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25C-251 (110) t a — 'Demi ri Commercial BuildinR Permit May 15,2000 City of rth mpton sPipe "„ MAY - 3B41ng e ment urb cuw lveWa M in S reet Smiled$, ticav Roo 1it er/WeAA DrPT.of DUIID M 01060 TI itetsa rat Pl4jts� d4Y� x 413-587-1272e " Specify i �.liiIlPG�i� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING g0 i9-�/sa SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office SZ FA= IAC O —_ .. '; Map �R 15-Ci Lot RS Unit 0/040 Zona Overlay District Elm SL District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) ' l Current Mailing Address, Signature Telephone 2.2 Authorized Agent: s acs 7 T< f L� d o �SLt .;a as Name(Print) Curren Mailing Address Signature Telephone SECTION 3-P&TIMATED CONSTFKCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only ,completed by pernnit applicant i. Building �1) - (a)Building Permit Fee 2. Electrical �'.. (b)Estimated Total Cost of Construction from 6 _.._..___. ..._._. 3. Plumbing Building Permit Fee .ff� 4. Mechanical (HVAC) -""— W 5. Fire Protection 6. Total= (1 +2+3+4 +5) Check Number oZ/ This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commesioner/InspeGor of Bui Date I Version 1.7 Commercial Building Permit May 15,2000 r SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE t• v. Interior Alterations ❑ Existing Wall Signs ❑ Demolition El Repairs El Additions ❑ Accessory Building Exterlor Alteration ❑ Existing Ground Sign[] New Signs❑ Roofing[] ChangeAf Use❑ Other�l ' y/�M1_k, J V Brief Description .Enter a brief description here. �+� C,�tA..� "- .bY 1 Of Proposed Work: i J109 s$ ,F cr gve4 0 't- SECTION 5•USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly1:1A-1 11A-2 ElA-3 ❑ to ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1,3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ 5-1 ❑ S-2 ❑ 5B ❑ 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(so 2 d 2n0 ._.... 3� aro _.. _._... 4 _... _. . 4m _ Total Area (so Total Proposed New Construction s_f)_ Total Height(ft) Total Height ft 7.Water Supply(M.G.L.e.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ Oo site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON.ZOMNG Existing Proposed Required by Zoning This eolumn in be filler in by Building Department Lot Size --- ---- Frontage ..__._ ......._ Setbacks Front Side L R _. L: R:. ... .. Rear _...._- Building Height "- Bldg. Square Footage % 1. Open Space Footage - (lut area minus bldg&paved - -- puking) A ofParking Spaces Fill: _. volume&[ aoon -- ---- __ A. Has a Special Permit/Variance/Finddiinng�ever been issued for/on the site? NO O DONT KNOW OCL ' YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW © YES 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: :..... . C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing,grading ex�caavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO \IJj' IF YES,then a Northampton Storm Water Management Permit Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 r t 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 Responsibility Address m Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Sgnature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of ResponsibJAy Address Regisirabon Number Signature Telephone Expiration Date 9.3 General Contractor Iw,zt ,,, Not Applicable Company Name T Responsible In Charge of Construction A Signatu Telephone Version l.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 SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorizA0 act an my behalf, in all matters relative to work authorized by this building permit application Signature of Owner Date 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 untler ins and penatt' Print Name _........ Signature of Owner/Agent Dine SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable Name of License Holder'. ----- — License Number Address Expiration Dale 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 in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 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: A J The debris will be transported by: / fVBy1 The debris will be received by: Building permit number: Name of Permit Applicant 3 itq Q/ �� "/ - Date Signature of P rmit Applicant �\ The Commanweatth of Massachusetts Department oflndusinEdAccidents 7 Congress Street,Suite 100 Boston,MA 02114-1017 wwtamassgohddia W11,witers'Compemation Imurance Affidavit:BmRden/Convr rslElect rims/Plumber¢. TO BE MAD WrM THE PERE I'MG A771HORM. Applicant Information I ple ase Print Lezil,l NeIDeB esyOBam®nmmrlmdrv�dmal) �c�An�-a G5 �Hw.tu Rori�n ryud,0 �i�jt iS Address: City/State/Zip: O/3 Phoae#: t/13 6�7-S�Zz Are ran meapoyer!Chwlsehe appsopsiate bar: Type of project(required): l.0 ima®pbymwim e�bycv(fwaod/mpmt-t®c).' 7. E]New construction 2.❑1®anle pmptimuarpamvship incl Wwmemploym wmh>o6 fmmeb 8. ❑Remodeling soyY.Mo wmkms'won �� m®m] 9. ❑Demolition 3.❑I®ahmmvmmdobgamwvk myrJC lHa wotlms'camp.rmvmce,eq®eat+ 4.❑I®ahmmwmmdw�Lhehvm[:�+usmmoJr Ow vamypoprny. Iwdl ]0❑Buildwg addition eonectbaa n.xes�'cmpm®um.armmb 11.❑Electrical repairs or additions v hmen,[� 12.❑Plumbing repaus or additions 5 ®.aeevvl maacvmdlmrstivrdmembwm.cmrsti�mmc emrhd ebur 13. f errs 7"thec mow,. haw e�gJoym mdmw :wodvs•cmP.ma®mreP����������,,�� 6.❑Wemeaeupmatimmdesoffsmshawevmecdt oghtofcn®pcooP MGL, 14" or'P —M� rrt,4rla4,wwehawm®pby<m.p+owodms•�p.b.mmaetesesal �y�e 'Avy rypa®t tbn tlrcY.e box al mum also 5m wmroe corm bebw showing the wodsms'wmprnwrov policy atmmmm iHomeowvms who submit thisc5tlavi[bdraevg they Rdoing am wink mdtlm hhe osmidccmtracewa®aashma¢naw sadasit ioAutmgs L. iContmcmrs am check this hoz mins mtecLM m edd'eiooal mcct abawag the vine of the wh-cmmaclm®d smm whmhm w vat Chow ati0a have ®goyw..Bthe mbwvmcbrs bine®PlaYess.thry msapmvide the wmins'r^w,.poary mmbm. I mm mn ewWloyer dsmis providing workers'eompensadon insaranee for my employees Below is the policy andjob site atfi rmaa 4C,E MSA LI...CI... oarpany Name: p Pohry#or Self-ins.Lia#: F�" 0C �y(s$7iuB-QNo,3yj�7��- I Expiration Date: 61 4 Job Site Add., V 4it S 1-- ' frMl�i.r ./'fes/ City/stamaip: /') I Attach a copy of the workers'compensation po' decL ation page(showing the policy number and expiration date). Failure to secure coverage as required order MGG c. 152,§25A is a criminal violation punishable by 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.A copy of this statement my be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby . under Hep®rs ofpe7my that the infarmagonprovidedisaueandcorreci Si Date: I ZO 19 Ph.#' -g 2. Offieid use duly. Do not wrice in this are;to be completed by city or town offwia1 City or Towns: Permit/L4cense# Inning Authority(circle one): 1.Board of Health 2 Building Department 3.City/Town Clerk 4.Electrical Impactor 5.Plumbing Inspector 6.Other Contact Person: Phone#: 04/17/2818 13:44 4135686788 ROGER WTLERINS PAGE 01/01 ACVRd CERTIFICATE OF LIABILITY INSURANCE "I= THOCERVICATE N bNiD AB A NAT OP INFOINU110N ONLY AMD COHFERH No NQKM UPON TIE CERTaTCATE MUM.THIS CEWnF ATE DOES NOT AFMINATELYOR"MATTVELY AIEW,IOMMORALTER THE COVERAOBAFFONOEOBY TE POLM" BELOW. TNS CEFUNWATEOF MURAME ODES NOT COMIUIE A COIRPACT BETWEEN THE MUM POLNUERMAURgROFO REPPJMS 1TATNE OR PRODUCEH,AND THE CIRT'"WH01.09t ANT: HNNAlhWbiNan DOWiEO,RNPMgAIMInNRRSrAA NA/.NEURERPrmAnnnsm M1mNB4. M 911BRDEATgN N YFATFp,MpNim BN YNr rd snitYMiXNitlr PTELP.nNNNI PkBn.W nNNR M M4AInNNSNt A NYNRNnI On NB tbtlRAb4ERN Rd rsetitl btlr MNlNb bNNbBNU RTANaU M4RInnmEANs(. 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