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25C-251 (100) 54 FAIR ST BP-2017-1049 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-251 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-2017-1049 Project# JS-2017-001804 Est.Cost: $1100000 Fee: $77.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH JASINSKI 057025 Lot Size(sq. ft.): Owner: HAMPSHIRE FRANKLIN& HAMPDEN AGRICULTURAL SOCIETY Zoning: SC(I00)/URB(1)/ Applicant: HAMPSHIRE FRANKLIN & HAMPDEN AGRICULTURAL SOCIETY AT: 54 FAIR ST Applicant Address: Phone: Insurance: P O BOX 305 (413) 584-2237 O WC N O R T H A M P T O N M A 01061 ISSUED ON:5/9/2017 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVAL OF EXISTING ENTRY AND SHED AND REPLACE WITH NEW ENTRY STRUCTURE 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# 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: II - I � -/ Building 5/9/2017 0:00:00 $77.009 3 t/e 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1049 APPLICANT/CONTACT PERSON HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY ADDRESS/PHONE P O BOX 305 NORTHAMPTON (413)584-2237 O PROPERTY LOCATION 54 FAIR ST MAP 25C PARCEL 251 001 ZONE SC(100)/URB(I)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT (� y Bee Paid .vw v,NN1l !1 (Pec_p Building Permit Filled out tiry ll c/Z/ Fee Paid Tvpeof Construction: REMOVAL OF EXISTING ENTRY AND SHED AND REPLACE WITH NEW ENTRY STRUCTURE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 057025 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 •— .liti. '0-la Atif Signature of B (ding O'icia 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 40k Contact Office of Planning Be Development for more information. Zj C - 2S/ Version1.7 Commercial Building Permit May 15,2000 Department use only i Jli City of Northampton Status of Pent*(;w,, L2 �' ' B ildinODepartment Curb Cut/Driveway Permit: - 12 Main Street Sewer/Septic Avad ty Room 100 Water/Weft Availability _� N hampton, MA 01060 Two Sets of$trudualPlans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Otter 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 54 Fair Street Map Lot Unit Northampton,Ma 01060 Zone Overlay District Elm St District CO District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Hampshire,Franklin and Hampden Agri. Society PO box 305,Northampton,Ma 01060 Name(Print) Current Mailing Address: (413) 584-2237 Signature Telephone 2.2 Authorized Aceto: Bruce Shallcross same Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official 11.- Only completed by permit applicant 1. Building $10,000.00 (a)Build++ 2. Electrical 3. Plumbing -lf 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+5) 17 This Sect Building Permit Number Signature: Building Commissioner/Inspector of Buildings VersionL7 Commercial Building Permit May IS,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wail Signs 0 DemoidIon❑+ Repairs Additions ❑ Accessory Building❑+ Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other Brief Description Enter a brief description here. Removal of existing entry and shed and replacement with new Of Proposed Work: Entry structure SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 0 A-3 0 to 0 A-4 ❑ A-5 ❑ 16 0 B Business p 2A ❑ E Educational 0 26 ( 0 F Factory ❑ F-1 ❑ F-2 0 2C 0 H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 0 1-2 ❑ 1-3 0 38 ❑ M Mercantile ❑ 4 ❑ R Residential 0 R-1 ❑ R-2 0 R-3 0 5A 0 S Storage ❑ S-1 ❑ S-2 0 56 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDtOR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTIONS BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor Of) • 1" 608 2" are 3.a 4th 4m Total Area(sr) Total Proposed New Construction(s° Total Height(ft) 21 Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 FloodZone Information: 7.3 Sewage Disposal System: Public [.) Private 0 Zone i13 Outside Flood Zone❑ Municipal On site disposal system!: Version!.?Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Bui[ding 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 Patting) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO d 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 O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO 0 IF YES, describe size, type and location: SIGN ON BUILDING FACIA D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO O IF YES, describe size, type and location: SEE DRAWING FOR SIGN PLACEMENT E. 6nhil l to construction activity disturb(cleating,grading,excavation,or filling)over t avro or is it part of a common plan that will disturb over'I acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 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 OF,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(late Name Area of Responsibility Address Registration Number Signature Telephone Expiation Date Name Area of Responsibility Address Registration Number Signature Telephone Expiation Date Name Area of Responsibility Address Registration Number Signature Telephone Expiation Date 9.3 General Contractor .. _ Not Applicable El Company Name: Responsible In Charge of Construction Address Signature Telephone if 4 Version!.