24D-001 (20) 257 PROSPECT ST-LANDER GRINSPOON BP-2019-0041
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:24D-001 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-2019-0041
Project JS-2019-000055
Est.Cost:$2500.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RICHARD PALMISANO 89485
Lot Size(sp.ft.): 154638.00 Owner: B NA1 ISRAEL CONGREGATIONAL
Zoning:URB(100)/ Applicant: RICHARD PALMISANO
AT. 257 PROSPECT ST - LANDER GRINSPOON
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 374-2719 n WC
HADLEYMA01035 ISSUED ON.711012018 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE SECTION OF WALL BETWEEN
CLASSROOMS, REFRAME AND INSTALL 7X6'8 INTERIOR 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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/10/20180:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File fkBP-2019-0041 PW y/]11
APPLICANT/CONTACT PERSON RICHARD PALMISANO i
ADDRESS/PHONE 87 SHATTUCK RD HADLEY (413)374-2719 Q
PROPERTY LOCATION 257 PROSPECT ST-LANDER GRINSPOON
MAP 24D PARCEL 001 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TypeofConstruction: REMOVE SECTION OE WALK13ETWEEN CLASSROOMS REFRAME AND INSTALL
7X68 INTERIOR DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included'
Owner/Statement or License 89485
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Variances
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
Signaf6leofthril mg al Date
Note: Issuance of a ing 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.
s Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Versionl.7 Commercial Building Permit May 15,2000
City of Northampton .,� 0,a1I
Building Department
212 Main Street
Room 100 dillilillli"rr„ SM
Northampton, MA 01060 TWOS�a 'Plana II Al
phone 413-587-1240 Fax 413-587-1272
Other
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
� wu,/n� Plates — !�
SECTION 1 -SITE INFORMATION 20 /(f /<l/,IS
1.1 Property Address) This section babe completed by oftics
7-5-1 io2osPL-c i S7-- Map a2`/ fl Lot I Unit
A�o/LrNfimPTD rJ Yf'!�} 0, 060 Zonis Oseday oisMct
--- ---------- Elm at Distrid CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAliENT
2.1 Owner of Record:
---�Td1>C`/L._�2-r✓l O0r-) .-_L/ ....Nmrly-. --.
Name(Print) Current Mailing Address _
Signature Telephone
2.2 Authorized Anent:
...6 LL 67./ _.lC .
Name(Print) Cumun Mailing Address
ZS Rose€qqu fi ulo2 ofaire
Signature Telephone l SD� L LL
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
win feted by pennutapplicant
1. Building yp 00 (a)Building Permit Fee
2. Electrical - (b) Estimated Total Cast of
Construction frau 6
3. Plumbing Building Permit Fee 77
4. Mechanical(HVAC)
5. Fire Protection -
6. Total=(1 +2+3+4+5) z..5"-00 Check Number
This Section For Official Use Onl
Building Permit Number Date RECEIVED
SIssued
gna � /.
ommi8aioner ries rof Buildings Date 7110114 DEPT OF BUIL DING INSPECTONS
C�VI�I('/I R2,�'tn72) IW, I� �i 4mal- � - CO»'1
Version L7 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 ❑ Demolition J!9- Repairs El Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here &fij0,✓6 €Gr/a./ 0 )'/Ar
Df Proposed Work:
CLt}SS2dOmJ Aa2e FltlJr-r6+_A-NfJ IrJ1 i/N-r— '/ til 6 8 MArs"2'b6O2
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 1A ❑
A4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational 2B ❑
F Facto ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3g
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-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(sf)
2 ..._ ..._._ 2"e _
3" ..._ P .... ..._..
Total Area(sf) �Q Total Proposed New Construction(sl)
Total Height(0)
Total Height It
7.Wa[er Supply(M.G.L.c.60,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private ❑ Zone. Outside Flood Zone Municipal On site disposal system❑
Versiori Commercial Building Permit May 15,2000
g. NORTRAMPFONZONFNG
Existing Proposed Required by Zoning
This coluam to be filled in by
Building Department
Lot Size
Frontage ------
Setbacks Front
Side L Rr' L _ R.
Rear
Building Height
Bldg.Square Footage -- - % --'"
Open Space Footage --- % --
(Lot oma mlaus bldg&paved ---
akin - -. _-
#of Parking Spaces : --
Fill:
volume&Location t_._ __--..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO � DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book Pae and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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: 5 pk pL q tr 1/1f 41 t-D 1JN FRoN/
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Venuori 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:
1' ------- Not Applicable ❑
Name(Registrant):
rl.. .I D *tZ -
- RegisVation 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 Re;1 stretion Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Tekphane Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
�T�frE e2ro2 p2 RaTIoJ JTJ Not Applicable
Company Name
Responsible In Charge of Construction
A tlr s
_yr3-� y zit 9
Sigh Telephone
,
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) �}1
Independent Structural Engineenng Structural Peer Review Required Yes O No rgL
SECTION 11.OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize Y _1 L'l'f q f2- to
act on my halt 'Five to work authonzetl by this building permit application
Signature of Owner I 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 underthepains and penalties of perjury
PrintNam _- ... _. __ ... .
� -q(9I('�'
Signa ince of OwnerlAgent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:n Not Applicable ❑
Nam.of License Holder
nn License Nuu�mbeJr
Adq Expnatian Date
VoP� f N� t� ) qis3?yz�lg --
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 O 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: zS9
The debris will be transported by: /mPs � n 1 r;flF»rSd
The debris will be received by:
Building permit number:
Name of Permit Applicant ��yL �� ✓s/Jno J 9 ren �I
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
I CongressA02114-2017
2 Suite
Boston,MA 02 714-2 01 7 7
www.mass.gow'dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information (� Please Print Le ibl
Business/Organization Name: f7/{'y' t!-r� L'/�TY�fG2 ��I✓0V,f7—)fj�
Address: F�/7 4=12c C 12P.
City/State/Zip: 14-P2 LrY Mf} 0I125� Phone#: ()13 3-74 2 7% 9
Are you an employer?Check the appropriate box: Business Type(required):
1IQ I am a employer with Z_employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.ElI am a sole proprietor or partnership and have no 9. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8.60 Non-profit
3.❑ We 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 workers' comp. insurance required]* 11 E]Health Care
4.El We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] 12.0 Other
'My applicant That checks box#1 must also fill out the rectus,below showing Their workers'compmuatiov polity information.
"Ifthe wrpomteoR ars have exemptedthemselves,bathe wr,,i, i has oNeremployees.aworkers'compwsatisnpolicy is requidaM such an
orga,rzatiom should check hox#1.
I am an employer that is providi�workers'comp�e5adon insurance for my employees Below is the policy information
Insurance Comp any Name: 11i✓C)G c J 7gez�
Insurer's Address:
City/State/Zip: 'L p 0/e76�
Policy#or Self-ins.Lic.# �T/ L)4—6 d7 Z7 3 39 7 Expiration Date: 3
Attach a copy of the workers' compensation policy declaration page(showing the policy number find piration 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
hrvestigatio o the D r insurance coverage verification.
I do hereby er the n d penallies of perjury that the information provided abov is n and correct
Sent 9r 1(IAAAQ M, Dz j4
Phone#: `q[3 ` 377 ' t
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.Cityrfown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every 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,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,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 o£the
dwelling house of another who employs persons to do maintenance,constmction 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 state 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"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation 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 the affidavit. The affidavit should be resumed of
city or town
that the application for the permit or license is being requested,not the Department of Industrial Accid s Should you
have any questions regarding the law or if you are required 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 will he used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves 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, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or I-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Reviscd a2-23-15