Permit App - Bath HouseA,The Commonwealth of Massachusetts
Office of Public Safety and Inspections
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two-Family Dwelling
is Section For Official Use Onlv)
Bu ilding Permit Number:Date Applied:Building Official:
i. n I SECUON 1: LOCATION
No. and Street City /To{rn Name of Builcling (if appl
Assessors Map #Block # and/or Lot #
SECTION 2: PROPOSED WORK,'
Edition .,f
Demoiition D (Please fill out and submit Appendix 2)
Other I Specify:
Are building plans and/or construction documents being suppliecl as part of this pennit application? Yes
Is an Independent Structural Enginee Yes
!{, D^escription of ProposeclWork:
SECTION 3: COMPLETF THIS SECTION IF E)(ISTING BUILDING UNDERGOING RENOVATION, ADDITION, ORCH \GE !N!qE eB eqqq4Nq
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) n
Existing Use Group(s): _,_-.__, ] Proposcd Use Group(s):_
Existing Building I Alteration fI Addition tr
Change of Use tr Change of Occupancy tr
SECTION 4: BUILDING HEIGHT AND AREA
Existing
No. of Floors/Stolies (include basement le
I'otal Area (sq. ft.) and Total F
rea Per Floor' (sq. ft.)
SEC'IION 5: USE GROUP as applica
Assembly A-1 D A-21 Ni ub tr A-3 n A-4 n A-5 D I B: Business I E: Educational I
F-1 D F2l,H: Hieh Hazard H1n H..2 n F{-3 n H-4 D H-5 0
b{'t"!g"4_[l
Storage S-1 I
r-2 n r-3 D M: Mercantile I I R: Residential R.1n I{'2 n R-3 n R-.4 n@grggarlrrge*.rt:!e1.-y,-_---
iai Use I)escription:
N 7: SIT,E INFORM (refer to 780 CMR 105.3 for details on each item)
SECTION 6: CONSTITUCTION TYPE (Check as applicable
IIIA tr IIIB tr
Water Sup
site svstem l
---R"iil;;a;rsht-6;i; T'
Is Structure wijl+i
t to Build enclosed I
Flood Zone Inf
rport approach area?
T'rench
A trench not be
or trench
is enclosed I
vn ni'ti,iil
Is their con-rpleted?
Nol
Debri
Licenserl
or specify
s Remova-l:
Disposal Site fl
Yes ! or No fl
SECTION 8: CONTENT OF 'IFICATEOFOCCUP CY
LJse Grou
Yes I
Edition of Code:
Does the building contain an
Tvpe of
Special
Construction:
Design Occupant Load r and Assernbly space:
Stipulations:
ff+ii'li:
Name (Prfnt)
If applicable, the property owner hereby authonzes:
niV 63 A1
Name
for and act on the
10.2 General Cofitractor
SEC'IION 9: PROPER'IY OWNER AUTHORIZATION
City/I'own zlp
1\38fr:Bg
Telephone No. (cell)e-mail address
o,51 |
Zip
ita
$.---
Building Permit Fee ,- -l'otal Construction Cost x -_-_,, (lnsert here
appropriatc murricipal factor) =.$ _ _ .
g-Note: Minimum fe'e = $(contact rnunicipalitv)
Street Address City/T
owner's behalf, in all matters relative to work authorized this buildi
wlhau&n
Telephorre No. (busi ness)
iIGUroi
ConrpirrvLM
Nirrnc of Persr.rn Responsiblc lor Condt*{rction t License Ntr.EaThornp*n Qd ThoupsoY)srrcctAdircss t - Citv/Town
Name of Persgrn Responsib)c for Condt*{rclion ,l License No CT __eEZ-l -7
%_aL?l5?_,O452 lsv
State zipri I . Cowta53:p452 %_Qf,a?_,o4sz l5l
-l-r.
I gphonc N o. (.b!!Ugo _ rq!..p-b9ne_N9.(9[L
SECTION l1iWoRKERS'coMPE (M.G.L.c.152.
A Workers' Cornpcnsation Insurance Affidavit frorn thc MA Department of Industrial Accidents Inust bc cornpleted and
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimatecl Costs: (Labor
ancl Materials)Total Construction Cost (frorn ltern 6) = $
i,1491'e -
2. Elecirical
{----I' r[Tbils -4. Mechanical (HVAC)
5. Mechar.rical (Othe
SECTION 13: SIGNATURE OF BUILDING PERMIT.APPLICANT
By entering my name below, I hereby attest ur.rcler the pains ancl per.ralties of perjury that all of the information contair.red in this
applicatiou is true and accurate tg thgbest of p;y klrowleclge and uncierstanding.
tr,.A:":, F.Y:i,-*' | - @y1 T'- i':Er.-' t?J -fu oT 06 z-77 &{H;i 7'd;-*,Street Address Citv/Towr-r State Zip r/Email Address
SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 1)
lf a building is less than 35,000 cu. ft. of enclosecl space ar.rd/or not uncler Construction Control then check h"r"X
section 107 in the code) as required.
1O.f @.Refponsible for Construction_C_ontrol (the professional coordinlting dolument submittals)
Narme (Registrant)Teleolrcael\lo. e-rnail address
Street Address City/Town pline Expiration Date
sL -g*?5 t €v P-oB -3r-ZO?
and Type if Applicable
e-rnail address
Municipal Inspector to fill out this section upon application approval: _-___.
Name
CITY OF NORTHAMPTON
SETtsACK PLAN
MAP:_ ____ I-OT:__. _ _
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
FRONT SETBACK
F'RONTAGE
City of Northampton
Massachusetts
DEPARII''ENT OE BUILDING flVSPECTTO}'S
2t2 ltl€-j,n Street . Uunicipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
R ALL DEMOLITION AND RENOVATION PROJECTS)
ln accordance of the
Number
isions of MGL c 40, S54, a condition of Building Permit
is that all debris resulting from this work shall be disposed of in a
properly lice4sed was disposal facility, as defined by MGL c 1I1., S 1504.
The debris willl be d of in: EZ ,DisPosq- I
Location of Fdcility: Z Ra-,\roal 5t ReveFe.MA 6ztsl
The debris willl be tra
Name of Hauler:
Ao*4,tSignature of {pplica Date: lZ -o I - ZOZO
I
I
I
lnitial Constrr*cticn Ccntrol Docgutent
Tc be srrb*ritted r+'ith the burlding per*rit epplicatiorL fog 6
Registered S*sign ProfessionaX.
f*r u,'ork p*er ffte nrnfk erlifi,ox *rf fku
&{sssschusetts Stfite E*rkling Cocien 7'SS C:}f& Serfiou ls7
Froject Titlc:
Fr-opelty .ddd:r*ss:
F;oject: Check {x3 cne o
Project descxiptiun:
beth es ryrplicable:lrier+',csnstrurt.iorr Existfng Construction
S{i\' R.rgistrafi'en l trnrb*r:Exp:katicn date:, am a rugistered desifil profession"al, and I har-e
prepaled sr d:ipectltr tsed the preparatian of a1l ptr,anso cornptltati*ns and .specifications concern:ing:
Archilectul S,tnrclur I\dechanical
0ther:Ffue Fro'tecti Elee
far the absr,e nam*ri
rctnputations an',tr spec
cject *nd that the best of mv kno.r.rtr*dge. inf,or:*ati.on, and belief s+rch pl.ans,
atisfls ureet applicable prol:isio*s of the ]rXassachusetfs State Euilding Cade" i7E0
C],E.R). and accepted ,f,rs Pf f*s the f'H$Fased pretrect. I und*estend and ag"ree that I (or mn'
designee) shal1 perforu,r
and pedodic hast^s to:
prefessi*nal sefi"ices and be Frrese:l.t nrr thE cpnstnrctinn site sn a roegular
1" Re"*iew, for c to thds code a*d dre design concept, shop dx,alt'ing:s" samples a*.d other
srbnrittalg b',r tlre in accor'.danse l..iith the requirernents nf the ccxutructi*r'r docume*ts.
