32A-143 (19) 36 MAIN ST BP-2020-1112
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32A- 143 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categry: ROOF BUILDING PERMIT
Permit# BP-2020-1112
Project# JS-2020-001863
Est.Cost: $2000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WILLIAM FULLER 111440
Lot Size(sy. ft.): Owner: CARLE R E LLC
zoning:CB Applicant: WILLIAM FULLER
AT. 36 MAIN ST
Applicant Address: Phone: l�tsrrrunc e:
26 MAPLE ST (413) 345-0864 SOLE PROPRIETOR
SOUTHAMPTONMA01073 ISSUED ON.51712020 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSING 40' OF SOFFIT IN REAR OF
BUILDING
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 Si(_,nature:
FeeType: Date Paid: Amount:
Building 5/7/2020 0:00:00 $100.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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O — r,
i a a Versionl.7 Commercial Buildin=Permit May 15,2000
Department use only
M_ C�ty of Northampton Status of Permit:
n Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
0 Room 100 Water/Well Availability
0
N 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
A Map -3Z A Lot Unit
Zone Overlay District
"'- Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -5T
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
ti,� , (1A L< S i
Name(Print) Current Mailing Address:
`\ � n q 137) 3%4,:;"-�c��y
Signature W\,X , 'L 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)
�L" •CO
5. Fire Protection
6. Total =(1 +2+ 3+4 +5) Check Number f
OQ
This Section For Official Use Only
Building Permit Number Date
��-
Issued - �-
P12- -
Signature:
— 2 z
5 - �- zoo
Building Commissioner/Inspector of Buildings 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. /
Of Proposed Work: �trttti*T,�•� —��i C ;c��'T; }- r�t �-tG r C��' 13u jh��hc; qd
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 19 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:
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)
15`
15f
2nd 2nd
3rd 3"d
4cn
4in
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
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
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ® No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, � , P> CL �,;-,C1,-J- as Owner of the subject property
herebyauthorize LJ<(/� c,+, 11 ��)lar i »s -.�str� �,,,� �,LC to
act on my behalf,in all matters relative to work authorized by this building permit application.
�� -•-�T ....-fes � f�1 CU
Z z
Signature of Owner Date
I, `w• 1 1 @-, A rA,r 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.
11 rot
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: W . l j �_M ) I i q L1 0
License Number
Mrk Lfo-?I IIIt`7 /Zs�
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 ® 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: �-
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
51g I Zozo VJ , ,�
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aomlicant Information Please Print Lctibly
Name(Business/Organization/Individual): W r L j.;,s ��.,,�#;o�
Address: ZLie ill,_,L, s F
City/State/Zip: m of . (� ;3 Phone #: 413) S-O'luy
Are you an employer?Check the appropriate box:
Type of project(required):
L Q I am a employer with employees(full and/or part-time).* 7. ❑New 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.]
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition
10❑Building addition
4.❑1 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 1 I.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:] p
Roof repairs
These sub-contractors have employees and have workers'comp.insurance.,
6.❑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#1 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.
#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.
1 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.Lic.#: 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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 'fi n G—�, Date: -z -zc
Phone* `i (3) 34, o`�`�
Official use only. Do not write in this area,to be completed by city or town ogwiaL
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#:
Name :
Number 4
Practice tracing the number •
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