32C-163 (30) RANDOLPH PLACE BP-2017-1456
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 163 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Porch Reoajf BUILDING PERMIT
Permit BP-2017-1456
Project# JS-2017-002418
Est. Cost: $19100.00
Fee:$134.00 PERMISSION IS HEREBY GRANTED TO:
Const.Gloss: Contractor: License:
Use Group: MARK SMITH 104325
Lot Size(s(t. ft.): OwnersRANDOLPIIRANDOLPH PLACE CONDOMINIUM ASSOC
Zeroing:URCO05}/WP(53 ( Applicant: MARK SMITH
AT: RANDOLPH PLACE
Applicant Address: Phone: Insurance:
5 ANNA ST (413)531-7342
WAREMA01082 ISSUED ON:6/16/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE & REPLACE RAILINGS**36" HEIGHT,
4" SPACING**
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: Smoky: 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 6/16/20170:00:00 $134.00
212 Main Street,Phone(4131 587-1240,Fax:(413)587-1272
Louis Hasbrouck .Building Commissioner
File tt BP-2017-1456
APPLICANT/CONTACT PERSON MARK SMITH
ADDRESS/PHONES ANNA ST WARE (413)531-7342
PROPERTY LOCATION RANDOLPH PLACE
MAP 32C PARCEL 163 000 ZONE URC(105)/WP(531/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECK! ffiT
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out * 1 1 j
Fee Paid .c `♦ n SP puN
Tvpegf Constmction: REMOVE&REPLACE RAILINGS .4436 r16,I tern
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 104325
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQ16IATION 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
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 MOL 40A.Contact Office of
Planning&Development for more information.
Versionl.7 Commercial Building Permit May 15,2000
Department ti"Dory
r ' ),7 ity of Northampton Status of Perm#
uilding Department Curb CWDMavay.Permit
` N 3 212 Main Street Sewer/Septic.Availadury
(_ Room 100 WaterMel Availablity
-- r,Vorthampton, MA 01060 Two Sets of Sbucture'Piens
phone 4113-587-1240 Fax 413-587-1272 Ptotlsite Plays
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: // (( 1 This section to be completed by office
�FJDoLPt4 RIAGe Coactofh1NIUM Map ✓o;'L Lot 1 (,( 3 Unit
`iZM4cja1-Pk TInce Zone Overlay District
ND imp -ot4 MA-- Elm St District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
fatrrc. c toe/., �rr r �6hczjer �uwp Luc )f yaf. f D, &x 4f6
Name(Print) Current Mailing Address:
Signature. I%T_ _ Tel
s /� - Telephone /72 m el. cc'
Yr3 - � 57J - Gack
2.2 Authorized Anent: �1 I_ W1
MA�4-- 5 M I 5 / 4 Jp 'fr. Afe 4'M A--
Name(Print) , G Current Mailingdress:
� f1- 4I3 r 531 �FZ
�3
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
V IL
2. Electrical - (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection `
6. Total=(1 +2+3+4+5) Check Number 57 5 ✓P/3Cf
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition Repairs' Additions ❑ Accessory Building 0
Exterior Alteration 0 Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other 0
Brief Description Enter a brief descriptionLhere.
Of Proposed Work: Ve_mot
l Ace 8,4_ rjA-
SECTION 5-USE GROUP AND CONSTRUCTION TYPE T`
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ' ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational 0 28 ❑
F Factory ❑ F-1 ❑ F-2 0 2C ❑
H High Hazard ❑ 3A ❑
I Institutional 0 1-1 ❑ 1-2 0 1-3 0 38 ❑
M Mercantile 0 4 ❑
R Residential lg. R-1 ❑ R-2 rg R-3 ❑ 5A ,❑.,/
S Storage ❑ S-1 0 S-2 0 5B III,
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
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
n 1'
t
3111
'° 3
4N 4m
Total Area(sf) Total Proposed New Construction(sf)
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 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version1.9 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 L:. It: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot arca 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 ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O 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 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 ® NO O
IF YES, describe size, type and Location: C(i -vb Trove('l/y,
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O 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 0
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 Date
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 Registration Number
Signature Telephone Expiration Dale
9.3 General Contractor
V\lOQ'bSnt ' [1 S Not Applicable ❑
Company Name:
M c 5M ITI-1
Responsible In Charge of Construction
5 A-Niq 'SI—, ViVe f 01,03Z—
Address
1113.531 -SO--
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 O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS¢/ AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �/j(�Nf ak... �A'+— D/f+ /t. ,as Owner of the subject property
hereby authorize M ARV--5"s4
-` to
act/ons my behalf, in all manors re`lattivve to
work authorized by this building permit application.
Signa uyre�of�Ownper �s11 - Date
I, f A rr e`T-- L( r b1 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 perjury.
Yuan 5mcn4
Print Name t, — (.0WI7
Signature of Owner/AgentDate
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 31M( CS 04-32-C
License Nu bar
5ANNA • (1‘)Rrc N1 - 1 1311
Address Expiration ate
1413 -551 -7542—
Signature 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
M the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
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: {�A141Da _PL} NicientAtilmenTYYL
The debris will be transported by: W)(Rf �`'4'w(' r NA
The debris will be received by: 1(1-' 1 - �fiUt-Sky � � t'L2 eeJVi ►"-
Building permit number:
Name of Permit Applicant
(p(12`\i �
Date Signature of Permit Applicant
i. The Commonwealth of Massachusetts
wt= Department of Industrial Accidents
t—'s9 - Office of Investigations
Et°(pxl- 1 Congress Street, Suite 100
=10= ` Boston,MA 02114-2017
1.v :s
www.mass.gov/die
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le
gibly
NameSusiness/Organimtionandividual): 1
14M ,L t!14 (4..0bSMiT&5
j
Address: 5 at i S{
City/State/Zip:
Geta- MA Q 32-- phone It: �t 3-53(=tS4''7 -
Are you an employer? Check the appropriate box:
Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I
_.employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.tZ'i T am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These subcontractors have g, 9 Demolition
workingfor me in anycapacity. employees and have workers'
P tY t 9. 0 Building addition
No workers' comp,insurance comp. insurance.
required_] 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I1.9 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.9 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.9 Other,
comp. insurance required.]
*Any applicant that 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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'romp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information r� tt '',t ��t
Insurance Company Name: C rt4t'ir t S. Ce.11
Policy#or Self-ins. Lic. #: C/ i (e 1 L.."03 —3 Expiration Date: 4g)t) 17
- n,��i
Job Site Address: 1-`t{t tub LQ(( C Va.. City/State/Zip: �Q(`litAk f� MA'
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 cera under the pains AanddJpeennalties of perjury that the information provided above is t ue and correct.
Signature: �*/ 2 t —7 `7— Date: (5112—�11
phone#: L\17•'�It - i 3'I`'__
_
Official use only. Do not write in this area,to be completed by city or town ojjicial.
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#: