Permit Application ATC SignedVersion 1.7 Commercial Builds
City of Northampton
Building Department
212 Main Street
Roam 100
Northampton, MA 01000
phone 413-887-1240 Fax 413-587-1272
Permit May 15, 2000
Department use only
Status of Permit;
CurbCut/Driveway Permit _
Sewer/Septic Availability_
I aterlVVeII AvaiIahiIity.
Two Sets of Structural Plans
Plot/Site Pians
Other Spe ify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
THEFT THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
11 Property Address:
296 Nonotu k St.
Florence, M
This section to be completed by office
Map
Zone
Elm St. District
SECTION 2 - PROPERTY OWNERSHIPIAUTHO IED AGENT
2.1 Owner of Record:
Ncnotuck Mill. LLQ;
Nafne (Print)
Signature
2.2 Autho0zed Agent:
Seth Crocker
Name (Print)
Bignatore
Lot Unit
Overlay District
B District
296 Nonotu k 5t., Florence, NSA
Current Mailing Address:
(4 13) 519-0765
Telephone
186 Stafford St., Springfield, MA 01104
Current Mailing Address:
X413) 737-7803
Telephone
SECTION 3. ESTIMATED CONSTRUCTION COSTS
Item
1. Building
_ Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5)
Building Permit Number
ig nature
Estim2ted Cost (Dollars) to be
completed by permit aoolicant
$350.000.00
$140X0.00
$50,000.00
$65,00.()0
Official Use Oniy
(a) Building Perrnit Fee
(b) Estimated Total Cost of
Construction from ()
Building Permit Fee
Check Dumber
This Section For Official Use Oni
Date
Issued
Building Commissionerilnspector of Buildings � Date
ersiotnl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPADE
Interior Alterations Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ Neter Signs ❑ I oofing❑ Change of Use ❑ Other Q
Brief Description Renovate a portion of the second floor of the office building for Couples Therapy
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION T`fPIE
USE CROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly
❑
A-1 ❑] A-
❑ A-3
1A
❑
B Business
❑
A
❑
E Educational
❑
B
❑
F Factory
❑
F-1 ❑ F-2
H High Hazard
❑
A
❑
InstitutiDnal
❑
I-1 ❑ 1-
❑ 1-3
B
❑
M Mercantile
❑
4
❑
R Residential
❑
R-1 ❑ R-
❑ R-❑
5A
❑
Storage
❑
S-1 S-2
B
❑
U utility
❑
Specify --
. ......
....s�
M Mixed Use
❑
Specify:
S Special Use ❑
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Croup. B Proposed Use Group:
Existing Hazard Index 780 CMR 34):
SECTION 0 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
Floor Area per Floor (sf)
1 St
nc
ra
4 th
Total Area (s }
Total Height (ft)
1 Si
8.854
nj
3rd
4th
Proposed Hazard Index 780 CMR 4):
PROPOSED NEW CONISTRUCTIOM
$,854 Total Proposed New Construction sf
Total Height ft
OFFICE USE ONLY
v�
7. Nater Supply (M. .L. c. 40, § 54) 7.1 Flood Zone Information: 1 7.3 Sewage Disposal System:
Public ❑ Private 11 Zone Outside Flood Zoned IMunicipal Ej On site disposal system❑
8. NORTHAMPTON ZONING
Lot Size
Frontage
Se-lbacks Front
Side L,
Rear
Building 14eight
Bldg. SgUare Footage
Opera Space Footage
( Lot area minus bld a paved
parkin )
of Parking Spaces
Fill:
(VOIL)Me &. Location)
Version 1.7 Commercial Building Permit May 15. 2000
Existing
I:X
L;
Proposed Required by Zoning
This column to bp, filled in by
Building Department
Is
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES C)
IF YES, date issued:
IF YESO Was the permit recorded at the Registry of Deeds?
NO C) DON'T KNOW � YES 0
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C)
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed granges to or additions of signs intended for the property ? YES 0
IF YES, describe size, type and location:
YES O
J
NO O
E. VVIII the construction activity disturb (clearing, gradings, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre"? YES 0 O (�)
IF YES, thea o Northampton Storm Water Management Permit from the DPVV is required,
Version l
.7 Commercial Budding 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:
1 1 6 Pleasant St, Suite 311, Easthampton, MA
Not Applicable ❑
Name (Registrant):
663
1 16 Pleasant St. Suite 3 11, Easthampton, MA
Registration Number
Address
08/31/2020
{413) 529-9434Expiratfor�
Date
igpature
Telephone
9.2 Registered Professional Engineer(s):
Name
Area of Responsib lit
Address
Registration Number
Signature
Telephone
Expiration Date
Name
Area of Responsibility -
y
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 Daae
6.3 General Contractor
Crocker Building Company, Inc,
Company Name:
Not Applicable El
William Crocker
Responsible In Charge of Construction
186 Stafford St., Springfield, MA 01104
Address
signature
Telephone
Version 1.7 Commercial Building Permit May 1 , 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110,11
Independent Structural Engineering Structural Peer Review Required Yes 0 No C40
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Doug Icy
as Owner of the subject property
hereby authorize Ot�l rocker
act on my behalf, ' ail mat rss lative to work authorized by this building permit application.
3/17/20
Signature of Owner
Date
to
I Seth Crocker
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_
Seth Crocker
Print Name 1, y
Signature of Owner/Agent
SECTION 1 - CONSTRUCTION SERVICES
14.1 Licensed Construction Supervisor:
Name of License Holder : William D, Crocker
1B0Stafford St.. Springfield, MA011d4
Address
Date
(41 3) 737-7303
Signature Telephone
3/17/20
Not Applicable ❑
-067305
License Number
4119/20
Expiration Date
SECTION 1 -WORKERS' COMPENSATION INSURANCE AFFIDAWT (M,O.L. c, 162, § 25C(6))
Workers Corrrpensation Insurance affidavit must be completed and submitted with this application, Failure to provide #his affidavit will result
in the denial of the issuance of the building permit,
Signed Affidavit Attached Yes � o
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 0 No (i)
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Doug McVey
I as Owner of the subject property
Seth Crocker
hereby authorize to
act on my behalf, all ma rs lative to work authorized by this building permit application.
J 3117120
Signature of Owner Date
Seth Crocker
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.
Seth Crocker
Print Name
3117120
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Not Applicable ❑
William D. Crocker
CS -067805
Name of License Holder:
License Number
186 Stafford St., Springfield, MA 01104
4119/20
Expiratipn Date
Zddre
(413) 737-7803
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 0
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:
116 Pleasant St, Suite 3404, Easthampton, MA
Not Applicable ❑
6634
Name (Registrant):
116 Pleasant St, Suite 3404, Easthampton, MA
Registration Number
.08/31/2020
Address
Signature
(413) 629-9434
Telephone
Expiration Date
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
Signature
Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature 9
Telephone
Registration Number
Expiration Date
9.3 General Contractor
Crocker Building Company, Inc.
Not Applicable ❑
Company Name:
William Crocker
Responsible In Charge of Construction
186 Stafford St., Springfield, MA 01104
Addres
(413) 737-7803
Signature Telephone
City of Northampton 212 Main Street,, Northampton, NIA 0 1060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S541 I acknowledge that a
r 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: A. . ,.
The debris will be transported bar: 14 tt '7r c c k -
The debris will be received b :
Building permit number:
mer Permit Applicant pp � � A.
Z7, -2e
Date Signature of Permit Applicant
�L\
The Commonwealth of Massachusetts
epartnient of Industrial Accidents
I Congress Street, Smite 10
Boston, MA 02114-201
ww . mass.go v dia
N1-arkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNITYI-INU AUTHORITY.
lieant Information Please Print Legibly
Name (Business/Or ai,i7ationIlndividual): Crocker Building Company, Inc.
Address: 18taifford St
City/State/Zip: Springfield. MA 01104
Are you an employer? Check the appropriate box:
Phone #,(413) 737-7303
3. 1 ain a employer with 0 employees (full and/or part-time).*
?.❑ I am a sole proprietor or partnership and have no employees working for mein
any capacity. [No workers' camp, ia�surancc r�clu-red-]
I am a honleovw-ner doing all work myself. (No workers' comp. insurance required.]
4.F1 1 am a home -owner and vvilC be hiring contractors to conduct all Werk on my property. T vilC
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
.[D i ain a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have empIovees and have warkers' camp. insurance t
6.M We are a cc]rporation and its officers have exercised their right of exemption p-crJMG1. c.
152, § I(4). and we have no cmpioyees ilio workers' cornp. insurance required-]
Type of project (required):
7. ❑ New con;truetion
S. 0 Remodeling
. 0 Demolition
10 [J Building addition
1 1.Q Electrical repairs or additions
1 ?. 0 Plumbing repairs or additions
13. Roof repairs
14. Other
•Any applicant thaI ehecls box # I must also fill c ut the section beIow showing their workers' compensation policy inforrmation.
} 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 cheek this box must attached an additional sheet showing the name of the sob -contractors and state whether or nit those entities have
employs. If the sub -contractors have employees- rhey rnust provide their workers' comp. poh
iev number.
I iiia an employer Ih(it is providing workers' compensation ins ur a ce_ for troy employees. Belaiv is the policy and job site
inj rmation.
]nsurance Company Name. The Ohio Cas ualty Insurance Co.- L1borty Mutual Insurance
Policy # or Self -ins. Lic. #, XIf O ( 0) 57 69 93 99
-- Expiration Date -4/1/20
Job Site Address: 9 Nonotuck St. City/State/Zip: Florence, M
Attach a cope of the workers' compensation policy declaration page (showing the polio 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 ofa STOP Vw'DRK ORDER and a fine of up to $250.00 a
day against the violator. A copy of'this statement may he fonvarded to the Office of Investigations of the D[A for insurance
coverage veri icdtion.
1 do he"hy cerlify under Ihepc ins and peiralfies ofperjury flair the information provided abore is true and correct.
Signa
Da
Phone #: (413) 737-7803
Official Erse only. Do not write in this area, to be completed by city or town official.
City or Two a: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
. Other
Contact Person: Pbone #: