32C-067 (5) File#BP-2004-0031
APPLICANT/CONTACT PERSON HAYES DALTON
ADDRESS/PHONE 129 SOUTH ST (413)296-4031 Q
PROPERTY LOCATION 64 MAPLEWOOD SHOPS-COOKING SCHOOL -2 CONZ ST
MAP 32C PARCEL 067 001 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � 55-
Fee Paid y�
Typeof Construction: REMOVE NON-BEARING INTERIOR PARTITIONS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement-or License 074570
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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 t Commission 11M
Signatu of Building Offic4*7ial Date
44.4 °1-
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.
Versionl.7 Commercial Building Permit May 15,2000
Department use only
Citof Narlthampton Status of Permit:
E c 1 flUiifPartme n t Curb Cut/Driveway Permit -
Street Sewer/Septic Availability
i �100 Water/Well Availability
IQel am ; MA 01060 Two Sets of Structural Plans
; phone 413.587- 240 Fax 413-587-1272 Plot/Site Plans
4 �'��r - OtherSpecify
APPLICATION "N91126 ALR, OVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
t OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Llok.r-J'il 5t1Opc —0.2 (a/it 5' . Map Lot & ? Unit
Zone Overlay District
-4e,47-741,e,0-7)-6 a ela-
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner o Re ord:
/c,'�ntiir /gjf p 6 i4 , Al 01033
Name(Print Current Mailing Address:
f r/3 • �,,z9- ,2-uY,�
Sign re Telephone
2.2 thorized Agent: --d`1cva
r 4)9' 5'
0,4 sK arP5-(t- 6 e a Piet
Name Current Mailing Address:
G. -- yz/3-�?�7g - q03/
Sign re 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
2 Electrical (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) - Check Number /06 4 3,
// This Section For Official Use Only
Building Permit Number: /MOI ----3j Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Version1.7 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 ❑ Roofing El
Exterior Alterations DemolitionV New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building [ ] Repairs [ ]
See -rr % ( . 0v-e 1/1 eea )IN er)or P�.r )4)Q 1S .
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly I Al- ❑ A-2 0 A-3 ❑ 1A I 0
A-4 ❑ A-5 0 1B I 0
B Business lif 2A ❑
E Educational tifl 2B I ❑
F Factory ❑ F-1 0 F-2 ❑ 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 0 1.2 0 1-3 0 3B 0
M Mercantile 0 4 0
R Residential ❑ R-1 ❑ R-2 ❑ R-3 Cl 5A 0
S Storage ❑ S-1 El S-2 ❑ 5B 0
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)
lit
1st 2nd
3rd
2nd ari'
.
3rd
4tn
Fd . $
�Y
4th g, r- ��
Total Area (sf) Total Proposed New Construction (sf) ,,.- t
:,:',',''''' ' ' ''
Total Height (ft)
Total Height ft
Versionl.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 El Private 0 Zone: Outside Flood Zone ❑ Municipal 0 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&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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
IF YES, describe size, type and location:
•
Version1.7 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
ii2 / ✓1 Not Applicable ❑
Company Kme:
Responsible4Charge of Construction /
Address
Signat Telephone
Version 1.7 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 ❑
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, GGC I C 4C- j t , as Owner of the subject property
herebyauthorize G �� eae) to on
� � � � act
my behalf, in all matters rel tive to work authorized by this building permit application.
Signature of Owner Date
I, 4 , as Owner/Authorized Agent
hereb de are t at 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 0
Name of License Holder : J.��. y,01-' /9 /4
License Number
1=X7 c14. � �1� �io�� 41 ;5��4�
Address Expir ion Date
'/3 a,6 (It&3/
Sign u 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 QJ No ❑
. •
04•tttA1•IP�O
*� s, Giti Iaf x fI amptori 1 _
g giv4, le'l f assarlinsrthi -AIL—
"
n, DEPARTMENT OP BUILDING INSPECTIONS I IEl i=
212 Main Street • Municipal Building
Northampton, Mass. 01060 ew''s
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
/G /6
anser/permittee)
with a principal place of business/residence at:
•
.s61A-A . «t°3&6 eM1i 1,4eu. t'7 IC (phoneg)4/3 del(-O3
(street/city/stale/rip)
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 working on this job:
(Insurance Company) (Policy Number) • (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed ifneceauy to include information pertaining to all oc tractors)
lVl I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE:please be aware that while hoc owncra who employ persona to do troint.n.xw,corm ruction or repair work on a dwelling of
not more than throe units in which the homeowner resides or oa the grounds appurtenant thereto arc not generally considered to be
a.. employers under the worker's compensation As (GL152,ss1(5)),application by a homeowner for a license or permit may evidence the
legal datms of an employer under the Worker's Compensation Ad
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents'Offroo of Insurance for the
coverage vaificatioo and that failure to seatre coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
oomistiag of a fine of up to S 1,500.00 anycr imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against toe.
For dcpsrtmrstai sac orgy
Permit Number
� 7/.73 Map4 Lot#
Sitaui t fLicenser/Pc