston, MA 02I11
www.neass.,govfdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A .licant Information Please Print Legibly
Name(Business/OrganizatioMndividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.E l am a employer with 4. 0 I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6eco construction
listed on the attached sheet 7. Remodeling
2,0 I am a sole proprietor or painter-
ship and have no employees These soh-contractors have g, 0 Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[Na workers'comp.insurance comp.insurance.I
5. We are a corporation and its 10.E Electrical repairs or additions
required.]
C
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing or additions
myself.(No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t e. 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required.]
'Any app/leant that checks box PI 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 must submit a new affidavit indicating such.
klontractors that check this box must attached an addition[sheet showing the nacre of the sub-tonnanors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide thea 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# Self-ins.Lic. d: 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 ofMGL e. 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 WOR: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.
f do hereby certifyi under the pains and penalties ofpenury that the information provided above is true and correct.
Signature: Slate:
Phone#: _.._.
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: `__ Phone fi:
The Commonwealth of Massachusetts
t IS[l, Department of Industrial Accidents
_fi-
_
-4.-116--= ,. I Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.ntass.gov/dia
11m•kers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/OrganizatioNlndividuap:Stapes Builders& Excavation, LW
Address:110 N Hillside Road
City/State/Zip:South Deerfield, MA 01373 phone#:413-665-0185
Are you an employer?Cheek the appropriate box: Type of project(required):
Lot i am aemployer wilt 13 employees(full am&rx parotorm r 7. 0 New eoastrnction
2,01 am a sole proprietor orparmership and have no employees working for me in 8. O Remodeling
any capacity.[No workers'compinsurance required.]
ED I am a homeowner doing all work myself [No workers'compinsurance required.]• 9• ❑Demolition
4.Ot am a homeowner and will ire hiring cVeaactors to cot-duet all work on my property i will 10❑Building addition
ensure that all contractorseither have Corkers'compensation insurance or are sole 11..0 Electrical repairs or additions
proprietors with no employed
12.0 Plumbing repairs or additions
5.0 I am a general contractor and l have hired the sub-contractors listed on the attached sheet 3.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6 E We are a corporation and its officers have exercised their right of exemption per MGL a 14.QOther
152,61(1),and we have no employee (No workers'comp.insurance required.]
'Any applicant hat 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 must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
employees. If the subcontractorshave employees,they must provide their workers'comp policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below iv the policy and job site
information.
Insurance Company Name:A.I.M Mutual Insurance Co.
Policy ft or Self-ins. Lic.ff:WMZ-800-8005664-2016A _._ Expiration Date:June 25, 2017
lob Site Address: 137 West Street City/State/Zip:Northampton 01060
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited under MGL c. €52,§25A is a criminal violation punishable by a fine up to 51,500.00
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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby ander t ns and penalties of perjury that the information provided above is true and correct
/PJB,
Sinnam f. �U(i )
( `- ,/ /-'Y .441 P. �/ O//Q / Date: r) - —/ 7
Phone q.413-665-0185
Official use only. Do not write in this area,to be completed by an`or town official
City or Town:_ Permit/License#
, Issuing Authority(circle one):
{ 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.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: /37 W eSf 5 9- No 'Y 7)'
The debris will be transported by: IA/ ��c.c
d Cts
The debris will be received by: c4( e-
I arc r C1
Building permit number:
Name of Permit Applicant eirlitaictS gib-LA/titS
(OA 7 p� Menagmg
Member,LLC
Date Signature of Permit Applicant