32C-017 (23) s e n
BP-2005-0254
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -I$ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0254
Project# JS-2005-0318
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY GUIEL 029501
Lot Size(sq. ft.): 4094.64 Owner: TRIDENT REALTY CORP
Zoning: CB Applicant: JEFFREY GUIEL
AT: 78 MAIN ST
Applicant Address: Phone: Insurance:
187 POWELL RD (413) 634-0182
CUMMINGTONMA01026 ISSUED ON:9/1/04 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE EXISTING FLR, SHEETROCK & NEW
COUNTERS
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 9/1/04 0:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2005-0254
APPLICANT/CONTACT PERSON JEFFREY GUIEL
ADDRESS/PHONE 187 POWELL RD CUMMINGTON (413)634-0182
PROPERTY LOCATION 78 MAIN ST
MAP 32C PARCEL 017 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out l'V C,
Fee Paid �/
Typeof Construction: REPLACE EXISTING FLR, SHEETROCK&NEW COUNTERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 029501
3 sets of Plans/Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 'on
lyi46.4 dUD
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.
S
. . Versionl.7 Commercial Building Permit May 15, 2000
Depai indrit use only
City of Northampton Status of.Permit:
Building Department Curb Cut/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 C, : k - ' • e •,'.4NI Y OF, OR DEMOLISH ANY BUILDING
OTHER THAN ' Qt E¶1 /C� Att1I�' e �E N
IG
vH_____._-f-SECTION 1-SITE INFORMATION U�
AUG 3\ O2OO4
i i _.__•_ _-This section to be completed by office
1.1 Property Address: i OFM r , , ';. ,.''~f n; ,
7 S A,)0 <"I p:p ap — .-Lot Unit
w
ct rnkrz.,< L It , S fir, saw \ iZone Overlay District
"Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner o/f Record: �-7
1 i i-itlycle/L. _AA- of c'Lt/
Na (Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
R, )7c ?el/ 4,6i_dce., -j U( Gyl
Name(Print) Current Mailing Address:
- 14r3 -Sc1 -<mb
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building v z., , (a) Building Permit Fee
2. Electrical ( c7 c) v (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) C , 0C Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
f-
Versionl.7 Commercial Building Permit May 15,2000 . .
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions 0 Roofing 0
❑ 0
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ LL Accessory Building [ ] Repairs [ ]
BRIEF DESCRIPTION: R�,vL►� f -1 OC" r AJ J 5 c4 .t ('/�
,ii.,„4-, Ne.0 Cv,..* S
p
SECTION 5-USE GROUP AND CONSTRUCTION TYPE ,
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 0 A-1 0 A-2 ❑ A-3 0 1A 0
A-4 0 A-5 0 1B ❑
B Business 'E] 2A 0
E Educational Cl 2B ❑
F Factory ❑ F-1 ❑ F-2 0 2C ❑
H High Hazard 0 3A 0
I Institutional 0 I-1 0 I-2 0 I-3 0 3B 0
M Mercantile ❑ 4 0
R Residential Cl R-1 0 R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 0 5B Cl
U Utility 0 Specify:
M Mixed Use 0 Specify:
S Special Use 0 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 EXIS I ING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf) 1st
)-‹ Ai 2nd/
�st V _
•
2nd 3rd
3rd —
tr 4m
4
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft
•
Version1.7 Commercial Building Permit May 15,2000
7.Water Supply(M.G.L. c.40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system 0
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume Sr Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO • DONT KNOW
YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No J
IF YES, describe size, type and location: C' � 7� .(S�`/i2 5
•
Version 1.7 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 ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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 Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
` I
JL �1r a � i ran Not Applicable 0
Company Name:
Responsible In Charg of Construction
(Z `Ic ic-d
4ddress
Signet Telephone
i r
' Version1.7 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....,€a
SECTION 11 - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
•
I, � RiL g /- ri £ A i co` as Owner of the subject property
y
hereby authorize GU'Gil., I to act on
my behalf, in all matte relative to work authorized by this building permit ap licati n.
Signature of Owner Date
I, ,C. Stikistek
, 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.
�'�IC/G Svt.4�4—.
Print Name Signature of Owner/Agent 4110
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : -'S-e-/' r..1(/ f`1 Cr, (> f .: ( C7 `) S2
License Number
rE6' 7 y0 (.'r,ii j�ed C/PN A i., _5' ti `it 7 ,__ Is_- ,
Address Expiration Date
.� ) '-'•'-� 639 6 Iit.
Si a ,p / 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
r a
•
R-(tv.J-f pi,
..O •c.3ic,Oy
14.41 �� � '`e (riff of Northampton 1
92�Y/�;�-�� E ,atasanrhnt:r((a' —
— DEPARTMENT OP ➢uiwrJG INSPECTIONS ♦'
212 Main Street ' Municipal Building,
Northampton, Mass. 01060 r''
WORICER'S COivf'ENS ATION DiSURANCE AFa))AVIT
(lic c scr1permitttx)
with a principal place of business/residence at:
Ice) ®cc.'-e-11 iCI ccivii0" 4) oq r'i 1? (phone:-) (139c1 )-
(sa .t/a ty/stalely p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees worl6ng on'this job:
(Lasurnm Comczcv) (Policy Nuabcr) (Ex-piration Date)
('y' I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the conn-actors listed below who hzve the following worker's coopenc2aon policies:
(Name of Co t: cto-) (Insurance CornoanyfPoiic; Num cr) (Exptrdeon Dalc)
(Name of Conractor) (Ir1_stuanec Company/Policy Number) (li -piration Date) •
(Name of Contractor) (Insu anc: CA Milany/Potic-y Number) (Expiration Date)
•
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) .
(atucb :ice-II tzScct ifcooc-zap•to c,cu&iafortoaaoa pctaiaias to all coact-sr—on)
-
On I am a sole proprietor and have no one working for me. .
( ) I am.a home owner performing all the work myself.
NOTE:plesc be awyre the.u-1Je bomeowocn wbo asploy pczoos to do ;,i.-,gym =�,:e.loo c rc�aa wort on a d..c1LZ of
art mat the o t'.sx tags io w$ich the bocnoowocr rido or oo tho arutnAl zppautcv:r1 tbedo c.-c co(cc -ally oecrid-rcd In be
employe- unto the vomte m -,-tion Act(GL152sI(5)),application by a bomooavc fox:lir,civ:a{u:uit rn:y cvirlca«(bc
lc-gal rta7tc of as esploy -under tho Wo,icor'a Cocapomaiion Act
I uoderstao4 that a copy of thin mlecoom may bo forwarded to tbo peoartmeoct of I,"t+,sriJ Acndaots'Orroo of It ,r-a000 for th-
oove,tgc vairestioo and ay.,.L•ilta•c to icatrt'covcrab-e tmdcs socziai 75A of MOL 157 c`<n led to the I.-`,+,Oioa of aimicul pm-116,z
oomisiag of a am of up to 51,500.00.flats iscprisoccaoccrt of up to coo ycor Lod civil pr+•ltto to do form or.Stop Wort Ordct nod a
flea of 5100.00 a thy t£aius me
," 1 For da' uae only ,
Pcrm1l Nl1rI1
./ Map:: Lot K a
Si i m•
cc Date J