18D-040 (16) 111.11.11, BP-2008-0182
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-2008-0182
Project# JS-2008-000283
Est. Cost: $8000.00
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: Pride Convenience Inc
AT: 17 DAMON RD
Applicant Address: Phone: Insurance:
246 Cottage St (413) 584-9485 Workers
Compensation
SPRINGFIELDMA01104 ISSUED ON:8/23/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE SIDING
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: Date Paid: Amount:
Building 8/23/2007 0:00:00 $50.0010041330
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
f ,
Versionl.7 Commercial Buildin Permit May 15,2000
use only
City of Northampton Status of Permit:
Building Department curb Cu`/Driveway 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 413-587-1272 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_4.SiTE INFORMATION_
gam, This•section to be completed by office
---- fi'1 Property-Address: • ,.
Pr/ LotUna
� � �
/.7 /,/Jy`1Y) on> Overlay District
Af U A-1 /lam' 1 Mn- _ „t, �W }
Elmt:'Distnc CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/f03u—r f?ireatat_C. 2y� e 7 Sri Snf• �
Name(Print) Current Mailing Address:
if/ 73-7 Gg92_
Signature Telephone
2.2 Authoriz d Agent:/144 ek-
-Pi k-.cf e•7Lo eZI 5
L r SPfLo
Name(Print) Current Mailing Address:
03 73 7—G 9E7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be - Official Use Only
completed by permit applicant
1. Building4 E� �. (a)Building Permit Fee
2. Electrical QI (b) Estimated Total Cost of
Construction from (6) _________
3. Plumbing ! Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) q' irra . n Check Number
This Section For Official Use Only
Building Permit Num"bet Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
r
•
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS-LEss THAN 35,000
CUBIC FEET OF ENCLOSED'SP..ACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition 0 Repairs❑ Additions 0 Accessory Building 0
Exterior Alteration ign❑ New Signs 0 Roofing❑ Change of Use❑ Othe
Brief Description Enter a brief description here.
Of Proposed Work. ! Q �j ,ll
/�
SECTION 3-USE GROUP AND CONSTRUCTION,TYPE '
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A3,1 0 A-2 ❑ A-3 ❑ 1A I ❑
_ CIA-4 ❑ A-5 El1 B CI
B Business — ❑ — 2A ❑
E Educational ❑ 2B I ❑
F Factory Cl F-1 ❑ F-2 ❑ 2C ❑
H High Hazard El 3A CI
Institutional CI 1-1 CI ❑ 1-3 El3B El
• Mercantile CI4 CI
• Residential ❑ R-1 ❑ R-2 ElR 3 El 3A
CIS Storage ❑ S-1 ElS 2 El El
l ❑
U Utility ❑ Specify:I
M Mixed Use El Specify:
S Special Use 0 Specify:
.COMPLETETHIS`SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS;ADDITIONS:AND/OR CHANGE IN USE
Existing Use Group: I Proposed Use Group: I
Existing Hazard Index 780 CMR 34):l I Proposed Hazard Index 780 CMR 34):i I
-SECTION`6BUILDINGHEIGHT>ANDAREA- -:
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION i _r � x
Floor Area per Floor(sf) v
r St i • ..• " . -..-.a^"'.. 't;tr-any i,
St 1 j I ''s' y'C ice' m
2nd 2nd xv+a., .. .,#. 1;0 i,`20 4-
r'
3bi i ,.,P.•, _ ,s r s -'a
,aza +Ys
����
Total Area(sf) Total Proposed New Construction(sf) - , .'
I 701,
j Ek. a;wy 4 'a` '�",. r l '
Total Height(ft) ` I n 'v',g"`r3 M
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 El Zone's . Outside Flood Zone❑ Municipal ❑ On site disposal system El
Versionl.7 Commercial Building Permit May 15,2000
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i i
1
Frontage
Setbacks Front ! ! "
Side L:' I R: L: R:i l �F
3
Rear
-._.. _ Buildmg Height I ,
Bldg.Square Footage % i s— p
Open Space Footage
I
1
(Lot area minus bldg&paved I i
parking)
1 ( i I I I
#of Parking Spaces
Fill: ' j
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW er YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW e 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 a YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: ':
C. Do any signs exist on the property? YES er NO 0 -
s
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO er
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exca ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® ` NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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
Not Applicable 0
Name(Registrant):
Registration Number
i
Address
Expiration Date
1
Signature Telephone
9.2 Registered Professional Engineer(s):
•
Name Area of Responsibility
Address Registration Number
1
Signature Telephone Expiration Date
Name Area of Responsibility
i j
Address Registration Number
i
i 1
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
� + 1
t .
