24A-221 (7) 21 LOCUST ST-CORLISS CLEANERS BP-2019-0836
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-221 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-2019-0836
Project# JS-2019-001383
Est.Cost: $3000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GEOFFERY GOUGEON 96151
Lot Size(sgft.): 10715.76 Owner: WESTGATE LLC
Zoning:NB(100) Applicant: GEOFFERY GOUGEON
AT. 21 LOCUST ST - CORLISS CLEANERS
Applicant Address: Phone: Insurance:
13 S CHESTERFIELD RD (413) 695-1335
WILLIAMSBURGMA01096 ISSUED ON.112512019 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADDING A WALL TO SEPARATE DRY CLEANING
EQUIPMENT AREA FROM RETAIL AREA
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 1/25/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0836
APPLICANT/CONTACT PERSON GEOFFERY GOUGEON
ADDRESS/PHONE 13 S CHESTERFIELD RD WILLIAMSBURG (413)695-1335
PROPERTY LOCATION 21 LOCUST ST-CORLISS CLEANERS
MAP 24A PARCEL 221 001 ZONE NB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: ADDING A WALL TOSVA—RATE DRY CLEANING EQUIPMENT AREA FROM
RETAIL AREA
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 96151
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INf F9RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMTT 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 MGL 40A.Contact Office of
Planning&Development for more information.
7
Version 1.7 Commercial Building Permit May 15,2000
Departt�t�use on�r
City of Northampton Permit
Building DepartmentC;wWve y Pem
212 Main Street tgwidseptic Ayeiti y
Room 100 WaWNVell I�
Northampton, MA 01060 Two Sets of Structuiis ,..
phone 413-587-1240 Fax 413-587-1272 Plotter
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANG E TH F,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE O TW FAMILY DWELLING
AN 2 4 2019
SECTION 1-SITE INFORMATION' OZ Y� aZ
1.1 Property Address: This section to co pleted by office
__._....- __ ___....._.d n __..�. DePY OF BUILDING INSPKTIoN$
Mae NORTHAMPTON,MAO*W Unit
/f/01 A,1- O"O 7,4U Zone Overlay District
_... Elm SiL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
.......
aNis v
Name(Print) Current Mailing Address.
Signature Telephone
2.2 Authorized Agent:
(760e �1 eo . . .... ......... !/S ?I 1
Name(Print) Current Mailing Address
p
Signature Telephone
SECTION 3-ESTI T ONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building d (a) Building Permit Fee
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 (�1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
-ems% — gou-9con aL1a,®a01_e0yy\.
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 ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. 'o'AO-LjC&1( `{ S e
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
'USE GROUP(Check a °1 plicable) CONSTRUCTION TYPE
A AssemblyElA 1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A ?❑ A-5 ❑ 1 B ❑
B Business - 2A ❑
E Educational ❑ 2B El
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi h Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
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(so
1 St 1 St
2nd 2nd
3rd _. 3rd
4th
Total Area(so Total Proposed New Construction (so
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood ZoneInformation: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[:]
t
Versionl.7 Commercial Building Permit May 15,2000
S_ NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _ ._._... ..__...__...........
Frontage _... . ......... ,,......_.
Setbacks Front
Side L: ...._-. R: L:. ._.... R:'
Rear _..
Building Height �
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking) _..._....._
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW . YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES
IF YES: enter Book Pae and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO kN DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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? YES0
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i,
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 ❑
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 Date
9.3 General Contractor
�C�CbM4r, Not Applicable ❑
Company Na
6eO�ceLy Cao2eon
Responsible In Cha ge of Cons ction
s :�� � �laDlD�l�
Address j
Signature Telephone
f
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 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
....
as Owner of the subject property
hereby authorize to
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 under pains„and penalties of perjury,
Print Name
Signature of Own gen Date
SECTION 12-CON RUCTIONSERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: . _ .. f t 11_ .__ ......
License Number
Address Expiration Date
Signa a Telephone X)10
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 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: 2� Le'<-�
The debris will be transported by: V
The debris will be received by:
Building permit number:
Name of Permit Applicant
451
23
Date Signature of Permit Applicant
3
The Commonwealth of Massachusetts
Department of Industrial Accidents
s I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: 4 6
Address: l I T d � `rf Pr i r k ca
City/State/Zip: 1 hone#: q13-6 957-/3 3 �
Are you an employer?Check the appropria box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.�I am a sole proprietor or partnership and have no 2• ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• E]Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.ZOther
ler
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
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#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$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 certify, n erZ2-
aims and nalties of perjury that the information provided above is true and correct
Si nature: Date: ` 3-�
Phone#: 3 6k]1 3 5
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.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
L
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 a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an 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 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 returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. 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 be 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
may be 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 burn 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 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
From:
T5v A-n
�y(31 C�9s-r3 �s�
To:
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, 1 request that you
grant a modification to waive the requirement for construction control of the project at
because the work is of a minor nature,will not affect structural elements, health,accessibility, life or fire
safety, and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,
CORLISS WESTGATE, INC.
21 Locust Street
Northampton, MA 01060
Telephone: (413586-0100
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