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31B-230 (11) Versionl.7 Commercial Buildint Permit May 15,2000 , Department use only City of Northampton Status of Permit: ,- 4 Building Department CurbCut/Driveway Permit - . Q 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 PlonSlte Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPA - • 7 OR r • • ISLLANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWEL 'G --_,... SECTION 1 -SITE INFORMATION /-{mem) ?-e ( w.f .�--e_a YJ t 17—/0 /f 1.1 Property Atldress. This s:• •n to be completed by office C �j (J 6 V (,,,.�>�-�4/c iN* , Map C7/ e Lot a W Unit AIJ .3 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /=2eo Cif:ferl--- Name(Print) Current Mailing Address. -I Signature Telephone 1. 2.2 Authorized Agent: LC,L.13 6'4 /7/ XI"AC .9 .3b" (/ 6..,�4 /y„ ,6/itAni- Name(Print) / Current Mailing Address: Signature 'ii �M� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only l completed by permit applicant 1. Buildingi . (a)Building Permit Fee 2. Electrical / PC .-- (b)Estimated Total Cost of / Construction from(6) 3. Plumbing / I N Cn Building Permit Fee 4- Mechanical(HVAC) 5. Fire Protection 6. Total =(1f9a 3 ( 5) /fi['p C. Check Number This Section For Official Use Only Building Permit Number Date Issued /7 Signal ��7[ 1.C. / Sm ding Commissioner/Inspector of Buildings Date 3C a:iJr C ( � A` Version).7 Commercial Building Permit May 15,2000 I SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs 0 Demolition Repairs Lp' Additions ❑ Accessory Building ID Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use❑ Other❑ Brief Description Enter a brief description here../ /, Of Proposed Work: ,L r0.5 ittliko,J kr tL.bi c�r�c J#ait) /30R7te/!f /✓a S(fc--/e �h""(( SECTIONS-USE GROUP AND CONSTRUCTION TYPE tV?Jta `9 USE GROUP(Check as applicable) ✓ CONSTRUCTION TYPE A Assembly ❑ A-1 0 A-2 0 A-3 0 IA I 0 A-4 ❑ A-5 0 1B 0 B Business ❑ 2A 0 E Educational 0 28 ❑ F Factory 0 F-1 ❑ F-2 0 2C ❑ 14 High Hazard 0 3A 0 I Institutional 0 I-i 0 1-2 0 1-3 ❑ 38 0 M Mercantile 0 4 0 R Residential 0 R-1 0 R-2 ❑ R-3 ❑ 5A 0 5 Storage 0 S-1 0 S-2 0 5B 0 U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE P8 C (vrn Ex sting Use Group: Proposed Use Group'. Existing Hazard Index 780 CMR 34): / Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA Pe ( LL[PIC) BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 2nd o` 3'° 4i:. 4m Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) IIS Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: I Public 0 Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Version1.7 Commercial Building Permit May IS. 2000 8. NORTHAMPTON ZONING )/i Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side I.: R: I.: R: Rear Building Height Bldc.Square Footage Open Space Footage .� IWI arca minor bldg&paved parking) of Parking Spaces Fill: nuinrne&Localimp A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Re istry of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO E5 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over II acre or is it part of a common plan that will disturb aver II acre? YES O NO n 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: r/4- Not Applicable 0 Nome(Registrant): Registration Number Address Expiration Dale Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Andress Registration Number S:gnature Telephone Expiration Date Name Area of Responsibility Andress Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Ill Signature Telephone Expiration Date 9.3 General Contractor Payr¢. (`c tC C Not Applicable 0 Company Nang ft Responsible In Charge of Construction .1 jt ,CP.�ye * • net/8,1--17.// (yr 6J Aodr s / ( .../Lr�� J s30_ tura Telephone Version'?Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No7'0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. 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 70 I j Cr7/4 N en G �' ,as Owner/A�h�orized) 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 perjury. fru / j 6- A //lei ifea-o Prot D g fi!G �jC �A/ //J Sign f Owner/Agan( Oa€ SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: /' .A / Not Applicable 0 Name of License Holder L. e� u / J C `/ / / ( ft/$Lc ( _S —cJO!�22K �n.' License Number /3) /�7 $,n.C ;OeO ;e 9 . {lzoe/,O,J k(9 ern 0 L (oh 1/7 I Address / / Expire n Dat g a ure Telephone 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 permit. , Signed Affidavit Attached Yes e No 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: ov (:::c4 It. C 3 `t • 44 _ u l- The debris will be transported by: % C-=7- • The debris will be received by: V �c�1 � 3 Y F,u/d* k�Alit Building permit number: Name of Permit Applicant I- U ✓ i�(r ,c frtti� ////rrf �� 2/(k c0 Date Signature of Permit Applicant ct\ The Commonwealth of Massachusetts _. Department of Industrial Accidents :?';11,a...4-.1:-_ Office of Investigations / I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� y� Please Print Legibly Name (Business/Organization/Individual): 1ea7170 ( {fNf7-oc'C C (04' Li) C' Address: d )-_ 3 \ v ' C cif d- . City/State/Zip: A-,.,- ILL--'11-[1 M 4 0/or 1 Phone#: 9/ ? - 3 Xi -r D'&-? Arc you an employer? Check th appropriate box: Type of project(required): I.E I am a with employer -> 4. ❑ I am a general contractor and I _.� 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.1j I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.' required.] 5. ❑ We arc a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3 n I am a homeowner doing all work myself [No workers' comp. right exemption perMGL I2.❑ Roof repairs insurance required.] * c. 152, .51(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] `Airy applicant that checks box I/I must also till out the section below showing'heir workers'compensation policy information. ' I lsmcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Cone actors 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 sub-contractors have employees,they must provide their workers'comppolicy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. // Insurance Company Name: 7 717- Xn Policy # or Self-ins. Lie. N: 1<) -pee,- Poo - 61.#-3-AC ]*7 ziC1— Expiration Date: ezA /a' (- Y 6e 4.4- C at ' ig,l- -- lob Site Address: / City/State/Zip: Va'r'li?ft kill' / ! / Ff/C:7 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 flue up to 511,500.00 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 hereby certify underthe pair and penalties of perjury that the information provided above is true and correct S innturcf{r.s / --c— ' Date: 74/7 _..— Phone8: 2//3 - cyf - C i e 3 1 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#: