32C-171 (17) 256 PLEASANT ST BP-2017-1370
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:32C- 171 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:demolition BUILDING PERMIT
Permit# BP-2017-1370
Project# JS-2017-002285
Est. Cost:$9999.00
Fee:$0.00 PERMISSION IS HEREBY GRANTED TO:
Const-Class: Contractor: License:
Use Groin TRUCK CRANE SERV INC 074442
Lot Size(sq.ft.): 17119.08 Owner; WHITE GAIL,M AKA LABARGE GAIL M C/O NORTHAMPTON LUMBER
CO
Zoning:04(100)/ Applicant: TRUCK CRANE SERV INC
AT: 256 PLEASANT ST
Applicant Address: Phone: Insurance:
20 FAIRFIELD AVE (413) 562-9465 WC
WESTFIELDMA01085 ISSUED ON:5/26/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE 25 FT OF ROOF FROM DRY STORAGE
- SOUTHEAST CORNER - SLAB REMOVAL AS WELL
POST TIIIS 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# 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:
FeeType: Date Paid: Amount:
Building 5/26/2017 0:00:00 $0.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis I lasbrouck-Building Commissioner
Version l.7 Commercial Building Permit May 15,2000
Department use only
ity of Northampton Status of Permit
: ilding Department Curb Cut/Dnveway Permit
•12 Main Street Sewer/Septic Availability
`
SIS
2,6 Room 100 Water/Well Availability
rthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APP 'CATION 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
Zs? P'-,�-4n -/
s ' S r Map �� of //
Unit
Zone Overlay District
--- -- ---- Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Ip/J4 N C
3d wirizr 57. Al-
Name(Print) 1 1t, Current Mailing Address
Signature 70 1`evP 1 'I s� ^- '.� " Telephone
2.2 Authorized Anent
Name(Print) current Mailing Address.
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ' (a) Building Permit Fee
2. Electrical ` (b)Estimated Total Cost of
Construction from (6)
3. Plumbing '. Building Permit Fee
4. Mechanical(HVAC) - -- - - "v. i
5. Fire Protection
6. Total=(1 +2+3+4+5) Ct (`( t�, �,� Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signafur �� 77
Building om inner nspector of Buildings Date
Versiont_7 Commercial Building Permit May (5,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition Repairs 0 Additions 0 Accessory Building
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use Other 0
Brief Description Enter a brief description here. — SCe'3 241Ate/9t- raS I-tr. 4_
A
Of Proposed Work: c
i.v.wv-t_ ZS goof y-I-ipait oiai 5TaC?6' � ,s,49iTC e,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP{Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 ❑ 1A ( 0
A-4 ❑'' A-5 ❑ 1B 0
B Business 0 2A 0
E Educational 0 / 28 0
F Factory 0 Fell 0 F-2 0 _ 20 0
H Hiph Hazard 0 7 I 3A 0
Institutional 0 •d 1-1 0 k2 0 1-3 0 3B 0
T—
M M4 ❑ercantile ❑/
R Residential [ R-1 0 R-2 0 R-3 ❑ 5A 0
S Storage '0 S-1 0 S-2 0 sB 0
u Utility ❑ Specify
M Mixed U ❑ Specify _. _.
S Spool Use ❑ Specify: , ...._.
.OMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group -....._. .._..._ -i Proposed Use Group: _....
Existing Hazard Index 780 CMR 34) ___. _. _ ,. Proposed Hazard Index 780 CMR 34) _...
SECTION S BUILDING HEIGHT AND AREA
7
BUILDING AREA EXISTING PROP SED NEW CONSTRUCTION OFFICE USE ONLY
FTTr.Tr:.
per Flour Mt) - � -
i ....
°
_.. __..
3
4
4"
Total Area(sf) Total Proposed Ne w CentelN tion fsf} ,
Total Height(ft)
Total Height ft
/
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ 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
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?
NC Q DONT KNOW 0 YES 0
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 Q DONT KNOW 0 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 Q NO 0
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 Q
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Verion1.7 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 ResponaiblliN
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibmty
Address .....__ Regtsfranon 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
____ _ _.... ._.____._ .._.__. __.._-. _____,,.. __.__.__: Not Applicable ❑
Company Name:
Responsbie In Charge of Constmchon
Address _ __ , .. .._
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Se
I, ?�L T h,l'iiDc j? ' T.U.s . _ Io� T
asmle�o(the subject property
to,
® to
act on my behal n all matter to,rk'' . -ed by this building permit application.
Sig :4 o 0 ner 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 Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: I Not Applicable El
Name of License Holder: ?nide- _T hlP iCK, /Pim j-C..._5 —Tice.
License Number
PS
20 FfilgRiak)
Address / Expiration Date /
`ii 3 ,c3 /-�`1c - 7"ZG l4S
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(KG/.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 e doling permit.
Signed Affidavit Attached Yes No C
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
z 600 Wash/no/on Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. 0 I am a general contractor and T
employees(full and/or part-time).' have hired the sub-contractors 5. 0 New construction
2,0 I am a sole proprietor or partner- fisted on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition.
working for me in any capacity. employees and have workers' 9. [—] Building addition
[No workers'comp.insurance cony. in'1ranCe.a
required.) 5. ❑ We are a corporation and its 10.-1 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 12.0 Roof repairs
insurance required.]t c. 152,§1(4), and we have no
employees.[No workers' 13.0 Other_
comp. insurance required.)
'Any applicant that checks box NI 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 such.
teen tractors that check this box mast attached an additional sheet showing the nave of the.sub-contractors and state whether or not those=dries have
employees. lithe sub-contractors have employers,they must provide Oleic 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-ins.Tic. #:_, Expiration Date:
Sob 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sitmanrre: Date:
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 S.Plumbing Inspector
6.Other
Contact Person: Phone 4:
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: Z9-to -k-W5,59127- S
The debris will be transported by:// �� / ./' '' I S '
The debris will be received by: 7JJc -Lic7C22 Jg-HJ5- 2. irk)cL fern
Building permit number: 1
Name of Permit Applicant `ii�LT I�lp ice- J-6..-s ,-1
/1ecT -iC e Vrikcs-Y CDC
S 7(c., - l?,
Date t; '3natur- of "ermit Applicant