july 2014 BUILDING PERMIT COMMERCIAL 196 Pleasant StVersion1.7 Commercial Building Permit May 15, 2000
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
Department use only
Status of Permit:
Curb Cut/Driveway Permit ____________________-
Sewer/Septic Availability______________________
Water/Well Availability________________________
Two Sets of Structural Plans___________________
Plot/Site 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
Map Lot Unit
Zone Overlay District
Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print)
Signature _________________________________________
Current Mailing Address:
Telephone 2.2 Authorized Agent:
Name (Print)
Signature _________________________________________
Current Mailing Address:
Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be
completed by permit applicant
Official Use Only
1. Building (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 This Section For Official Use Only Building Permit Number Date
Issued
Signature:
________________________________________________________ Building Commissioner/Inspector of Buildings
Date
Version1.7 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
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ! A-2 ! A-3 ! 1A ! ! A-4 ! A-5 !
1B ! B Business ! 2A ! E Educational ! 2B ! 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 ! 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:
Existing Hazard Index 780 CMR 34):
Proposed Use Group:
Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
PROPOSED NEW CONSTRUCTION
Floor Area per Floor (sf)
1st
2nd
3rd
4th
1st
2nd
3rd
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
OFFICE USE ONLY
7. Water Supply (M.G.L. c. 40, § 54)
Public ! Private !
7.1 Flood Zone Information:
Zone Outside Flood Zone
7.3 Sewage Disposal System:
Municipal ! On site disposal system
Of Proposed Work:
Brief Description
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
L:______ R:______
L:______ R:______
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 DON'T 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:
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.
Version1.7 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:
_______________________________________________________________________
Name (Registrant):
_______________________________________________________________________
Address
_____________________________________________________ _______________
Signature Telephone
Not Applicable !
____________________________________
Registration Number
____________________________________
Expiration Date
9.2 Registered Professional Engineer(s):
_______________________________________________________________________
Name
_______________________________________________________________________
Address
______________________________________________________ _________________
Signature Telephone
____________________________________
Area of Responsibility
____________________________________
Registration Number
____________________________________
Expiration Date _______________________________________________________________________
Name
_______________________________________________________________________
Address
______________________________________________________ ________________
Signature Telephone
____________________________________
Area of Responsibility
____________________________________
Registration Number
____________________________________
Expiration Date
_______________________________________________________________________
Name
_______________________________________________________________________
Address
______________________________________________________ ________________
Signature Telephone
____________________________________
Area of Responsibility
____________________________________
Registration Number
____________________________________
Expiration Date
_______________________________________________________________________
Name
_______________________________________________________________________
Address
______________________________________________________ ________________
Signature Telephone
____________________________________
Area of Responsibility
____________________________________
Registration Number
____________________________________
Expiration Date 9.3 General Contractor
_______________________________________________________________________
Company Name:
_______________________________________________________________________
Responsible In Charge of Construction
_______________________________________________________________________
Address
______________________________________________________ ________________
Signature Telephone
Not Applicable !
Version1.7 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 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 matters relative to work authorized by this building permit application.
____________________________________________________________________________________________________________
Signature of Owner Date
I, _______________________________________________________________________________________, 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 the pains and penalties of perjury.
______________________________________________________________________________________________________________
Print Name
______________________________________________________________________________________________________________
Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Name of License Holder :___________________________________________________________
___________________________________________________________________________
Address
___________________________________________________________________________
Signature Telephone
Not Applicable
_____________________________________
License Number
_____________________________________
Expiration Date
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