Signature Telephone Expiration Date
t 1
I1
Name Area of Responsibility
1
Address Registration Number
t
(
Signature Telephone Expiration Date
9.3 General Contractor
'/
Not Applicable ❑
Company Name:
o 56
Responsible In Charge of Construction
� r i
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-=STRUCTURAL;PEER REVIEW::"(T80 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 BUILDING-PERMIT
1 .
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, 761/fit -,/,--—*—/Z Gc, C' 1 ,as Own:./Authorized
Agent ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
elief.
Signed under the pains and penalties of penury.
Print Na
�. /23 67 l
Signature of Owner/Agent Die
SECT_[ON.12-=CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �b B LID CA,C..., I 0 3 1 1 t
License Number
I I H--
Address Expiration Date
i
Signature Telephone
SECTION 13-WORKERS'COMP_ENSATION°INSURANCEAFFIDAVIT(M G.L c.152 ,25Cts))
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 No0 -F 75 X(f D
r
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a
The Commonwealth of Massachusetts
Department of Industrial Accidents
I"—'- =xi •
Office of Investigations
=orb=`d 600 Washington Street
F�— Boston,MA 02111
' www.mass.gov/dia
.-'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a contractor and I
general6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub contractors have 8. ❑Demolition
workingfor me in anycapacity. employees and have workers'
P ty. $ 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officershave their 11.
3.❑ I am a homeowner doing all work exercised ❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
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.
I 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: .. -
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
08/23/2007 09: 47 4137315852 PRIDE PAGE 01
The Commonwealth of Massachusetts
Department of industrial Accidents
`}; Ti � Office of Investigations
=_'its,_ _, 600 Washington Street
_ = = Boston,MA 02111
www-mass.gov/dia .
Workers' Compensation Insurance Affidavit General Businesses
Applicant Information Please Print Leribly
Business/Organization Name: P DE Co Al V5JV(4"ive..6 jAIe -//4' I-Avi/?L7) P 7' Sf`iA
Address: q (,10*4 -E. sr
City/State/Zip: 3 f R IN -F/ L-D/ �`'Ph #: Li/ 3— 737 6 992
Are you an employer?Check the appropriate box: Business Type( lam):
951,..1 am a employer with, 9 d U eu ployees Gill and/ 5- Z Retail
or part-time).* 6. ❑Res: urantJBar/Eating Establishment
2_❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,anti%etc.)
employers working for me in any capacity. g 0 Non-profit
workers'comp.insurance required] ff
3.❑ We are a corporation and its officers have exercised f 9. ❑Entertainment
their right of eraernpptrion per c. 152,§1(4),and we have 10.0 Mrsrmfacturing
no employees.[No workers'comp.insurance required]."
4.❑ We are a non-profit organization,staffed by volunteers, 11_D Health Care J
with no employees. [No workers'conrp.insurance req.] 12.0 Other i
•Any applicant that checks box 01 meat also fill oat the section below showing Moir workers'compensation poky in orms tie.
"If the yr par a cf9ccra have acernpled$tanselres,but the corporation has otter employees.a workers'<vo yeur:a "policy is required and lull an
organization ahotld check box X I-
I am an employer that isprovtdhtg workers'ennpewsation Insurance for rip employees. Below is are policy information..
Insurance Company Name: /4 d-SS• JQ EP4(L KO L bQ C k!4 Ail 5_ (f ,C. d LI /VC
Insurer's Address: )b fb 1T/S14•-...A-!iflaAlc AAi 61-VP - -
City/StatelZip: tiii A- Y►1 , ivy i . l/o
Policy#or Self-ins.Lie_# 0!Li O U 5o 'Q I C 61 a Expiration Date: /0 l re
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)_
Failure to secure e coverage as required wader Section 25A of MGI.c. 152 can lead to the imposition of criminal penalties of a
fuze 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 S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ccr1J +, err tepabet end ties of perjary that the information provided above is erne era correct
Signature: • �_ _ pate:. `� 3�C'�
Phone#: to 3- 7 3.7- c,9 IF _.
�-
p,,icial arse only. Do not write In this area,to be completed by city or loon officiaL
City or Town _ Pernait/L.icense# _
Issuing Authority(circle one):
1.Board of Health 2.Bonding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 1
6.Other I
Contact Person: Phone#:
www.maas.gov/din m_