?" Perform bhe duU registe*d design profeseionals in 7&S Cfu{R Chapter 1"?, as app'licabtre.
3- Ee pr*sent at in a1s apprapriate to the rtage of constructien to becsfire generall"r'facriliar r.rith the
Drgefess aflcl Gle'I v of the rr"ork and to detersftine if the rssrk is being performed Hr a ffrarmer consister-lt
rr.ith ttre ap cunstrsction dscufiients asrd Sr:is corJe"
-\*thing ur this retrietes f}re cotrtractor of its responsibilitl. regard*rg the prc";isiorxs sf ?ES CI'IR 10,;.
lfhetr requir:ed the nffirial, n shall subsrit fietrdlprogxess r'eE*rts isee itenr 3.J togetherr.\'ith pertinent
C0tltinel}X5, !li't ptable to tJre huilding sffici,ll
U-pon canr r+f t}te or&, tr s$.s.11 sxrbmit to the brdldinE efficial a 'Firtal Corrstruction Control Documentn
Enter in the space to ttre
electroni"c sigrtature and
Fhorre number:
ght a "u.ef' tr
Email:
Suilding Sffiri,al Nasner
Euitri{ing O$ir:rai Llsr 8xl3r
Per:rrit No,r D'*ter
l'io*s tr Indicste qdth gn's:'
.dlor*r:. pr*:.-id,e .e .descripli*n-
r"ssic'n,Ul [1 3l]l$
,3*sig* g*an-.. coxrpulatierrs EnC :p*cilhaEners il-r*t e'c,x pr*p,are"3 os ,lirec*r super'**sed $'olher' i.=
Appendix 1
Construction I)ocumentg are required for structures that must comply with 780 CMR 107. The
checklist below is a comfilation of the documents that may be required. The applicant shall fill out
the checklist and providri the contact inJormation of the registered professionals responsible for the
documents. This appen{ix is to be submitted with the building permit application.
*Areas of Desisn or Construction for ns are not complete at the time of applfcation subrnittal rnust be identified herein. Work so identified
rnLrst rlot be cornrnenced until this apjplication has been amended and the proposed construction docutnent amendment has been approved by the
au thoritv having jurisdiction.
ftegistered Prof essional Contact Inf ormation
Name (ltegistrant)Telephone No.e-mail ac'ldr Registration Number
Street Address City/Town Discipline ExpirationDate
Name (Registrant)Telephone Reeistration Number
Street Address Discipline ExpirationDate
Name (Registrant)
Sireet Address
Checklist for Construction Documents*
Mark "x" where applicable
Architectural
Foundatior-r
St^r.t"."1
Piumbins (include
Gas (Natural,Medical or other
Surveved Site Plan tilities, Wetland, etc.
Structural Peer
Structural Tests & lnspections Proeram
Fire Protection Nar tive Report
rvev/ Investiqation
Conservatioh Report
Architectural Access Review (521 CM
tion DocurnentationHazardous Materia
Other (Specif
il.v,/Town Statc Z
Telephone No. e-mail address Reqistration Number
Discipline ExpirationDate
Please follow this link for colstruction control forrns to be used by Registered Design Professionals
Z. {u'ding
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$Arr2
City of Northampton
Massachusetts
DEPARTMET{T OF BAILDTNG Ii'SPTCTTOI!'S
212 Main Street r Municipal Building
Northamlrton, tilA 01050
{nocnnu E F'OR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI AMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
4genr.
Qne set of
$ite Plan w
$onst
Workerts C
Application signed by legal owner and filled out by owner or authorized
and specification of proposed work (digital and hard copy).
location of proposed strucrure(s) and setbacks.
Debris Affidavit filled out and signed by applicant.
Insurance Affidavit filled out and signed by applicant.
Qontractors st supply a copy CSL and proof of Liability Insurance.
$nergy C
$ote any
Compliance Certificate (if applicable).
ation and/or Special Permit requirements (if applicable).
IDrivewav P (if applicable).
froofofW and Sewer entry fees paid (if applicable).
french (if applicable).
Ihitial Control Documents filled out and signed by the Registered Design
responsible charge.