18D-040 (15) A 75 KING ST-PRIDE STATION BP-2005-0724
GIS#: COMMONWEALTH OF MASSACHUSETTS
' CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0724
Project# JS-2005-1004
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BOLDUC 038811
Lot Size(sq. ft.): 42209.64 Owner: Pride Convenience Inc
Zoning: HB Applicant: ROBERT BOLDUC
AT: 17 DAMON RD - 375 KING ST - PRIDE STATION
Applicant Address: Phone: Insurance:
246 COTTAGE ST (413) 737-6992 Workers
Compensation
SPRINGFIELDMA01101 ISSUED ON:1/19/05 0:00:00
TO PERFORM THE FOLLOWING WORK:CHANGE CANOPY PANELS
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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 1/19/05 0:00:00 10034648 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2005-0724
APPLICANT/CONTACT PERSON ROBERT BOLDUC
ADDRESS/PHONE 246 COTTAGE ST SPRINGFIELD (413)737-6992
PROPERTY LOCATION 17 DAMON RD-375 KING ST-PRIDE STATION
MAP 18D PARCEL 040 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /6tD 3 9 Yr &6
Typeof Construction: CHANGE CANOPY PANELS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 038811
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co 'ssion
Zoo
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
( T +' ,,' ---- ---1 Version1.7 Commercial Buildin Permit May 15,2000
i4 V, I 11 V .E . f A''` DeparFlent use only
1 l lr-S ---- f Northampton Status of Permit:
5
Bin • g Department Curb Cut/Driveway Permit 1 L JAN 1 4 2005 'Main Street Sewer/Septic Availability
Rom 100 Water/Well Availability_
j N ampiton, MA 01060 Two Sets_ of Structural Plans
it Y pE ptorzF B1)It phot��e � 87-140 Fax 413-587-1272 Piot/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 _
fit Property Address: --'., \ This section'to be'completed by office
�.:�� i�►N(� ST, `� Map Lot_ Unit
i /7 I) ei4Y1C5Y1 /419 � � �,
i oneK „ erg
i
Etm SL Iri'Z� 41-' B513- lifidt. .14:40-1
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:r
1"iatDF�' ` [�►.1J��l% C n1C• i 0.4i a Ct'Frync..,.' S-4--. PR i Pa 6 Fi 64....-N MA 0i)( (
Name(Print) ' . Current Mailing Address:
r
'fl� 'T , 7_ L,9RZ
Signatur '>,.; On Ro.Q f.-- Telephone
2.2 Authorized Agent:
i %),—. A• SA(30,..)1z1.3 1( Car-robe-Sr. SPEC AAA
Name(Print) Current Mailing Address:
�'---� '411.. -7 3-7- (. 9'-qz- '
Signatu .._ )1 :--cQ,4--• - -•--- 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
l/ 'ir,pnc)
2. Electrical (b)Estimated Total Cost of
Construction from(6) ,
3. Plumbing ' Building Permit Fee
4. Mechanical (HVAC) --
i
5.Fire Protection ,
6. Total=(1 +2+3+4+5) Check Number id03 I t V5?)-'
This Section For Official Only
Building Permit Number Date
Issued
.,-
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
f..
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS"LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs El Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign 0 New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. C'\nur, Cu ctc u O"oe C'r C'cfo•
Of Proposed Wo
PR iTE COLo'frS•
! _
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
-
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 0 A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B El
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C El
H High Hazard ❑ 3A El
I Institutional El 1-1 El 1-2 ❑ 1-3 0 3B El
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 El R-3 El 5A ❑
S Storage ❑ S-1 ❑ S-2 El 5B El
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)
1st 1st
nd
2nd: 1 2 (
3d 3rd '
4'h ' j 4
to
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 0 Private ❑ Zone Outside Flood Zone E] Municipal ❑ On site disposal system
Versionl.7 Commercial Building Permit May 15,2000
8 NOIZ�TON ZONING d" i..Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:' i R:' L: i R:i
Rear
-ButTding Height— 1 ` i
Bldg.Square Footage r—
Open Space Footage
(Lot area minus bldg&paved i i i 1 I
par g)
#of Parking Spaces
Fill: '
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book I Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location: 1
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q ' NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r .
Version1.7 Commercial Building Permit May 15,2000
SECTION "9-.PROFESSIONAL DESIGN"AND-CONSTRUCTION-SERVICES-FOR BUILDINGS AND STRUCTPRES SUBJECT;TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000-C.F.OF ENCLOSED-SPACE)
9.1 Registered Architect
Not Applicable 0
Name(Registrant):
Registration Number
I
Address
i : Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
i j
Address Registration Number
1 I
Signature Telephone Expiration Date
j
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
1 k
Address Registration Number
E
i
Signature Telephone Expiration Date
i I
Name Area of Responsibility
1
Address Registration Number
1 1
l I j
Signature Telephone Expiration Date
19.3 General Contractor
V i P2 i�6 { Not Applicable 0
Company Name:
2aben4- ,lduc 1
Responsible In Charge of Construction
I
i -tiLo w tx- S( CPO NVFicc.-o i 0iio '-(
Addre 60:41,
Signature Telephone
• 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 0
SECTION 11 -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
I, 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
I, ,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.
•
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: '1' r c I
License Number
,
Address Expiration Date
' 3'7-G99 Z-
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 0 No 0
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Alassachnctis• . -Q-_- ---.,
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- , DEPARTMENT OP BUILDING INSPECTIONS
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212 Main Street • Municipal Building
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' • Northampton, Mass. 01060
•
WORKEIt'S COMPENSATION. GIST AFFIDAVIT:
I, PiZI-TE (OA//C.'Ai iCiV06 .. -nl C.
—--
(liccesXYpermittrx)
3.4itil_a__p_npailplact. of bu&i-gtssirsidencc at: ' - -
. (phonej0
• (str=kity/statelzip)
do hereby certify, under the pains and penalties of per-jury, that . .
( ) I am an employer providing the following vt.orker's compensation coverage for my •employees wording on this job:
I .
\, •
J
( iica Company) ' (Policy Number) (Expiration Date) .
•
• • ,.
( ) I am a sole proprietor, general co. ntractor or homeowner (ciscie one) and have hired
the contractors listed below who have the following worker's compensanon policies: . •
•
(Name of Contractor) (insurance Company/Policy Numhc ) (Expiration Date)
•
' •
• . . •
(Name of Contractor) ( an Compa.ay/Policy Number) (Expiration Date) • ,• , •(Name of Contract&) ansurancc Company/Policy Numbar) (Expiration'Date)
•
• •
(Name of Contractor) (Insuratam Comparry/Policy Number) - (Expiration Dale)
,(aa...cti luiditioc..,,,,,zi if noo=sry to'endue!o intor-m... 00 pertaining to all coccrec....or) . 1
t
i.( ) I am a sole proprietor and have no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE:PI=K be aware the.oet.rjo bp:1=0wpm wbo ccaploy pa-Low to do=a ir,-.1 t nn• cy-1=-•—..:C.J.,0 c'repair work co a dwdlinc of
not cooc-m thin t,...ol.unit in which the bornonwocr rtnie}c or•on the crouodi xppuricsect tbc-do e-^c oot g-r=.0-2.1.1y cocridamd to be
cdtPlor="3 ue"--='thc woke?l cr-r1),-----.lion Ac (GU Si2-s-s 1(5)).npplicition by a borneoopa for i hc:c..-c or pertnit rr....ty viola=the
• legal rt..=of an=player uoder tho Woricoet C000peomatioo.Act
I understand dast a copy of this crxtheocat al.ay bo forwoectod to tb.Dop...r:onot of bado,*rie./Anadent.,'OfGoo of ismarsom for tb.
coverage verifientioo and atti.Eiltz-c to secure Nonvcracc under section 25A of MOL 152 CU]Ici.;:l to the inosition anticlinal pceultios
coca/Aix%of a floe of up to S1,500.00 encVoc in:Tainoanoccri of up to occ yrlr end civil p,,-e.him in the focal of.Slop wort°2-6:'.I'd.
rin.0(5100.00 idly against coo..
For departne-,-,--.1 u.,e only
c__ Pcren--
it Number
A.;
Sigxinturc of L.iocmsc.c/P c rrrii a cc
....N.{.3 IA Lot#