30A-032 (41) t
Versionl.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 01060Two Sets of Structural Plans _
phone 413.587-1240 Fax Site Plans
l� t Specify --
APPLICATION TO CONSTRUCT, REPAIR, RE14� ATE, CHANGE THE US CCUPANCY OF, OR DEMOLISH ANY BUILDING I
OTHER MAN FA WELLINGJ Ll
I
i
DEPT OF BUILDING INSPECTIONS
SECTION 1 - SITE INFORMATION NORTHAMPTON,MA 01060
1.1 Property Address: \\ This section to be completed by office
Map 36 Lot Uni '�
Zone Overlay District
T� Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
U l rl t� 0 C , AA �j l� N'ta��v� S} I�lr I"t��,lpk y�
Mame(Pri ) Current Mailing Address:
awkC_�(x - 13YI
Signature f Telephone
2.2 Authorized Agent: �y(��� �ps
DUJ lu � 1a+1C' C�I(3c� 20�f Lf S} fax GD/�lz
Na Pr' Current Mailing Address:
ff��)(-eq
S kna e 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 1 (b) Estimated Total Cost of Construction from 6
3. Plumbing ��- Building Permit Fee
4. Mechanical (HVAC) 6 d Q
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Check Numbero
This Section For Official Use Only
Iluilding Permit Number: �/�d� 7�0 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Co nercial Building Permit May 15,2000
SECTION 4- CONSTRICTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
SECTION 5 USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 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 ❑ 1.1 ❑ 1-2 ❑ 1.3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify: i
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: 8-Pp Cf Proposed Use Group: sct-3'1 1
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)
St
1st 2nd - v
3rd
2nd .,;
4th � A
3'd
F
4th R x x
r
Total Area (sf) Total Proposed New Construction (sf)
...................................
Total Height(ft)
Total Height ft --------------------
Versionl.7 Commercial Building Permit May 15,2000
F Water Supply(M.G.L. c. 40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
iblic ❑ Private ❑ I Zone: Outside Flood Zone ❑ I Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
his column to be filled in by
C�a,'Vlm wilding Department
Lot Size
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:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES date issued: 't'r Ne
IF YES: Was the permit recorded at the Registry of Dee
D '000,
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Versionl.7 Commercial Building Permit May 15,2000
FSEON 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
TRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
1 Registered Architect:
41111%A Not Applicable ❑
Name(Registrant):
Registration Number
aft Am
Address `
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
gnature 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
ddress
Signature Telephone
- Versionl.7 Commercial Building Permit May 15,2000
F-'rCTION 10- STRUCTURAL PEER REVIEW(780 CMR 110.11)
lependent 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, as Owner of the subject property
hereby authorize >Uc1\w5 T�irr��hAe �J �'\LI '��-e �J �� Y1 to act on
my behalf, liq all matters relative to work authorized by this i ding p mit application.
Ica
Signature of Owner Date
ve,yl, ,-A i^Ae ' as Owner uthorized Agent
he eby decl a th the statements and informati n on the regoing application a true and accurate, to the bes o
knowledge and belief.
Signed under the pains and penalties of perjury.
Print N e -
3
,naiture of er/ en Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: (J Not Applicajble ❑
Name of License Holder : dt1e�`�S 1 ���T�DV✓� "� 00 1/ -2 `7
01-0 License Numb r
/11 1 , t
Address to e F101-e Expira on ofate
S' tur Telephone
`G{
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...... 0
�CtSA1 fP�
as �asSArl�ItsrltE
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WOREMWS COMPENSATION INSURANCE AFFIDAVIT
t I,
Doi
(Iicenscdpermittee)
with a principal place of business/residence at:
2 Oq L(gCJS S-j— ��J( PrI.C�e_ (phone#) � y�
i (stzeet/czty/stalrJrip)
do hereby certify, under the pains and penalties of pedury, that:
, . ) I am an employer providing the following worker's compensation coverage for my
'{ /em to ees working on this job:
P Y g ]
�4 1 D 3D
(Insurance Company) (Policy Number) (Fxpiration Date)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's rompensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (InsuranceCompany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Portcy Number) (Expiration Date)
(Name of Contractor) (Insumace Company/Policy Number) (E)piration Date)
(attach additional sheet if neocniry to include information pertaining to an coabmd )
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowaera who employ pertoa:t4 do ma**+__ _• conouction or repair work on a dwclliag of
not more than throe uaits is which the bomeowner r+aidcs or oa the grounds appurtenant thereto ars not gaowany coander d to be
employrra under the worker's oxnp=satica Act(GL152 fa 1(5)),application by a homeowarr for a Haase or permit may evidcocc the
legs(clams of an employer uoderthe Wodcoda Compemation Ac L
I underataad that a copy of this statement may be focwnr+ded to the Dcpartmm2 of Indiuhial Aocidea&Offioe of kmtraooe for the
eovmge unification sad that failure to secure covecagea under section 25A of MOL 152 cera lead to the impositioa of aimmsl penalties
y oomisting of a fipe of up to 51,500.00 anNor of up to one ytw and civil penalties in the form of a Stop Wotlt Order and a
fine of S100.00 a day against ma
For departwimtal use oatY
Permit Number
Map# Lot#
: x
i6of icansee/Pertnittee TF
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MAR 2 0 2001
���ae �e4ideoctcaE
�aot4t�uutlaar * ,�egavatlox DEPT Of BUILDING INSPECTIONS
209[mag$tweet, 64 60142 NORTRAM°TON,MA 01060
7&w,ze, 7&a44, 01062
413-586-9491 57ax 582-0275
March 18, 2001
Alan Verson
56 Main Street
Northampton, MA 01060
- SCOPE OF WORK-
320 Riverside Drive Job
The scope of work consists of the following interior renovations:
Add partition and door to second floor office.
Frame existing partition to ceiling in second floor office.
Add door and frame in existing partition.
Install new heating system in second floor office.
Wire to code. Add light fixtures.
Change sink in utility area.
Install new window on first floor rear (west).
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MAR 2 0 2001
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON MA 01060
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