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21-0403 Smith Bldg Permit Application PacketCity of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL & MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work (Digital & Hard copy). 3. Site Plan with location of proposed structure(s) and setbacks. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker’s Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CSL and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (if applicable). 8. Note any Conservation and/or Special Permit requirements (if applicable). 9. Driveway Permit (if applicable). 10. Proof of Water and Sewer entry fees paid (if applicable). 11. Trench Permit (if applicable). 12. Initial Construction Control Documents filled out and signed by the Registered Design Professional in responsible charge. 13. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton 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 (This Section For Official Use Only) Building Permit Number: ____________ Date Applied: ______________ Building Official: _______________________ SECTION 1: LOCATION _________________________________________________________________ _________________________________________ No. and Street City /Town Zip Code Name of Building (if applicable) ________________ __________________ Assessors Map # Block # and/or Lot # SECTION 2: PROPOSED WORK Edition of MA State Code used _____ If New Construction check here  or check all that apply in the two rows below Existing Building  Repair  Alteration  Addition  Demolition  (Please fill out and submit Appendix 2) Change of Use  Change of Occupancy  Other  Specify:___________________________________________ Are building plans and/or construction documents being supplied as part of this permit application? Yes  No  Is an Independent Structural Engineering Peer Review required? Yes  No  Brief Description of Proposed Work:__________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ SECTION 3: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION, OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34)  Existing Use Group(s): __________________________________________ Proposed Use Group(s):__________________________ SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No. of Floors/Stories (include basement levels) & Area Per Floor (sq. ft.) Total Area (sq. ft.) and Total Height (ft.) SECTION 5: USE GROUP (Check as applicable) A: Assembly A-1  A-2  Nightclub  A-3  A-4  A-5  B: Business  E: Educational  F: Factory F-1  F2  H: High Hazard H-1  H-2  H-3  H-4  H-5  I: Institutional I-1  I-2  I-3  I-4  M: Mercantile  R: Residential R-1 R-2  R-3  R-4  S: Storage S-1  S-2  U: Utility  Special Use  and please describe below: Special Use Description: SECTION 6: CONSTRUCTION TYPE (Check as applicable) IA  IB  IIA  IIB  IIIA  IIIB  IV  VA  VB  SECTION 7: SITE INFORMATION (refer to 780 CMR 105.3 for details on each item) Water Supply: Public  Private  Flood Zone Information: Check if outside Flood Zone  or indentify Zone:__________ Sewage Disposal: Indicate municipal  or on site system  Trench Permit: A trench will not be required  or trench permit is enclosed  Debris Removal: Licensed Disposal Site  or specify:_____________ ______________________ Railroad right-of-way: Not Applicable  or Consent to Build enclosed  Hazards to Air Navigation: Is Structure within airport approach area? Yes  or No  MA Historic Commission Review Process: Is their review completed? Yes  No  SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: __________ Use Group(s): __________ Type of Construction: ________ Does the building contain an Sprinkler System?: _________ Special Stipulations: ___________________________________________ Design Occupant Load per Floor and Assembly space: _________________________________________________________________ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner __________________________ ______________________________ ____________________________________________ ___________ Name (Print) No. and Street City/Town Zip Property Owner Contact Information: _______________________________ _____-_____-___________ ____-_____-___________ _______________________________ Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes: _________________________________ ____________________________________ ___________________ ______ _____________ Name Street Address City/Town State Zip to apply for and act on the property owner’s behalf, in all matters relative to work authorized by this building permit application. SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 1) If a building is less than 35,000 cu. ft. of enclosed space and/or not under Construction Control then check here  . Otherwise provide construction control forms (see section 107 in the code) as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) ______________________________ ____-_____-___________ _________________________ Name (Registrant) Telephone No. e-mail address ______________________________ ______________________________ ______ _________ Street Address City/Town State Zip _____________________ Registration Number _______________ _______________ Discipline Expiration Date 10.2 General Contractor __________________________________________________________________________________________________________________ Company Name _________________________________________ ____________________________________________________________ Name of Person Responsible for Construction License No. and Type if Applicable ______________________________________________ __________________________________ ______ _____________ Street Address City/Town State Zip ____-____-_______________ _____-_____-_____________ ____________________________________________________ Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11: WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) A Workers’ Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes  No  SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost (from Item 6) = $_________________ Building Permit Fee = Total Construction Cost x ____ (Insert here appropriate municipal factor) = $________. Note: Minimum fee = $________ (contact municipality) Enclose check payable to __________________________________ (contact municipality) and write check number here ______________ 1. Building $ 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ 6. Total Cost $ SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. ______________________________________________________ ____________________________ ____ -_____- ________ _________ Please print and sign name Title Telephone No. Date ____________________________________ _______________________ ______ _____________ ____________________________ Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: ____________________________________ _____________ Name Date CITY OF NORTHAMPTON SETBACK PLAN MAP:_______ LOT:________ LOT SIZE:____________ REAR LOT DIMENSION:_____________________________ FRONTAGE_____________________ REAR YARD _____________ SIDE YARD______________ SIDE YARD______________ FRONT SETBACK_______________ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number ________________ is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: ___________________________________________________ The debris will be transported by: Name of Hauler: ______________________________________________________ Signature of Applicant: __________________________________Date: ___________