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25C-251 (122) 54 BRIDGE ST-FAIRGROUNDS BP-2019.1230 GJSu: COMMONWEALTH OF MASSACHUSETTS MamBtock:25C-251 CITY OF NORTHAMPTON Lot:_001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinst DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:stage BUILDING PERMIT Emil# BP-2019-1230 Proiect9 JS-2019-401988 Eq Cost$}000 00 Fee• S10000 PERMISSION IS HEREBY GRANTED TO. Con —t Class: Contractor., License: Use Grouo: T JAMES HANABURGH - RONIN PRODUCTIONS— Lot RODUCTIONS_L t Size(sa fl.), Owner: HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY zonine: SC(100)/URB(I)/ Applicant: T JAMES HANABURGH - RONIN PRODUCTIONS AT: 54 BRIDGE ST - FAIRGROUNDS ApplicantAddress: Phone; Insurance: PO BOX 398 (4)3) 687-8522 SUNDERLANDMA01375 ISSUED ON:5/2/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-TEMP STAGE POST THIS CARD $O IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House It Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Firo 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 Si n r rc FeeTvpei Date Paid: Amount: Building 5/1"20190:00.00 $100.00 212 Main Strom,Phone(4I3)587.1240, Fax:(413)587-1272 Louis Flasbrouck -Building Commissioner Tamp SUN, -------------------------- Version) 7 Corr 13 pia i i a 15 2000 Department termor idy City of Northam ton SP t 1H� Building Depart ent MAY 2 Permit 212 Main Stre t �tR vailabilRy Room 100 DFpT OF BUL11 NO or ellA lability Northampton, MA ^IOPTHANr ON 'A k of Mimi - phone 413-587-1240 Fax 413-587-1272 r i ONer SPeeity APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION S P— ( 11-1250 1.1 Property Address'. This section to be completed by office �Q lr Sd-• _... ',. Map e C Lot a6 Unit ^JDYA�"-(� y�f} r�ia6a Zone Overlay District ..._. .._._. _... _.._ Elm St Dii CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Pont) Curt t Mating Address w3) s$�I -z237 Signature Te ephone 2.2 Authorized Apent: , T sees A..:�iflµ� � _ P O• �ox 39 8 �,ly4kfT�rd,,G1� ofa Name(Print) CurrenI Malin Address N55 687- 05-2-z Signature Telephone SECTION 3.E IMATED CONSTR C ION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by Permit applicant 1. Building D� � � 0c, (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee r•�� 4. Mechanical(HVAC) S. Fire Protection fi. Total=(1 +2+3+q+5) �b .�D Check Number ] This Section For Official Use Only Building Permit Number Date Issued Signature: 5 z- 2619 Building Commissionerllnspector of Buildings Data Version L7 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❑ Other❑, , I Brief Description Enter a brief descriptioR here. Of Proposed Work: w/SaJpe� a-f`� e_ g - 1 -5 r"ei v 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 ❑ IS ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Facto ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ElR-1 ElR-2 ElR-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'. _._. ..__.. 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(sf) 1 1° 2" .._.. _. 2"' ...... ... 3,° 4u Total Area(sf) Total Proposed New Construction (stl. Total Height(ft) _.......... . ..... Total Height It 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 9. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size ------- Frontage --- ----- ------ Setbacks Front Side C R ........_ L R: __.. Rear Building Height Bldg. Square Footage Open Space Footage _ % _ — (Lot area minus bldg&paved artin #of Parking Spaces -- Fill: .._.. _... volume&Location) —'--- ---- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO -eL. DON'T KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES--O ....._.. _.._. IF YES: enter Book Page ,,--��(( and/or Document# B. Does the site contain a brook, body of water or wetlands? NO P DONT KNOW O 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 10 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 . NOV/l IF YES, describe size, type and location: ✓. E Wil the construction activity disturb(clearing, grading,tLgavation,or filling)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 storm Water Management Permit from the DPW is required. Versionl.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 ❑ 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 Respans ble In Charye of Constmctim n� • 1C_ Adapss (yi3 6d7-� 7 Signator Telephone Versionl.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 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. Signature of O wner 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�r e pains and pallies ury Print N me Signature of Owner/Agent 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.152,1 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the tlenial of the issuance of the b ilding permit. Signed Affidavit Attached Yes No 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: 5Y Fa- The debris will be transported by: ?-0'1 rt, The debris will be received by: Building permit number: Name of Permit Applicant 7 L-t� Date Signature of Permit Applicant \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-1017 www.mass.gov/dia WXVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Plemse Print Lasuiblv Nagle(Business/1nsOrgmimtiomindividduap: NN a 1- Address: �• V ' pow r7 / City/State/Zip: Phone Are you air employer?Check Me appropriate box: Type of project(required): IAlameemploycrwids 0 on'byees(fullanNorpmHime)t 7. New construction ,F1 1 am a sole pownetor Or pmmcrship and have no employees working far me in g. Remodeling any capacity (No workers comp.insurance rcyulred.l 37 I am a hommwaer doing all work myself(No workerscomp.insurance acquiredl' 9. ❑Dildin ion 4�1moa homeowner and will be hiring counselors mon cdadall work on my property. I will 10 Building addition =.m that ell coma mrimer nava.rakers ownpemmion womm,ne01 are aide 1 LE]Electrical repairs or additions prepnemrs with no employees' 12.❑Plumbing repairs or additions 51 am a general contractor and 1 have hired the sub-commcmrs listed on the attached shcel. ❑These suh-contracm have employees and have workers'comp.emotions.: 13.�ROof repai mrs ee fi.❑cooare a cowutstion and in otTcers have exewcad flanr right of exemption pet MGL c, 14. Other Nt V 152,g 1[4),and we have no employ.,[No worker%comp.inammiae required.] 'My apPb=ant that checks box pl must also fill out the section below showing favor workers compensation policy information. r Hum.wners who submit this andavit mdiwting lacy are doing all work and tarn ave ou¢ide cavuacmrs must suhmit a new aRJavi[indicating such. employees. thatcheckthis Wxmuste emploairadditionalsheetshowing taemm�e Ofinesub-contrmber and state whether or not those rntities nave employees. Ifthe sub-cpnhacmrs M1ave employees,they most provide they workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: /�) L� I/' P"Zrl[1tp7 7t751�./y1C� C� Policy#or Self-ins.Lie. #: bJ irk L451 i9a3��--I Q Expiration" Date: r ,fes Job Site Address: Fcir rS�• City/State/Zip: /:,I Y�{Y -/N� blbko Attach a copy of the workers'compensation policy declaration page(showing the policy number and a irratiTon date). Failure to secure coverage as required under MGL a 152,525A is a criminal violation punishable by a tine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm 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. 17 Ida hereby ce{i oder the ins penal ' of perjury that the information provided above is true and correct Signature t Date: Z 17 Pone#: 7 — Z$22 Oficial use only. Do not write in this area,to be completed by city or town offrciat. 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 ofa 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 of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency spall 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 ofthis 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 certificate(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 requiredto 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 bonom 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 pentrublicense 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 proof that a valid affidavit is on file for future permits or licenses. Anew 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 bum 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. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia