25C-251 (119) 54 FAIR ST-EXTRAVAGANJA BP-2019-1139
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 25C-251 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa TENT BUILDING PERMIT
Permit# BP-2019-1139
Project# JS-2019-001845
Est. Cost:$2600.00
Fee: $100.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: T JAMES HANABURGH - RONIN PRODUCTIONS_
Lot Size(sp. ft.)7 Owner: HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY
Zoning SC(100)/URB(1)/ Applicant. T JAMES HANABURGH - RONIN PRODUCTIONS
AT. 54 FAIR ST - EXTRAVAGANJA
Applicant Address: Phone: Insurance:
PO BOX 398 (413) 687-8522
SUNDERLANDMA01375 ISSUED ON.411612019 0:00.00
TO PERFORM THE FOLLOWING WORK:TEMP STAGE
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 Occuoancv Sienature:
FeeType: Date Paid: Amount:
Building 4/16/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-1139
APPLICANT/CONTACT PERSON T JAMES HANABURGH- RONIN PRODUCTIONS
ADDRESS/PHONE PO BOX 398 SUNDERLAND (413)687-8522
PROPERTY LOCATION 54 FAIR ST-EXTRAVAGANZA
MAP 25C PARCEL 251 OOI ZONE SC(100)/URB(DI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T eofConsruction: TEMP STAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included-
Owned Statement or License
3 setsof Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
Z�Z_ Ll-4 Z019
Sigitatureof Bu J mg Official Date
Now: 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.
Verson I.7E-p dtjiug PemihMgay 15,2000
Department use any
City of North mptbn of god:
Building Dep rtm nt C rNereey Permit
212 Main tree APR 16 2019 s Availability
Room 00 ' 'rNV It Avallabilitf
Northampton, A0 , mol om;r ins.=c setsS1nlcWral,Plarls
phone 413-587-1240 8ia'92'7N ru,oi its lis
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
��V7�yJ/r�, Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
lX.fP.�
Name 1 111 Cu nt Mailing Adders
Signature Telephone
2.2 Authorized Agent:
Bob!
Name(Print) Current Ma In Addr ss
,N 61/-gS242-
Signature Telephone
SECTION 3.ES ATED CONSTR TION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bennita Bram
1. Building 7gOD p� (a)Building Permit Fee
2. Electrical p b (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee f✓��n�
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 2, Oa' Oo Check Number
This Section For Official Use Only
Building it Wigi7er Date
Issued
Signature:
q-16 ZX
Building omm,,sicnedlnspeR it of Buildings Date
Versimnl.7 Commercial Building Permit May 15,2000
SECTION4.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❑ Otherx ,...
Brief Description Enter a brief description here.
Of Proposed Work: Ar , 1y hY'q ,X,Zr1 /
SECTION 5-USE GROUP AND CONSTRUCTION TYPE T 7
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business 2A
Ed ❑
E ucational ❑ 2B ❑
F Fad. ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3g ri
M Mercantile ❑ 4 g!R Residential
El ElR-211R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify: ..
S Special Use fir( Specify ;r"
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
y86
4" 4,h
Total Area(sf) 20Y/�'L t� Total Proposed New Construction(so
.{s
Total Height(ft) ....� krecf .... -
TotalHeightit
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
8. NORTRAMPTONZONING
Existing Proposed Required by Zoning
This catmnn m h FEW N by
Building Depa t
Lot Size _....
Frontage ._....___. ..._..___...
Setbacks Front --
Side L ._.... R:_ L... R ..... .
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&Paved
mkin
9 ofParking Spaces --
f.nmme&Lowcmn) — —.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW tS' YES O
IF YES, date issued: /_
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW.., YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 'GP YES O
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 NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E, Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O 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 Registei Architect:
_.. _.... _.___... ...._. _.. Not Applicable ❑
Name(Registrant):
- - Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Resporni ility
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
Adtlress Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
I-- NoAA ''
t Applicable PP
Company Name:
P.�nt�x fiuAl� �J0/�G�+4F!ts
Responsible In Charge of Consumption
7`5 "P,--
Add
Y13 d 87:_fSh
5gnat a Telephone
Verston1.7 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 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.
Signatureof
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 rrtthhee pains and penalties of perjury
i6 r9
Signatur fOwnerlAgent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: ,. Not Applicable
Name of License Holder
License Number
Address Expiration Date
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 NoQ
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: eA/.,f. lAmz do
The debris will be transported by: t�'e4,X "k. P^epw cJ�*b
The debris will be received by: ) WN AJb> Prs��cc'}Io� S
Building permit number:
Name of Permit Applicant lj ,s /> �C.�t p�er/7 A,�t� P�,� • ��e,s
Date gnature of Permit Applicant
The Commonwealth ofMassaehusetts
I� Department of lndustrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
winig.mass.gov/dia
1A orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organiz�atiGwlndividuaal):: TI-ALNJS A6,L nfA63-&A C6/`ws
Address:i P. 0 . jrix �"1 b
City/State/Zip: 1 61375 Phone#: 97-0_21K_
Are you an employer."Check the appropriate box: Type of project(required):
I_❑l am a employer with employees(fall and/or pert-time)-' 7, ❑New construction
2�l am a sole pmpdemr or pvmeanip g. ❑Remodeling
Q.('tr+IGlfr ' 9 ❑Demolition
3.F_1 1 am a homeowner doing all work myself[No workers'comp.insurance required.]'
4.❑I am a homeowner andwill fe hiring coytraaurao coMudml workonm 1 will
ensure we 10❑ Building addition
Y n, oil
et all convectors eitherhw=workers'compensatiov.-or are 11.❑Electrical repairs or additions
pmpdebrs wila no employees. 12.❑Plumbing repairs or additions
5❑1 am a general eonmnnd
hacr, I have hired the sub-connactors listed no Me atuchsd sheet
These sub<nno-acmu have emp oyees and have worars'comp.iesurance. 13.�Raaf repairs
6.❑We area coryromem it,. me—have exercised wort nght of exemption per MGL c 14.pOther
152,G I(4),and we have no employees.[No workers comp.insurance required.] T`'
,
,say applicant that checks box RI must also fill out the section below showing they workers'compensation Whey into atlon.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors last check this box must couched an additional Shen showing lie wane of the sub-contractors and state whether or not those entities have
employees. If the subcanvaemrs have employees,they most provide their workers comt,policy number.
I ase an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information. /• pp
Insurance Company Name: Gg u, D
Policy#or Self-ins.Lic.#:C C ' ',r L d�,,Efxpiration Date: 111 2070
Job Site Address: �y Flt-' r7T• �ilTk1j1P7Un r//hi�ty/State/Zip: J / (a ®
Attach a copy of the workers'compensation policy declarer 'on 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 a 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 cerdfy�/�j)der the pains rid pe es of perjury that the informa ion provided rte/} one and correct
S' n tutu I '//'-"—y Date'
Ph 1*116 s7` 8 5tz
Oficial use only. Do not write in this area,to be completed by city or town officio!.
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#:
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 ajoint 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 ofsuch 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their cenificate(s)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
ofthe 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)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat 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, Suite 100
Boston, MA 02114-2017
Tel.# 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
A�d CERTIFICATE OF LIABILITY INSURANCE a"o„Zo,"9"'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the eslURcaNa Maids,ken ADDITIONAL INSURED,the policy0es)must be endorasd. N SUBROGATION IS WAIVED,subject to
the Nares and conditions of the policy,certain policies may requite an s ndoneement A statement on this cerii8ceta time not conkr rights W the
cerii6cete holder in lieu of such endolssmenits).
PRODIN:Ea CONTACT
HANE: MARY BENJAMIN
ROGER BUTLER INSURANCE AGENCY INC .ESL lata)ssz-z3o4
mpnE MBENJAMIN�RBUTLERINS.COM _
5COURT ST XSVRERe AFFORaHOCoyERAee Noce
WESTFIELD MA 01086 INSURFn A: ACE AMERICAN INSURANCE CO_ 22667
INSURED IXEURER B: _
HANABURGH TODD JAMES INSURER C: T
DBA RONIN AUDIO PRODUCTIONS IHsuueDi
—�—
P O BOX 399 INSURER E:
SUNDERLAND MA 01375 IN8 RMF:
COVERAGES CERTIFICATE NUMBER: 393771 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE U57ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING MY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
INSR MEOFROURANCE .= Ua PONCYHUMRER eat EFF Hssed PERP Lems
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:(YFMFWyIn Xlq i EL DREASE-lU ENPLOYEE S 100,000 _
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DMMPTMN OFOPEMRONSILOCATMNS I VENICLee(ACORD 101,AJtlltlme RenuM1e SeeEuH,may No exvcNM Um ni Fpw Is repuk+et
WorkersCompen ethos benefile A de paid M Meadoehueexe&MMOyaes only.Furs ua+t M Endorsement WC 40 03 OB B.no aUthanzafwn a given to pay cMims for where M
employees in states Other than Massachusetts it the insured hires,or has hired Mose employees direide M Massachusetts.
This cedigrete of inedranra an.the pd.,in here on Me date that this ceNRrate ,as issued henew as the expiation date on the above polity precedes the issue dela of Me
cerYficateofinsuanre). Thestalusaf Nis Covmegeranbemon,Wre dailyhyacaeasing Me Pr00fof Cave2ge-LOverape Veofiwtm Sear wdat
www.mess.govdwtllwwlmrswmpenceeonfnvesSpeEOrW
Sole proprietor has not stitched coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXMRATION DATE THEREOF, NOTICE WELL BE MUVERED IN
Town of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
210 Main Street
ANNONZCOREPRFbENTATVE
Northampton MA 01060 �
Daniel M,C y,CPCU,Vice President–Residual Markel–WCRIBMA
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