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24D-070 130411-permit application REVVersion1.7 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 238 King Street Northampton, MA The Stop & Shop Supermarket Company LLC 1385 Hancock Street, Quincy, MA 02169 (617) 770-8878 Jeff Morgn 1385 Hancock Street, Quincy, MA 02169 (617) 770-8878 $280,000.00 Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000CUBIC 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 ✔ ✔ ✔ 5,880 0 0 0 5,880 5,880 0 0 22 5,880 22 Redemise existing approximate 5960 sf premises and separate utilities for potential new retail. Modify exterior building to provide proper egress. 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. Retail Storefront signage Additional retail signs by future tenants 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 REVIE (780 CMR 110.11) Independent Structural Engineering Structural eer Re ie Re uired es No SECTION 11 - O NER AUTHORI ATION - TO BE COMPLETED HEN O NERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I _________________________________________________________________________________ as ner of the sub ect property hereby authori e_______________________________________________________________________________________________ to act on my behalf in all matters relati e to or authori ed by this building permit application ____________________________________________________________________________________________________________ Signature of ner Date I _______________________________________________________________________________________ as ner Authori ed Agent hereby declare that the statements and information on the foregoing application are true and accurate to the best of my no ledge and belief Signed under the pains and penalties of per ury ______________________________________________________________________________________________________________ rint Name ______________________________________________________________________________________________________________ Signature of ner Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Constr ction S er isor: Na e of License Holder :___________________________________________________________ ___________________________________________________________________________ Address ___________________________________________________________________________ Signature Telephone Not Applicable _____________________________________ icense Number _____________________________________ Expiration Date SECTION 13 - OR ERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, 25C(6)) or ers Compensation Insurance affida it must be completed and submitted ith this application ailure to pro ide this affida it ill result in the denial of the issuance of the building permit Signed Affida it Attached es No