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 6, 17 R1�Lfa 54.AuC424ss 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 Bruce R Shallcross 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 o perjury. Q1 wet r+BaO/ Print Name au.ea `k SIN AUtile ss . alai )172 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Joseph Jasinski 057025 License Number $3 (,p t= s_+'s Ntl t.' Y1a � MPt. Qt ai talent inAddrreS 'JJ ,,...�^� Expiration Date a � (413) 584-2237 S' alum Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GI.c.152,§2$C(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 0 No O 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: 54 FINAL 5'rec'tT The debris will be transported by: Qs p e. Ur hrtc& S'cRut dot s The debris will be received by: _ m kV4.4 c U. IarT6 S-qtarse-gs Building permit number: Name of Permit Applicant cc 40 Iwo. Date Signature of Permit Applicant ' The Commonwealth of Massachusetts 6 _ Department of Industrial Accidents Pker a sti um= Office of Investigations wigs) 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Buaine sargani a onIIndiviaaal): Hampshire, Franklin and Hampden Agricultural Society Address:54 Fair Street City/State/Zip:Northampton, Ma 01060 Phone#:413 584 2237 Are you an employer? Check the appropriate box: Type of project(required): I.© I am a employer with 7 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. Q New construction Rated on the attached sheet. 7. p Remodeling 2.❑ i am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers 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 1L0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI.. 12.0 Roof repairs insurance required.] ' c. 152, ¢1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 roust also fill out the section below showing their workers'compensationpolicy 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 teornractors 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-conm,ctors have empiovees,they must provide their workers comp.policy 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:A.I.M. Insurance Company Policy#or Self-ins. Lie. #:awc400-7035317-2017a Expiration Date:02/04/2018 Job Site Address: 54 Fair Street City/State/Zip:Northampton,Ma. 01060 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. 1 do hereby certify under rtthheypains and penalties of perjury that the information provided above is true and correct. Signature; ��IGaGC4 /( �wKr6.4.4Or Date:.... i Loa l/9......._.... Phone#: 413 584 2237 ' 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#: NOTICE , NOTICE TO TO EMPLOYEES 4 4ar EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I(we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M.Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC-400-7035317.2017A 02/04/2017.02/04/2018 POLICY NUMBER EFFECTIVE DATES 8 North King Street Sulte# 1 Webber 8 Grinnell Ins Agcy Inc Northampton,MA 01060 1413)588-0111 NAME OF INSURANCE AGENT ADDRESS PHONE Three County Fair BX 305 54 Fair Street Northampton, MA 01060 EMPLOYER ADDRESS 02/23/2017 DATE MEDICAL TREATMENT The above named insurer is required in races of personal injuries arising out of and In the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Y E 4V° 0 ♦ .�S to •.... OT.w ^'_ __.. J V 44—I I • W.,., N i no.xao taiitA 6 g t ( If{\7 .. _ O k el 0� Q J � _� Ic .,. .. � - le �� AIR s1 1 11". 41. +1106a.labottIt I > 1 4 . , sr ,rt, . 40-40Ir neripar, . . , .., tr . . . _ ... 'Ait I)' A ta ''.fisr ik-r, ••, - • . .r.,......: • • iii1. ft - [ 1t ellP S. , ..! r. ," m, ... '+ • ItesC 55-TPE Far Gauen OATS _ Inns 0000. 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N1.35.0/416. 35.35-0i415.5445=03416.3 54.1416. 32-33--0!416,31-3244/416.311.31411;415,25,-30-0/415,2q-19-410415,292849,415, E5-27431415.24-26=0/415 WEBS 12-35=310177,11-37-27651,2-39--543/525.11-1G=4473V487,7-404'294'l4 6-41=30311.3,3-42=-315/523,443,-252/116,3 44.4,71142,1424®31118, 15-33=-2r7/51,10-314-54.51525,Ifel BB-423(487.23-25-2571142 NOTES- l)Wr1d 15 sand:ASCETUS;-oomph:sed endOpsl;SCDLna.0psghh=2411;CIL 1;Exp G;end0sed;MWFFS vlWHI6e1 and C-Cns shown;zone; Lanrbev0left and right exposed:end verti.al 1211 and right exposed:0-C ea members and faces&1/1WFB51or reaclicnS shown: Lumber 4 IJLeas0 plate grip 004150 21 42665 devyneg for wind cads,in the plana et 9w Uues OMy. 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