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24D-002 (3)
237 PROSPECT ST BP-2018-1104 GIs#: COMMONWEALTH OF MASSACHUSETTS M=Block:24D-002 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-2018-1104 Project# JS-2018-001991 Est.Cost$500.00 Fee: $0.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: TRUCK CRANE SERV INC 074442 Lot Size(sp ft T 78408.00 Owner: NORTHAMPTON CITY OF WATER DEPARTMENT zonine� URB000)/ Applicant. TRUCK CRANE SERV INC AT.- 237 PROSPECT ST ApplicantAddress.- Phone: Insurance: 20 FAIRFIELD AVE (413) 562-9465 WC WESTFIELDMA01085 ISSUED ON.412612018 0:00:00 TO PERFORM THE FOLLOWING WORK RAZE AND REMOVE FIRE DAMAGED DRY STORAGE 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: Building 4/26/2018 0:00:00 $0.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Veaion1.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit Building Department Curb Cul/Driveway Permit 212 Main Street Sewer/septic Availability Room 100 NtaterAiVell AvaiYatiiffty Northampton, MA 01060 T"Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Matti 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 ZS�....�QVsf-�C\.T S�/e-�!/c_r Map Z"/ D Lot 002- Unit Zone Overlay District -- - - - Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: CI T"( of N ' tfi p r. Name(Print) Current Mailing Address: c'4"Tnr'- ANaegl� Signature S11P/ - /`a Telephone 2.2 Authorized Agent: i-ei Na a(Pnnt) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED O TRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by pennit a blicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing O Building Permit Fee 4. Mechanical(HVAC) - - 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signatu Bui tling Commissionerllnspector of Builtlings " 4Dat /// f Version l7 Commemlal 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 ❑ Demolition El Repave El Additions ❑ Accessory Building El Exterior Alteration ❑ Existing Ground Sign E3 New Signs❑ Roofing❑ Changeof Use❑ OthereK 'p�Y`4O Brief Description Enter a brief description here. Li2v, Zff- f' MOV4- f'l4£, Pt+-Iric4o Of Proposed Work: .pe,,,f 557'aPr�,,t-- SECTION 5•USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable)' CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 �'[] A-3 ❑ 1A ❑ A-0 ❑ A-5 [] 1B ❑ B Business ❑ - _ 2A ❑ E Educational ❑ _ 2B ❑ F Factory ❑ F-1 ❑ F-2 []_ I 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 [] 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ IRA ❑ R-2 [] R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 [] 5B ❑ U Utility Specify: M Mixed Use ❑ Specify: S Special I e ❑ Specify: .. C MPLETE 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 Hazar ex 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSEDNEW NSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) tr I,'Yl'11T' lo _... 3m 4m . .. Total Area o ) Total Proposed New Construction (sb Total Height UB _. Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone 11 7.3 Sewage Disposal System: Public C] Private ElZone Oatside Flood Zone❑ Municipal ❑ On site disposal system E] 4 � Versiont.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be❑ in by Building De om Lot Size Frontage _ .... Setbacks Front Side LR _._ L. Rj Pr Rear --.--- 11 Building Height Bldg, Square Footage % Open Space Foo[ e ILot vaa minusb &Oevcd _ ___ akin ) #of rkin S aces Fill: (volume&I notion) A. Has a Special Permit/Variance/Finding ever been issued fay-an-the site? NO O DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the R stry of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a b ok, body of water or wetlands? NO DONT KNOW O YES IF YES, has a per been or need to be obtained from the Conservation Commission? Needs to be o tained O Obtained © , Date Issued: C. Do any sig s exist on the property? YES O NO IF Y , describe size, type and location: /D. Arere any proposed changes to or additions of signs intended for the property? YES ONOO ES, describe size, type and Location: construction activity disturb(clearing,grading, excavationor filling)over 1 acre or is it part of a common plan l disturb over 1 acre? YES O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versiom1.7 Comnnerck I 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(Rogirstrarrib. - ��'�J/ Registration Number Address Expiration Date Signature TelepFone 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 Addr s Registration Number Signature Telephone Expiration Date 9.3 General Contractor I Not Applicable ❑ Com any Name: Responsiblee IInnCCh�aMe of C ruction Signature Telephone Vcrsionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No O 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 ma relative to work authorized by this building permit application. Signature of Owner T�. Date I, .Pw L...T �.lc� �l �l'C'S TL' � . /^� � ,as Owner/Authorized Agent he declare that the statements and arm tion on a foregoing application are true and accurate,to the best of my knowledge elief Signed under the and penalb o Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: L� T Not Applicable ❑ Name of License Holder'. r/^'Lr �lP .....' 7 ✓ GS -�� (2 5 0777-//_ a License Number ress E Ipiration Date yi3 5'3I ' �7uf (Jwa--51/7?4e` 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 O No (7/�9 Ili �1 - C 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: The debris will be transported by: The debris will be received by: Building permit number: _--Name-_c f Permit ApOciant DateSignature of Permit Applicant 1�-) zt, ) - . r The Commonwealth of Massachusetts 0_9 wwDepartment of lndustrialAccfdeuts i I Congress Street, Suite 100 � Boston, 02114-2017 w .mamass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Address: City/state/zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required): I.❑ 1 am a employer with employees(full and/ 5. ❑Retail or part-time).* 6, ❑Restaurant/Bar/Sating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S, ❑Non-profit T❑ W are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§I(4),and we have 10.❑Manufacturing no employees. [No w orkers' comp. insurance required]" 11 ❑Health Care 4.E] W e are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.0 Other 'Am'applicant that chocks box it must also fill out the section below shoring theirv.'orkerscompensation policy infonnaten. '*If the mryornte offisrs hoe eeempted thern clloes,but the cmporanon Los.u., a workers'compevsav'on paliq'i,required and such an n should check box s I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy,t or Self-ins.Lic.# Expiration Date: 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 31,500.00 amUor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penahies of perjury that the information provided above is true and correct. Sumature: Date' Phone#' Official use only. Do not write in this area,to be completed by city or town ofjicial. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.city/room Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: uum.ruce, .,dia Information and Instructions Massachusetts General Laws chapter 152 requires all cmpl oycrs to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...ever}person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,aso dation,corporation or other legal entity,or any two or more of the foregoing engaged in ajcan enterprise,and including the legal representatives of a deceased employe;or the receiver or trustee ofm individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance.construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer," MGL chapter 152,§25C(6)also states that-'every sta"e or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Nenti er the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter lace been presented to th_contracting authority." Applicants Please fill out the workers' compensation affidavit co:mph tely,by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,ma rens and phone number along with a certificate ofinsurance. Limited Liability Companies(LLC)or Limited Liability P,otnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compen;atirn insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date time affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being reyue6led,not the Department of Industrial Accidents. Should you have any questions regarding time law or if you are requirec to obtain a workers compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit,license number which w 11 be used as a reference number.In addition,an applicant that must submit multiple pemilUlicense applications in any gi,en year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidr ail teat has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affid n'it is on file for furore permits or licenses. A new afPidai it must be filled out each year.where a home owner or c arum n is obtaining a license or permit not related to any business or commercial venture(i.c. a dog license or permit to bum leases etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, M S 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-NIASSAFE Fax 11 617-727-7749 www.mass.gov/dia Farm lh: ,i d 02-23-15