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32C-029 (16) I l BREWSTER CT BP-2020-0784 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-029 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2020-0784 Project# JS-2020-001273 Est.Cost: $49000.00 Fee: $343.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor., License: Use Group: GERRY SHATTUCK 058422 Lot Size(sa.ft.): 4268.88 Owner: EGELSTON JANET Zoning:CB(100)/ Applicant. GERRY SHATTUCK AT: 11 BREWSTER CT Applicant Address: Phone: Insurance: 25 S MAIN ST (413)237-9820 0 HAYDENVILLEMA01039 ISSUED ON:1/9/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:SUNROOM RENO 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: FeeT�nc: Date Paid: Amount: Building 1/9/2020 0:00:00 $343.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner it Sl a n r U��'►� Versionl.7 Commercial Building Pcnnit May 15,2000 Department use only City of Northam'i�p-t;�o�r--r p Status of Permit: Building DeparUzlel�_E I V E L. urb'Put/Driveway Permit - 212 Main Street ewet/Septic Availability Room 1001 - 8 2019a1 e I ell Availability Northampton, M/ 01 J8 wo ets of Structural Plans phone 413-587-1246 Fa - - Plot/S a Plans PFPT.OF BUILDING,INSPECTIO ther�3 eC NORTHAMPTON.MA 01060 p 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 l3re co u �'r Map Lot 011 Unit Zone Overlay District - -- --- Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Y13 — a 3 Signature Telephone 2.2 Autho ' d A nt: Name(Print) Current Ma" Address: v d�03 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 s 2. Electrical ' (b)Estimated Total Cost of Construction from 6 3. Plumbing QQ Building Permit Fee 4. Mechanical (HVAC) ---- �� - 5. Fire Protection i 6. Total= (1 +2+3+4+ 5) l Check Number his Section For Official Use Only Building Permit Number Date Q_ ')o r f'J Issued Sign ure: 15P Build g Commissioner/Inspector of (dings Date Z 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 Buildin Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use ED] Other Brief Description ;Enter a brie description here. Q r✓J.0 YE_ Crj Lt 11 Of Proposed Work: # % i} `�., P (� SRcr�t� r`'S 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 ❑ 1 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: 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: _ _5 Glk 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 1 st F 4-3 0 1� 5 2nd 2`id 3rd 3`d _,. Total Area (so gQ Total Proposed New Construction(sf) _ Total Height(ft) Total Height ft 7. Water upply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewa a 'sposal System: Public Private ❑ Zone C� Outside Flood Zone Municipal On site disposal system[:] 3 Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front F/1-1 F Side L:[V--1 R:C�J L: R: Rear Building Height Bldg.Square Footage T % gjD Open Space Footage % (Lot area minus bldg&paved �- 1 parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES Q IF YES: enter BookF— Page -� and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW © YES o IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtainedQ Obtained Q , Date Issued: _ C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: - /i'�I �� —_E D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation or filling)over 1 acre or is it part of a cornmorrplan that will disturb over 1 acre? YES © NO ?� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Lf Vcrsionl.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: x'12�� Not Applicable ❑ Name(Registrant): l Registration Number Address �G -kc �jQ� (_ S�r- � '{y� f �O C-1 66 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): F- Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number_ Signature Telephone (Expiration Date � E 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 C- rrviNot Applicable ❑ Company Na e: Responsible In Chargelof Construction Addres Sign Telephone f Vcrsion1.7 Commercial Building Pcrinit 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 PER 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 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 under the pains and penalties of perjury. __._. PrintIlliarne S nat of Owner/Agen 0 Date S ION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: =OT Z License Number o [ 26 _�,z©.�� Address Expiration Date VN 234 -qT2v Signa 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 b ilding permit. , Signed Affidavit Attached Yes 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: << KT— The debris �- �- eb swill be transported by. The debris will be received by (��Cl f�-J`� E bt� 4-'o Building permit number: Name of Permit Applicant lz t Z 't Date Signature of Permit Applicant + 7 The Commonwealth of Massachusetts z Department of Industrial Accidents - 0 1 Congress Street,Suite 100 Boston,MA 02114-2017 - h r www.mass.govldia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑1 am a employer with employees(full and/or part-time).* 7. 0 New construction 2Mam a sole proprietor or partnership and have no employees working forme in 8. emodelingDemolition t—'_any capacity.[No workers'comp.insurance required.) 9. 3.a I am a homeowner doing all work myself.INo workers'comp.insurance required.)t 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10E] Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.Q Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions ❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.[_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.I No workers'romp.insurance required. *Any applicant that checks box#I must also fill out the section belo%% showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors 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'compensation insurance for my employees. Below is the policy and job.site information. Insurance Company Name: Policy#or Self-ins.Li c.ff: Expiration Date: Job Site Address: City/State/Zip: 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 verification. I do hereby certi tit er the pains and penalties of perjury that the information provided above is true and correct. SiMture: Date: Phone#: � 2�� q p 2-o 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 I� Contact Person: Phone#: