24A-042 (7) 120 JACKSON ST BP-2017-1189
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-042 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:GREENHOUSE BUILDING PERMIT
Permit# BP-2017-1189
Project# JS-2017-002011
Est.Cost: 59000.00
Fee: 50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ERIC PAYNE 086442
Lot Size(sq. ft.): 27448.00 Owner: NORTHAMPTON CITY OF JACKSON STREET SCHOOL
zoning:URI;(1001/ Applicant: ERIC PAYNE
AT: 120 JACKSON ST
Applicant Address: Phone: Insurance:
32 BURTS PIT RD (413) 218-4276(l
NORTHAMPTONMA01060 ISSUED ON:54 2017 0:00:00
TO PERFORM THE FOLLOWING WORK:GREENHOUSE
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: Roth: 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:
FeeTvpe: Date Paid: Amount:
Building 5/1/2017 0A0:00 $000
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2017-1189
APPLICANT/CONTACT PERSON ERIC PAYNE
ADDRESS/PHONE 32 BURTS NT RD NORTHAMPTON (413)2181276 0
PROPERTY LOCATION 120 JACKSON ST
MAP 24A PARCEL 042 001 ZONE URB p002/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid (R�
Building Permit Filled out /
Fee Paid
TvneofConstruction: GREENHOUSE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 086442
3 sets of Plans/Not Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�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 Commission Permit DPW Storm Water Management
Demolition Delay
f� tom/ (t/.1117
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.
riikl
Version! 7 Commercial acidic.Permit Ma 15,2000
Department use only
O� icy of Northampton Status of Permit:
�My / Budding Department Curb tuUDnveway Permit
;� 212 Main Street Sewer/Septic Availability___
-S Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans_,. _
phone 413-5874240 Fax 413-587-1272 Plot/Bite 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
SA-C— <c' O H >—k j2EC r 50-kool, Map Lot Unit
Pi Zone Overlay District
- - -- - — - -- - Elm Ststrict CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
is
2.1 Owner of Record:
1141 Cif T1/4\0a\Miff tri 2AS Mia,-Aepc" t�()I ::4tri
1� Name(Pt, I Current Maung Address
tv{{{{}fi 651't' -s
Signature ��k Telephone
2 v2.2 Auth. !zed
n C.— t ra jr -a. ') 32 Bur's P?C bi0 bre
Name;Print) V Current Mailing Address-
,
Signature ___ _ Telephone `H1-5 "h-\C 42-7 6
SECTION 3 A ESTIMATED CONSTRUCTION COSTS
Item ____.7Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I Building tir tO pp , (a)Building Permit Fee
I
2. Electrical .. _ . .,,...- (b)Estimated Total Cost of ... .:.--...
Construction from(6)
3. Plumbing Building Permit Fee
_
4. Mechanical(HVAC} . . ._.
S. Fire Protection _._. � ))
6. Total= (1 +2+3+4+ 5) et 000 Check Number Vii* _o -
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May I5,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs 0 Demolition 0 Repairs 0 Additions 0 Accessory Building N
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing Change of Use Other 0
Brief Description Enter a brief description here.
Of Proposed Work: at5,4 evi \- e_-e_ �-T y2u e-11tr.: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 1 0
A-4 ❑ A-5 0 1B 0
B Business 0 2A ❑
E Educational 0 23 I 0
F Factory 0 F-1 0 F-2 0 ( 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 ❑ -2 0 1-3 0 1 3B 0
M Mercantile 0 I 4 0
R Residential 0 R-t 0 R-2 0 R-3 0 5A ) 0
S Storage 0 S-1 0 S-2 0 5B l 0
U Utility ❑ Specify
M Mixed Use ❑ Specify -- _- -
S Special Use ❑ Spec0y
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: __ _,. . . ,. I Proposed Use Group _.. ..
Existing Hazard Index 760 CMR 34) ._... Proposed Hazard Index 780 CMR 34): _..... ..
SECTION 6 BUILDING HEIGHT AND AREA 1
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sib
1" .1S Cab - -- 1s 366 _..
___
317
Total Area(sf) -3G-c, Total Proposed New Conslrwcdon(sfa
360 -
Total Height(ft) 1 a' _._...__
Total Height ft 1 t— _
7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private Zone ., Outside Flood Zone❑ Municipal 0 On site disposal system
•
Version 1 7 Commercial Building Permit May IS,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
parking)
k of Parking Spaces - ----- -
(volume&Location) .... .._ ....... _. ._. _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES C
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 0 DONT KNOW (9 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location ,j ¶ cp C,v.,p 0\ j
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO ibe
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
Versionl.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)
-- - Regstratlon 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 _ .
Signature Telephone Expiration Date
Name Area of Responsibility
Address Remstra0on Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
L(� . C6 NS w,� i ��._-._-..__ NotAPPlicable ❑
Company Name: _..
Responsible In Charge of Constru di ( i
130r )"-s" \k .1'1rnW-1 O\ v6V '
Address
41321 e one
Signature Telephone
Version I.7 Commence) Building Permit May IS,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS
/
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
p jot.) 1'9 as Owner of the subject property
i rebyauthorize. Er .I L._.. _.. .... ... to
a.N+n , ehal,fn .it matters relative to work authorized by this building permit application
lig� 6444,11
Si. Owner Date
,asOwner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledue
and belief.
Signed under the pains and penalties of perjury
t2L t�kat'L..
Pont Name
�J— .. . .
Signature of Own>e (Agent Date _
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor
� No/Applicable
0
Name of License Holder '1r \ L "u-�'"_�"�a" J —d A6 kt-
License Number
3.Z -3b f .. 5 N.T�!"n,tn,� ,... <t>1
b�t5 }...• ZZ ' t�
A ddressExpiration Date
q
Signature Telephone
SECTION 13 -WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(0))
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 0 No 0
The Commonwealth of Massachusetts
- _
Department of Industrial Accidents
Office of Investigations
rie6igs 600 Washington Street
_ klritorf tit fin Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Y L-n
Address: 2— 0 A( 5 1 �A- ON 1`\+\ \f L y 65
City/State/Zip: ... Phone#: `� �? 212 15'27 '
Are you an employer?Check the appropriate box: Type of project(required):
.(] I am a employer with 4. I am a general contractor and I 2
6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.J I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
-ship and have no employees These sub-contractors have g. Q Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
DR workers' comp.insurance comp. insurance
required.) 5. ❑ We are a corporation and its 10.(l Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I1.0 Plumbing repairs or additions •
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.1 t c. 152, §I(4), and we have no 13.E]Other
employees. [4o workers'
comp. insurance required.]
'Any applicant that checks box k mist also fill out the section below showing their workers'compensation policy information.
r 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 nark of the sub-contractors and state whether or not those entities have
employe . lithe subcontractors have gloyea,they nastprovide thea workers'comp.pokey mincer.
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-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 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$25000 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature'. C"' � Dataed
�i 1 C/1 [
Phone#: } y3 2 1c& los-2, -7 b ......
Official use only. Do not write in this area, to be completed by eh>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,u,:_
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 150k
b
Address of the work: �Ac SoG rfe�O St�✓l1J 6 (
The debris will be transported by: C±ki o IC p ve rt� � �
The debris will be received by:
Building permit number:
Name of Permit Applicant E r 1 ea 1�
Date Signature of Permit Applicant
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