18D-040 375 King BP-19-718375 KING ST -PRIDE
GIS#:
Map:Block: 18D -040
BP-2019-0718
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
""-'Pe=rm=it-'-: --=-B=ui=ld=in"'""g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2019-0718
Project# JS-2019-001177
Est. Cost: $15000.00
Fee: $105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
ROBERT BOLDUC 038811 Use Group: -------
Lot Size(sq. ft.): 42209.64
Zoning: HBO 00)/WP( 6)/
Owner: Pride Convenience Inc
Applicant: ROBERT BOLDUC
AT: 375 KING ST -PRIDE
Applicant Address: Phone:
246 COTTAGE ST (413) 737-6992
SPRINGFIELDMA01104 ISSUED ON:12/20/2018 0:00:00
Insurance:
Workers Compensation
TO PERFORM THE FOLLOWING WORK:REMODEL 1,400 SQ FT OF INTERIOR SPACE
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 12/20/2018 0:00:00 $105.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck -Building Commissioner
File# BP-2019-0718
APPLICANT/CONTACT PERSON ROBERT BOLDUC
ADDRESS/PHONE 246 COTTAGE ST SPRINGFIELD (413) 737-6992
PROPERTY LOCATION 375 KING ST-PRIDE
MAP 18D PARCEL 040 001 ZONE HB(l00)/WP(6)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T eof Construction: REMODEL 1 400 S
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 03 8811
3 sets of Plans/ Plot Plan
REQUIRED DA TE
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MA TION 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 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
c:L._ ;vJ
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.
...
Version! .7 Co
City of Northampton
Building Department DEC
212 Main Street
Room 100
Northampton, MA 0106 NORTHAM
phone 413-587-1240 Fax 413-587-1272
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 I /-0
1.1 Pro(:!emAddress: This section to be completed by office
" "" ·~,,, ..... t!D oWJ 375 KING ST Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record: .,.,,,
PRIDE CONVENIENCE INC .246 COTTAGE ST SPRINGFIELD MA 01104
Name (Print) Current Mailing Address:
~~ i(113) 737-6992
Signature Telephone
2.2 Authorized Agent:
:DAVID SABOURIN 246 COTTAGE ST SPRINGFIELD MA 01104
Name (Print) CurrentM,ailing Address:
~ -· ~\1
:(413) 737-6992
Signatur~'i\ -0 Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ··: (a) Building Permit Fee $5,000.00 . " ···-·. ....... w," """ 2. Electrical $2,500.00' (b) Estimated Total Cost of $15,000.00 Construction from (6) ..
3. Plumbing $2,500.001 Building Permit Fee
'" ~~
$ \OSOD 4. Mechanical (HVAC)
5. Fire Protection $5,000.001
6. Total= (1 + 2 + 3 + 4 + 5) 1~ onn Check Number 17/-1,q , ,
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Ut\ \) 'b s A &,).J R.1,./ (I' C (.. L. "1=t "I I 3-4 (3 =s . '1C, <:. c,..
'"DSAi3t:uR, ,J ~PR1t:::6 S',oiQ6:S., <"'0""1,
Version 1. 7 Commercial Building Permit May 15, 2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations !ZI Existing Wall Signs D DemolitionD RepairsO Additions D Accessory Building D
Exterior Alteration !ZI Existing Ground Sign IZI New Signs !ZI Roofing D Change of Use D Other D
Brief Description REMODEL INTERIOR DUE TO DUNKIN DEPARTURE. CABINETRY, INSTALL NEW EQUIPMENT,
Of Proposed Work: KITCHEN HOOD AND SUPPRESION SYSTEM AND SUBWAY. REMOVE NON SUPPORTING WALLS.
i'-~00 'r.-1;.).FT, ...
SECTION 5 • USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly D A-1 D A-2 D A-3 D 1A D
A-4 D A-5 D 18 D
B Business D 2A D
E Educational D 2B I D
F Factory D F-1 D F-2 D 2C D
H High Hazard D 3A D
I Institutional D 1-1 D 1-2 D 1-3 D 3B D
M Mercantile !ZI 4 D
R Residential D R-1 D R-2 D R-3 D 5A D
S Storage D S-1 D S-2 D 5B IZI
U Utility D Specify:
""",
.,._,
M Mixed Use D Specify:
.• . " . ...
S Special Use D Specify:
... uv •
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
U U~ A """ ...
Existing Use Group: Merchantile Proposed Use Group: Merchanti.le
Existing Hazard Index 780 CMR 34): 3 ... .. Proposed Hazard Index 780 CMR 34): 3,
SECTION 6 BUILDING HEIGHT ANO AREA I
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 4,400: 1st 4,400'
,,,,
2nd 2nd
..
,v .. ,
,•mH 3rd
3rd ,,,,.,v ,,,,,
... 4th 4th i
Total Area (sf) 4,400 Total Proposed New Construction (sf)
4,4:QO
Total Height (ft) 21 ,.,,
Total Height ft 2L
7. Water Supply (M.G.L. c. 40, § 54) 7.1 FloQd Zone Information: 7.3 Sewage Disposal System:
Public [Z) Private D Zone· ......... Outside Flood Zone!Z) Municipal !Z) On site disposal system D
Versionl.7 Commercial Building Permit May 15 2000 ,
8. NORTHAMPTON WNING I
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 1,.969 acre ........... . . .969 acre
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: 1, .....
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES @
IF YES, date issued: 02/26/1998
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES .. @
IF YES: enter Book 5369 Page; 80 and/or Document# 980011571
B. Does the site contain a brook, body of water or wetlands? NO @ DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued: :
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: Ground and Wall Signs
D. Are there any proposed changes to or additions of signs intended for the property? YES @ NO 0
IF YES, describe size, type and location: Change to face of signsto reflect Ile,w tenant/use,
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 Q NO @
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version 1. 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 [ZJ
"" ..
Name (Registrant): i
Registration Number
.. " ""
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
mM
Address Registration Number
""""
Signature Telephone Expiration Date
',., ,,, , , .. , .....
Name Area of Responsibility
....
Address Registration Nu.mb.er
Signature Telephone Expiration Date
'w= "·"
''""
Name Area of Responsibility
Address Registration Number
" " ,,
Signature Telephone Expiration Date
.. "P" , cUOM' •m•, ''""' . '"'"" u.,,S>-s•• "'"""
Name Area of Responsibility
''' '"
'"""'''
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
; Not Applicable [ZJ "'",
Com~any .Name: "="'
Responsible In Charge of Construction
Address
Signature Telephone
.. '
Version 1. 7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required
SECTION 11 • OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Yes Q No@
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.
12/17/2018
Signature of Owner Date
I, DAVID SA~OURIN , 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 pc1ins and penalties of perjury.
~,Ml~~~
Print Name
Signature of Owner/Agent
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Name of License Holder: ROBERT L. BOLDUC
49 WOODSLEY RD LONGMEADOW MA 01106
Address
Signature
Date
Telephone
Not Applicable D
CS-038811
License Number
10/31/2019
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 Q
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: 3'1s ;.(.•yG ~+.
The debris will be transported by: SQJ'.k:l~ ~, ~
The debris will be received by: -------------
Building permit number: -------------
Name of Permit Applicant ~,T.:;6" ko73e"~·\ ··~c.1::x} e-
Q~/!J.Lk 7
Date Signature of Permit Applicant
-¥-'
,.. Tl,e Com111011w1J11/rf1 ,~f',iitHs,1cl111seus
Departme1tl t>f /mltJstrial Accidmts
Office of T1westigatio11s
600 Waslibtgton Street
Roston, iHnss. 011 I.I
www.mass.go,vdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Plc:._u~f rint Le_~ib}v ··-·
Naine (Business/Orgallization/Jndividual) :_"""'?_R_1 "D __ ~'-'----------------·---·----
Address1 ~'-J(_q . ~S (SI,
City/State/Zip: SP~tNG:iP'tS:et::.,HA ou o"-1
Are tttt an employer? Check the appropriate box: ·
1. Ji;I am an employer wil.b -</tfc, 4. 0 I am a general contractor and I
employees (full and/or part time).• have hired the sut,..contractors
l. : 1 am a sole proprietor or partner-listed on the attached sheet.
ship and have no employees These sub-contractors have
working for me in any capacity. employees and have workers'
[No workers• comp. insurance comp. insurance. t
required] 5. C We are a corporation and its
3. : I am a homeowner doing all work officm have exercised their
myself [No workers' comp. right of exemption perm MGL
insurancerequiffil] t c. 1S2. § 1(4). and we have no
employees. [no workers'
comp. insurance required.]
Type of project (r~,1uired): !
6. 0 New coostrucrion
7. 1 Remodeling
8. ! Demolition
9. ·i Buildingaddition
l 0. · l Electrical repairs or additions
11. J Plumbing repairs or additions
12. 1 Roof repairs
13 .. I Other ------·
I 11111 tm empk,yer thtll Is J¥1"'vi4bll workm' compmsat/MI insurance for my empmµes. Below is the policy and job site
~~M~ C Insurance Company Name: /.lu'T'l)M.O'"'I" 1\J 6 :r~,a:s O f":<e.
Policy# or Self-ins. Lie.#: WC.. tt:::>.09 ot..o.C -oq
'
Expiration Date: IQ -8 f .. le, l'f' __
JobSiteAddren:. _______________ City/Smte/Zip: __________ _ ..
Attach a copy of the worken' compensation policy decltratlon page (showing the policy number and expiration (d:m}.
I
Failure to secure coverage as required under Section 2Sa of MGL 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 fonn of a STOP WOR.K ORDER and a fine ')f
$250.00 a day against violator. Be'advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification. -----------------------------------------·~.-.,lld~W I do lterby certify u r th• pain$ and pe!JJjlies of perjury that tht information provided above is true !llld correct.
Si nature: x...,,-,,...,. '7( / ~ Date: , .. ?,-.. -
Official use only ..... Do not write in tliis area to be completed by city or town official
CltyorTown: _________________ rermlt/lkeose #: __________ _
Issuln& Authority ( circle one):
I.Board of Heath l. Butldtng Department 3, Clty!fown Clerk 4. Electrical Inspector 5. Plun1bhtf! ln1pector 6.0tber _________ _
Contact person:_· _____________________ Phone#: ----~----~---------------------------------~---·---....... .,,