31B-081 (20) 131 ICING ST BP-2004-0639
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:31B-081 CITY OF NORTHAMPTON
Lot: -001
Permit Building
Category: BUILDING PERMIT
Permit# BP-2004-0639
Proiect# 3S-2004-0898
Est. Cost $500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: Thomas Gross 059093
Lot Size(sm.ft.); 24480.72 Owner: Service Net
Zonime:NB Applicant: Thomas Gross
AT: 131 KING ST
Applicant Address: Phone: Insurance:
237 Plumtree Rd (413) 665-8235 Workers
Compensation
SUNDERLANDMA01375 ISSUED ON.11/21/03 0:00:00
TO PERFORM THE FOLLOWING WORK REPLACE EXTERIOR DOOR
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 Occullancy Sienature:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 11/21/030:00:00 4627 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
Vemionl.7 Commercial Building Petnut May 15,2000 '41,1S
City of Northampton
Building Department
212 Main Street
Room
00
NOV 2 1 �� Northampton, MA 01060
phone 413-587-1x40 Fax 413-587-1272
— 1
APPLICATION ib�Wfiii R 'C REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
1.1 Property Address: _ --
l
tz
sEcr�aN-'a�Pat�,�n'� �1�7�RSNm�
.1 nroR rd: /
NamAe(P nt) Current Mailing :
i.,.,..,..0%.,1�
Signature Telephone
2.2 Authorized Agent:
/// OH'1 fJJ /y G.CCJJ 177 ✓r�h/R+-e_ ro
Name(Pnn Current Mailing Address:
Nil- 6GS- �1 JS
Signature Teleomne
SECIIOM3f5f[#fA7ED.COIYSIdU1L7TON�515e�y��
Item Estimated Cost(Dollars)to be Offic"dal-Use OnV
mm leted by Dermitapplicant
1. Building �S.a o �(a�'BWlding�etapd`Fee,..
2. Electrical
3. Plumbing -F
K
4
4. Mechanical(HVAC)
5. Fre Protection
6. Total =(1 +2 +3+4+ 5) `.C13e�kI+>tiitiber
,a r
gtildr` Fepipd:Nu xs- = :.', Issued:
p
'Signature:
&aiding Camnussiarer7ins7rednr of.Bnildugs: Date
Vmionl.7 Commercial Buildmg Permit May 15,2000 ~
Interior AlterationsV Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ Nev,Signs [ 3 Change of Use [ ] Other [ ]
x Accessory Building ( 1 Repairs I 1
BRIEF DESCRIPTION: �e 'LL� �X /nr.ti 661, 2 7 �� K G •T
SEC7IOl15-VSE�iROtW-+R'NA`�77S�,RU[�LtII-31(��_
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Cl A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
_ . .ON,�"r A'I��OR.CHANGE IN"USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
_s
SECISON EBUIi°DING•I?�I6Y@�,]�k ��",G;` -
BUILDING AREA B aSTING PROPOSED NEW CONSTRUCTION
i
Floor Area per Floor(sf) 19
a 2nd
2nd 3m
3'd
M
4d' 4
Total Area (sf) Total Proposed New Construction(st)
Total Height(ft)
Total Height ft
Versionl.7 Cmnmercial Building Permit May 15,2000
7.Water Supply'
M
-
G
L.c 40,954) 17.3 Flood Zone Information: 17.3 Sewage Disposal System:
Public ❑ Private C! Zone: Outside Flood Zone 13 Municipal ❑On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
nis win=in be filled in by
Building Depmmtrnt
Lot Size
Frontage
Setbacks Front
Side L:_R:_ U R.
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot vn annus bldg&paved
#of Parking Spaces
Fill:
volume&Lxaaon
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT 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
YES
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 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:
Version 1.7 Commercial Building Permit May 15,2000
JqjEICTTV-
SECTIOW9-,BROFESSIO L .4 1 '3 RIES-SL
THAN f—'F -LOSEDi
1`401 N
lC BE -sOFZNr ACE)
9.1 Registered Architect:
Not Applicable 0
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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 Date
9.3 General Contractor
Not Applicable 0
Company Name:
Responsible In Charge of Construction
Address
Signature —Telephone
A
Versionl.7 Commercial Building Permit May 15,2000
'$EC,F{}JQN to 57��H TU A'L 7kEfJ RgrI N 0 �v7R 11011]
Independent Structural Engineering Structural Peer Review Required Yes......❑ No., -0
SECTJON�.LMNERAUT'IORJZATJON TgfJ3C0MP1ETEO WHEN
O1Y{5�„RrSA ,ENT CO TAAOn,TQR" i?0ES`; R �''O(L1JING PERMIT ,
I, as Owner of the subject property
hereby authorize 'o act on
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[`u//nder the pains and penalties of perjury.
7411a ,, /V ram ie cJl
Print Name
Signature of Owne /Agent Date
6ECTJON S2w.C, INS, �{J1) ICuFs
101 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder: 7�dmA 6/LoJI �Sf/q7
License Number
Atltlress �J 6 Expiration Date
Signature Telephone
SEC.',OI13 S+ 5 gS�.Ows °CEAFFIDAVITdM'G L:ict15 , SC(6 .e r `
a fi:ry ., &7
�.� ... ,«
.�� .-:, 1... ,.G..'�%Yv s.'A..4 4M1` :4'Mti:. do R.x..* .a ra ••:k; .a.�q%4:nk .ie'
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavd
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... 0
trwrnr
Gill of �nrtflat)tytou - —
A ' f 91.....hear.'
OEPAATMENT OP nUIl FNG INSP2C 101dS
212 Mui. Street ' i`4uvicipnl Doilding
Nor(hamplon, Moes. 01060
WOBJ=Z'S CONIOENSATION CVSURAIvCE. AFFMAVIT
I
(lia'nsa'Jpermittce) -. - _ __.
vnth a principal place of business residence at.
(phone')
(svrsl/ci ry/iwcln p)
do hereby certify, under the pants -,ad penalties of perjury, hLu
O I am an employer providing die follOWing workers comocnsauon coverage fur 1 n
employees working on dus job
(Incur= .
Campacy) (Potic:N�-abcr) (L•yirrior, Dom)
( ) I.am a sole prooQ
ncror, general cooactor or homeowner(circle one) zIr d have hired
rhe coarraciors listed below who hive the following workers eocDttisacon pol!cies,
(Nome of Co.^.^cto-) (Insuenae Co' oO p PGGm Numccr) (E ST'daoo Date)
(NLveo(Coommor) (lnsu(anc CcmoaayrPofin' Numb') (Expiration Due)
Mame o(Coonaci,) (1n5wancc Compaoy(Potic) Nzmtb r) (E.1pir6e0 Dale)
(N'xmc of Cootranor) (Insuranc Compxuy/Policy Nutub r) (Exyiruoo Dale)
O I am a sole proprietor and Gave no one workdng for me.
O I am:a home owner performing all Lbe work myself.
NOM'Ir=ic4.m�M vSy<pttna+rteee..4 mml%tt bda me yy..ah m.d..ellja or
m«e V,." ��ia..'mA Ux bomomwo,ado«oe aK LL-6 tr,.b —f..oel Cmc.P a —1 u k
�Ioym uWc vhe wa#�hc -ym Ae(GL152v 1(5)J,ygliapoo%.6amao.m lm:ucxx«pvron�r
l.pl wue(m Q.leYv mdr We WorY�.Compm.tim A<
I wEen.oG mnampy e(Wi.mlmm m.yt.(«..ed,db�s,Cq..nmyf e(IMm�J i,mGmY aRw er Lavm rm N. '
m ay vci6 Sim�d llu Lauc u.mu.tov�rte mdc.ec4m 25A of MOL IS)oe hdu Vr L�aEim olvimio+lpmeluo
arnat�e(.Gee e(�q b S I JW.W uvY« +o�rID o(u0 b ua Yev ear c�i1 Fa`No-w Dc(«m o(.SW Wa4 On4.r.W.
f o(S 100.00.&Y.piS�
r«dm ..auKmy
Pcrmn Number i
_
SiPaawrc of LiomSWPcrtaiux --1��
a
COMMERCE AND INDUSTRY INSURANCE COMPANY 69194-0000 WC 969-54-56
15172 - ----------------"0;-3.82-0403-00
.I NEW YORK
SER129 KING
NG S INC w� Member Companies of
129 KING ST ,1
NORTHAMPTON, MA 01060-0000 American International Group
EXECUTIVE OFFICES:
TD PINE STREET, NEW YORK, N.V. 10270
SEE NAME AND ADDRESS SCHEDULE - WC990610
I.D# MA UI#
TPA INSURANCE AGENCY, INC.
WORKERS COMPENSATION AND EMPLOYERS 10 NEW ENGLAND BUSINESS CENTER
LIABILITY POLICY INFORMATION PAGE ANDOVER, MA 01810-0000
INSURED IS PREVIOUS POLICY NUMBER
NOT FOR PROFIT I NEW
OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WL 0610
nEM 2 POLICY PERIOD 12:01 AM.atanaara time at the Inaumes
maDin9aaarew - FROM 04/01/03 To 04/01/04
REM3 A. Workers Compensation Insurance: Par[ One of the policy applies to the Workers Compensation Low of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to the work in each area listed In Item 3A.
The limits of our liability under Part Two are:
Bodily Injury by Accident Is 500,000 eachaccident
Bodily Injury by Disease $ 500.000 policy limit -
Bodily Injury by Disease $ 500.000 each ..Play"
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed hare:
AK AL AR AZ CO CT DL DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ
NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI
mala The premium for this policy will be determined by our Manuals of Rules. Classifications. Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Eaunnuea Total Rale Per Estimated
Clessilieuions Cade Number Remuneration $100 OF Re- Purum
OAnnual 0 3 Yearin.mention O Annual 3 Year
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $4,424
EXPENSE CONSTANT EXCEPT WHERE APPLICABLE BY aTATEI $244 MA
MINIMUM PREMIUM $115 MA TOTAL ESTIMATED PREMIUM $94,041
U indicated below. Interim adlustmama of Premium:rill be mads:
F] Semi-Annually 11 ounMdY Monm" DEPOSn PREMIUM
ENDORSEMENTS(FORM NUMBERI SEE ATTACHED FORM SCHEDULE - WC990612
04/02/03 PARSIPPANY 82
Haue wle Isau late office Amnomod Representative we DD DD DI
]9962