31B-004 (37) 54 ROUND HILL RD BP-2019-0914
GIs#: COMMONWEALTH OF MASSACHUSETTS
:Block: 31B-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category demolition BUILDING PERMIT
Permit# BP-2019-0914
Project# JS-2019-001531
Est Cost $29000 00
Fee $210 00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groujx CROCKER BUILDING CO INC 067805
Lot Size(sn. ft.): 311018.40 Owner: 1924 LLC
Zorn=URC(1001/ Applicant. CROCKER BUILDING CO INC
AT. 54 ROUND HILL RD
AnalicantAddress: Phone: Insurance:
186 STAFFORD ST (413)737-7803 Workers Compensation
SPRINGFIELDMA01104 ISSUED ON:3/75/20/9 0.00:00
TO PERFORM THE FOLLOWING WORK:DEMO FOR FUTURE REBUILD PROJECT. NON
STRUCTURAL PARTITIONS AND FINISHES
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: House4 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:
FeeTvpe: Date Paid: Amount:
Building 3/15/20190:00:00 $210.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#APPLICANT/CONTACT
/[
APPLICANT/CONTACT PERSON CBUILDING CO INC
ST SP
ADDRESS/PHONE 186 STAFFORD ST SPRINGFIELD (413)737-7803
PROPERTY LOCATION 54 ROUND HILL RD
MAP 3 1 B PARCEL 004 001 ZONE URC(I00),
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid p
Building Permit Filled out 41 21U -1
Fee Paid f
Tweof Construction:_DEMO FO URE REBUILD PROJECT NON STRUCTURAL PARTITIONS AND
FINISHES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included,
Owner/Statement or License 067805
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQ 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 Penni[ 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
301I
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 l.7 Commercial Building Permit May 15,2000
Department use only
ity of Northampton Statue of Permit
r7o ilding Department Curb Cut Drivevray Permit -
212 Main Street Sewer/Septic Availability
Room 100 Waten'Well Availabiliy
No hampton, MA 01060 Two Sets of Structural Plans
4 3-587-1240 -.413-587-1272 Plo7Site Plana
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 �f
SECTIONI -SITE INFORMATION I7- ?/ /
1.1 Property Address'. This section to be completed by oRlce
54 Round Hill Road Map C-25/ Q Lot 00q Unit
Northampton MA,01060
Zone Overlay District
Elm SL District GB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1924 LLC�r333 Elm Street,West Springfield MA,01089
Name(Print) A%Ax %r¢k.�. Current Mailing Address:
413-737-7803
Signature Telephone
2.2 Autho ed Adept"
William Crocker 1136 Stafford St Springfield MA 01104
Name(Print) �1LQ -� ��`h+r-��' Current Mailing Address:
413-737-7803
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completedby e tapplicant
1. Building 20000 (a)Building Permit Fee
2. Electrical 2500 (b)Estimated Total Cost of
Construction from 6
3. Plumbing 4500 Building Permit Fee /l
4. Mechanical(HVAC) 2000
5. Fire Protection
6. Total=(1 +2+3+4+5) q,ppp Check Number
This Section For Oficial Use Only
Building Permit Number Is
Issued
Signature
Building Commissioner/Inspector of Buildings Date
buocxer& CrO uOakllckq . l
Versioul.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 El Additions ❑ Accessory Building C3
Exterior Alteration ❑ Existing Ground Sign❑ Naw Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Demolition for the future rebuild projeel. Non structural part�ands.
Of Proposed Work:
Exterior wall openings as shown.
SECTION b-USE GROUP AND CONSTRUCTION TYPE
USE GROUP Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A l ❑ A-2 ❑ A-3 ❑ to i ❑
A-4 ❑ A-5 ❑ .-2A 13B Business ❑ - ❑
E Educational ❑ J 2B I ❑
F Factory ❑ F-i ❑ F-2 ❑ 2C ❑
H Hi h Hazartl ❑ 3A ❑
I Institutional ❑ 41 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ ft-7 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S4 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
5 Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDIOR CHANGE IN USE
Existing Use Group: E Proposed Use Group: (t
Existing Hazard Index 7S0 CMR 34): Proposed Hazard Index 780 CMR 34).
SECTION 0 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
2 m 2 r
3- 3i°
4. 4`"
Total Area(so Total Proposed New Construction(sf)
Total Height(ft)
Total Height I
7.Water Supply(M.G.L.C.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private ❑ Zane Outside Flood Zone❑ Municipal On site disposal system❑
Versioul.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be fined in by
lluilding Depi nmen1
Lot Size
Frontage
Setbacks Front
Side L R U R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lm ams minus bldg&paved
parking)
#of Puking Spaces
Fill:
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO em DONT KNOW O YES
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 O NOKy
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 4"1 NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation,orbiting)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Ste"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 36,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
T63 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
Not Applicable ❑
Company Name'.
Responsible In Charge of Construction
Address
Signature Telephone
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: S4
The debris will be transported by:
The debris will be received by: SAM2
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
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 O No O
SECTION I1 -OWNER AUTHORIZATION-TO BE COMPLETED WREN
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
Omer Date
/�
I lti �� `f'L' Tot�lhcncYna. 3su ew0w.v 1NC� 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 un r tha pains antl pe. _s of perjury.
Print Name
Lx-,.�\s4 lum�.. yk 2�Zt/Id 19
Signature of Owner/Agent 11 Date
SECTION 12-CONSTRUCTION SERVICES
101 Licensed Construction Supervisor: Not Applicable
rs ❑
Name of Llnse Holder'. rAn l_.I�-� � ot
1 ``5- 06J?6US
License Number
3G SGe+��.a� 5• lu\�eewy.,,. Mn o1oSs Y/�9�oi8
Address � � Expiration Date
�/�j�� _ Q hvr• Y7�•ss&i
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 0 No Q
Massachusetts Department of Public Safety
ry�1 Board of Building Regulations and Standards
License: CS-067005
Construction Supervisor
WILLIAM D CROCKER,JR
36SPRINGFIELDST '..1
WILBRANAM MA/6t98� 1
�,J.%H Expiration:
Commissioner 4{118!2018
i
�Q\ The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston,tYIA 02114-2017
www.mass.gov/dia
*XwAkers'Compensation Insurance Affidavit Builders/Contractors/Eleetriciaas/Plumbers.
TO BE FILED WITH THE PERMIT f ING AUTHORITY.
Applicant I f tiPlease Print Legibly
Name (Rpsiness/DrganizatioMndividuap: l �/n4 3 VJ� `'u ,.�J e.1'
Address: t ey- AI;T'a:'N 'S'�
City/State/Zip: $ NA QNPhone#: Kf 3. 737.7 3
Are you an employer?Check
9 the appropriate bol Type of project(required):
m
1.9 I aa employer wilt employees(fial and/or part-time) 7, ❑New construction
2.n I am a sole proprietor or partnership and have no employees working for me in g, Remodeling
any capacity.[No wmlocrs'romp.insurance required_I
3-❑1 am a homeowner doingII If ed.l' 1 Demolition
a work [No workers conpinsuraneerequn
4.�1 am a homeowner and will be hiring contractors m conduct all work on my property. 1 will 10 E]Building addition
ensure that all emanations either have workere'compensturn insurance or are sole I1.❑Electrical repairs or additions
proprietors with no employees
12.E]Plumbing reports or additions
5. 1 am a general contractor and I have hired the am-commUon listed on the attached shr0. 13.�ROOF repairs
TM1eae sub-rontraGon have employees and have wnrker.�comp. insurance
6 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other }prem OaWO'
152,§1(4),and coo have no employcca.[No workers'comp.insamnec¢quiRd I
•Any applicant that chck
es box 41 must also fill out the section below showing their workers'compensation policy information.
t Hometwndrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors mat check this box must attached an additional sheet showing the name ofthe sub commonly and amid whether or not those entities have
employees- If theuub-contractors have employees,they most provide their workerscomppolicy number.
turn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. I
Insurance Company Name: 4'6Q 7 00 , -_
Policy N or Self-ins.Lic.#: X V.JO\aS769q 399 Expiration Date: al/r Ljal9
Job Site Address: Sed Ratio \\ er9•• City/State/Zip: Oy... rh,AO\O6O
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,¢25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cert�ifyyA dearthepains a alder of perjury that the information provided above is true and correct.
Signature: yy�� Data
2�z��Zo/9
Phone#: '//f- 73)•24PO3
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.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: