32C-328 (10) 6 SERVICE CTR RDI BP-2020-1243
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-328 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 P E RM I T
Permit# BP-2020-1243
Proiect# JS-2020-002101
Est.Cost: $68000.00
Fee:$476.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TIMOTHY S NEY 061088
Lot Size(sq.ft.): 13416.48 Owner: LAN ERS JO
Zoning: GB(100 Applicant. TIMOTHY SENEY
AT. 6 SERVICE CTR RD
Applicant Address: Phone: Insurance:
371 PROSPECT ST 413 667-0230
NORTHAMPTON MAO 1060 ISSUED ON.6/19/2020 0:00.00
TO PERFORM THE FOLLOWING WORK.-DIVIDE ONE TENANT SPACE INTO 2 AND ADD
BATHROOM AND MEETING ROOM
POST THIS CARD SO IT IS VISIBLE FRO1 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:
Feer e: Date Paid: mount:
Building 6/19/2020 0:00:00 $476.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Jay,
Version I.7COmmercial Building llcrrnit May 15.2000
Department use only
City of Northampton Status of Perrnit:
Building Department Curb CuVDriveway 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 413-5�7-1272 PlottSite 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 I -SITE INFORMATION
1.1 Property Address: This section to be completed by office
6 Service Center Road Map 3 0+r. Lot 3,DG Unit
Northampton, MA 01060 Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Jo Landers 27 Howard Ave
Name(Print) Current Mailing Address
Easthampton MA 01027
Signature Telephone 413-529-9954 or 413-222-7821
2.2 Authorized Agent:
Name(Print} Current Mailing Address'
Signature 3
SECTION 3-ESTIMATED CONSTRUCTION COSTS Telephone
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical 7 (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee Z 7
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+ 5) Check Number /040
This Section For Official Use Only
Building Permit Number Date
Issued
Signal i ire:
Buildi Commissioner/in dor of Buiidi4iji Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 0-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations El Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Divide one tenant space into two and add an accessible bathroom and meeting room off the
Of Proposed Work: common entry.Total tenant spaces will change from 2 to 3.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 p A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business S 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I 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 ❑ 56 ❑
U UtilityElSpecify:
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: B Proposed Use Group: )3
Existing Hazard Index 780 CMR 34): 2 Proposed Hazard Index 780 CMR 34): 2
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
:t
l� 1 4
7
ro... . _ 45rJa � '^' _.
m 2no
�_.
2^"
....�..�.,.,..,...«�..., ^� rd 3
M 4 th
Total Area{sf) 4576 { Total Proposed New Construction(sf)
_ 45-7t-
Total Height(ft) V-15
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public El Private ❑ Zone Outside Flood Zoned Municipal [E] On site disposal system❑
Version|7Commercial Building Permit May |5.2000
8. NORTHAMPTON ZONING I
E\isting Proposed Required by Zoning
This ec4umn lo be filled in bv
Building Department
Lot Size I L13076 .076
Frontage 138
Setbacks Front 42
Rear
Building Height -15
Bldg.Square Footage %
L4576 35 4576 35
Open Space Footage %
#of Parking
Spaces
A. Has aSpecial, PermiL/Vahauce/Finding ever been issued for/on the site?
NO «_ �� v��/��
��� DONT «�� YES
IF YES, date issued: 10/26/1989
IF YES: Was the permit recorded uLthe Registry ofDeeds?
��
NO �� DONT KNOW YES
�~� «~~� __-__._
IF YES: enter 8oa4 03408 Pa*~ 2'9'6 and/or Document#\ 2K43� !
'
�� ��
B. Does the site contain abrook, erorweL|and@ NO «�� DON7KNOVV v�� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �.ned Obtained '
�-�� �-»��� . Date Issued. �
C. Doany signs exbLnnthe property? ��� NO �_��
�
|FYES, describe size, type and location: roof,247'x^�^ |
/
D. Are there any proposed chany== ^"°. = .tionsofsigns intended for the property? Y[5 0NO G
IF YES, describe size, type and \ocmtimm:
�
E Will the construction activity disturb(clearing,grading,excavation,orfilling)over 1 acre ovieapart nfwcommon plan
that will disturb over 1 acre? YES ��K ] NO K��
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versions.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 760 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable
Name(Re,.!tram
_ ...
�"tiSh�.sr
Registra�tion Nur_*__.e.r
_.........._..
Address
Expiration Date
se
Signature Telephone
9.2 Registered Professional Engineer(*):
Name Area of Respons biitty
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
s
Address Registration Number
9
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
k
Signature Teiephone Expir0on Date
9.3 General Contractor
}iCrJ�y' Not Applicable O
Cogmny Name: _
Responsible In Charge of Construction
_
P mc r A 7
Address ,.,,,,_.
� b2 - M
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(760 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No E)
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize 'Y to
act on my behalf,in all matters relative to work authorized by tis building permit application.
Signature of Owner Date
—J_,as Owner/Authorized
4LIent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
an elief.-
Srgned under the pains and penalties of ppjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
N��af license Holder: Timothy J Seney CS-061088
_. ..
�_-3w
License Number
371 Prospect St,Northampton, MAO 1060 03/25/2021
Address Expiration Date � ` W
Y �4 3-626-1797
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 E) No 0
City of Northampton 212 Main Street, Northampton, MA 01460
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: rt+at �••�. „
The debris will be received by: yL „
Building permit number:
Name of Permit Applicant , ht. by -_k C°1—i' (,,,,a.
4
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 140
Boston, MA 02114-2417
www mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information Please Print Leeibh,
Name (Business Organisation/htdividual): � ,tom,
12
Address: 7 t rtv%P t-eX 5� x
City/State Zip: .t1..,5-h1-t _ Gt* Phone#: !
Are you an employer"Check the appropriate box:
Type of project(required):
I Er(am a employer with_ I mpioyces(full and/or part-time).* 7, [:]New construction
2.[]l am a sole proprietor or partnership and have no employees working for me to 8. Ttemodt ling
any capacity.[No workers comp insurance required.]
3.[31 am a homeowner doing all work myself.[No workers'comp.insurance required,]' 9. r_1 Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all wort:on my property. I will 10 C] Building addition
ensure that all contractors either have workers'compensation i surance,or are sole I I-Q Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.[:]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance
6.n We area corporation and its officers have exercised their right of exemption per MG1 c 14.[]Other
.152.§1(4),and we have no employees.tNo workers'comp,insurance required.]
Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
t Iiorneowners 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 fob site
information.
Insurance Company Name:_ t _..ktis
Policy ii or Self-ins. Lie. 4: Expiration
Job Site Address: �1AL"+e[- Taiiit- r Ci /State Zi
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. 12,§25A is a criminal violation punishable by a fine up to$1,540.00
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.
Si nature: — --- Date: a f
Phone#_.._ 4 Jfs t ' t
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):
L 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 a joint enterprise,and including the legal representatives of a 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 shall 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 of this 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-contractors)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 required to 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 bottom
of the 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 permit/license 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. A new affidavit must be filled out each
)ear. 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 burn 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.govldia