17C-183 (10) 57-59 CHESTNUT ST BP-2020-0669
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 183 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: ROOF I BUILDING PE RMI T
Permit# BP-2020-0669
Proiect# JS-2020-001140
Est.Cost: $19860.00
Fee: $139.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RICHARD PALMISANO 89485
Lot Size(sq.ft.): 15725.16 Owner: KILLIAN O'CONNELL/KILERINE LLC
Zoning: URB(100) Applicant: RICHARD PALMISANO
AT: 57 - 59 CHESTNUT ST
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 374-2719 W('
HADLEYMA01035 ISSUED ON.1112512019 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 11/25/1-0190:00:00 $139.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck Building Commissioner
Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map f 7C Lot � 3 Unit
Zone ap
- Elm St. Distri t REC
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
NMI ?_ 0 2019
2.1 Owner of Record:
f/� � eft�.t 1..- /^ n_ iris !�
F�!1.. �.-��lh� .,_ _ _.. W�._. .._��T�2�:+�r"T(�N � n � NS ,T.
Name(Print) Curr[nntt Mailing 1G
Signature Telephone
2.2 Authorize
Agent:
� k �c►-� -� �7 � y . ._. �AA
Name(Priin Curre Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection .._ _
6. Total = (1 + 2 + 3 +4_+ 5) Check Number 8 S
This Section For Official Use Only
Building Permit Number //A'/,Q Date
2,U ' C�l� 1 Issued
Sign ure:
Build g Commissioner/Inspector of Uldings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other ❑
Brief Description Enter a brief description here. V"Otl t'+�sT �5�4 f$ 5�
Of Proposed Work: �(r(. OS6 atx& C' ` U '
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 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
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. _. ._. _ Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): E
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCT N OFFICE USE ONLY
Floor Area per Floor(sf)
1si — .__ 1st
2nd
2nd
-- 3 d /ftL--
7.
3rd 4th 4Total Area (sf) Total PnstructionTotal Height(ft)
Total H,Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private 0 Zone Outside Flood Zone Municipal ❑ On site disposal system❑
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 f-
&k� r 0e. 2&Si 02 A'nov" . T -)C-• Not Applicable ❑
Com ane:
Responsible In Charge of Construction
1
AAA-
A r ss
Sig ure 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
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Liu�&CV, Ct�Yta-z' l as Owner of the subject property
hereby authorizeP0_(4AASC41 to<
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of 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.
Sign _ nde the ains and penalties of periury.
Print me
Signat e@ Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervis Not Applicable ❑
Name of License Holder: 'M; e-,,6 G t
License Number
ddl Expiration Date
Si ature 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 thq building permit.
Signed Affidavit Attached YesAD�/_ No 0
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:
The debris will be transported by: An6OA a
The debris will be received by:
Building permit number:
Name of Permit Applican
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
u Department of IndustrialAccidents
o I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Walkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH n PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appy priate box: Type of project(required):
aemployer with r'�employees(full and/or part-time).* 7. EJ construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.] ❑
9. El Demolition
3.[]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.r7 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 f repairs
These sub-contractors have employees and have workers'comp.insurance?
6.r_1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'com ensation iirsurairce for my employees. Below is the policy and job site
information.
Insurance Company Name: S
Policy#or Self-ins.Lic. –1Q�off"[3Expiration Date: 27
Job Site Address: A'!7/]_V7_ �M� City/State/Zip: r(6aRG.— AkA
-
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 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 ver' Ic tion.
I do hereby er fy n r the p i sand,penalties ofperjury that the information provided above is true and correct.
Si nature: Date: /Ia L
Phone
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#: