31D-164GIS #:
Lot: -001
Permit: Buildina
Category:
Permit # BP- 2011 -0539
Project # JS- 2011- 000891
Est. Cost: $2000.00
Fee: $25.00
Const. Class:
Use Group:
Lot Size(s4. ft.): 3528.36
Zoning: CB(100)/
BUILDING PERMIT
PERMISSION IS HEREB Y GRANTED TO:
Contractor: License:
GEORGE KOEBER 063492
Owner: UNITARIAN CHURCH
Applicant: GEORGE KOEBER
AT. 220 MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 507 (413) 665 -9576
WHATELYMA01093 ISSUED ON :1211612010 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO CHIMNEY & REPAIR SLATE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace /Chimney:
Insulation:
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 12/16/2010 0:00:00 $25.00
BP- 2011 -0539
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0539
APPLICANT /CONTACT PERSON GEORGE KOEBER
ADDRESS/PHONE P O BOX 507 WHATELY (413) 665 -9576
PROPERTY LOCATION 220 MAIN ST
MAP 31D PARCEL 164 001 ZONE CB(100Z
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: DEMO CHIMNEY & REPAIR SLATE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 063492
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON f �`
INF9RMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR
Major Project: Site Plan AND /OR
ZONING BOARD PERMIT REQUIRED UNDER:
Finding Special Permit
Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Septic Approval Board of Health
Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
JZ /6 to
Signa a 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.
Special Permit With Site Plan
Special Permit With Site Plan
Water Availability Sewer Availability
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
Version 1.7 Commercial Building Permit May 1- 2000
Department 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
010 Northampton, MA 01060 Two Sets of Structural Plans
p one 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 - SITE INFORMATION
1.1 Property Address
o
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
I his Section to De co Dy OTTICe
Map
Zone
Lot Unit
Overlay District
Elm St. District
2.1 Owner of Record
Name (Print)
Signature
2.2 Authorized Agent: >i't � Iii SNo(4 6E Ca tr ftfC TO'R-
F
D 12
Name (Print)
Signature 4��
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item i Estimated Cost (Dollars) to be
CS District
Current Mailing Address:
Current Mailing Ad ess
Telephone 413 .2G'- 7 73 7
Official Use Only
1. Building � (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5) Check Number
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings
Date
Version 1.7 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 ❑ DemolitiQdo�Repai&W Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs Roofing Change of Use ❑ Other ❑
Brief Description }Enter a brief description here.
Of Proposed Work: j
L_ u ;V _ �hL.
SECTION 5 - USE GROUP AND CONSTRUCTION PE
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑
A -1 ❑ A -2 ❑ A -3 ❑
A -4 ❑ A -5 ❑
1A
1B
❑
❑
B Business ❑
2A
2B
2C
I
❑
❑
❑
E Educational ❑
F Factory ❑
F -1 ❑ F -2 ❑
H High Hazard ❑
3A
3B
❑
❑
I Institutional ❑
1 -1 ❑ 1 -2 ❑ 1 -3 ❑
M Mercantile ❑
4
❑
R Residential ❑
R -1 ❑ R -2 ❑ R -3 ❑
5A
5B
❑
❑
S Storage ❑
S -1 ❑ S -2 ❑
U Utility ❑
Specify:
Specify: ,
M Mixed Use ❑
S Special Use F-1
Specify:;
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: ?, Cl _.._.
Existing Hazard Index 780 CMR 34):' .. .... .. . ... ...
Proposed Use Group::..
Proposed Hazard Index 780 CMR 34): _..
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING
Floor Area per Floor (so
1 5i
PROPOSED NEW CONSTRUCTION
OFFICE USE ONLY
St
2nd_..,_..__._.._._.,._._._.__..
..................._ ........ .._ . ... ........... _ v ... . .............. _._ ... _._____. s
2 nd
3 rd
.,. ....._....,._. - .a
3 rd
_.......,.,.
..._..._ ........«_...<
4 m 3
4 " yy
Total Area (so
Total Height (ft)
Total Proposed New Construction (sf) ,_
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54)
Public [] Private ❑
1 Flood Zone Information:
one Outside Flood Zone❑
[ Z7.
7.3 Sewage Disposal System:
Municipal E] On site disposal system E]
' Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 ^. ^M
IF YES: enter Book Page` and /or Document # ._
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW 0 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 �C NO 0
IF YES, describe size, type and location: �X
...._.S_.iyr.._......... _...
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO JK
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
_. __....__._ _,. ..._ .. __... .
... .... ... ...... _ _. _.
__.. _. __.....____._ ,:
Frontage
Setbacks Front
Side
L: .___ - R: —
L: l._ --- J R:
...._i �
I �JJ
Rear
Building Height
Bldg. Square Footage
____. __
,_.._.._.. %
f ___ _ 1
F
Open Space Footage
%
(Lot area minus bldg & paved
p arking)
# of Parking Spaces
Fill:
P
(volume & Location )
�—
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 ^. ^M
IF YES: enter Book Page` and /or Document # ._
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW 0 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 �C NO 0
IF YES, describe size, type and location: �X
...._.S_.iyr.._......... _...
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO JK
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version l.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):
Registratio Number
Address
Signature
r
Telephone
Expiration Date
9.2 Registered Professional Engineer(s):
Name
Area of Responsibility
Address
Registration Number
Signature
Telephone
Expiration Date
____._._....__..._...___...._..
...... ....... ...._.__....._......_
Name
Area of R
Address .
Signature
Telephone
Regstration Number
Expiration Date
Name
Area of Responsibility
Address
Signature
Telephone
Registration Number
Expiration Date
t
_....._ ..... .._._
Name
Area of Responsibility _
_... �_
i
Address
Signature
Telephone I
Registration Number
Expiration Date
9.3 General Contractor
..��,.,. .._.�.,
Not Applicable ❑
Company e:
ed_e�__j
Responsible In,_ ar of Construction
Address
ignature Telephone
4M
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 BUILDING PERMIT
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.,_,
Signatu a
Date
/Authorized
as Owner
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 penury., _
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION. SERVICES
10.1 Licensed Construction Supervisor
Not Applicable ❑
Name of License Holder
U
License Number
Expiratio Date
Address ......
gi f r� 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 a No 0
The Commonwealth of Massachusetts
R Department of Industrial Accidents
Z :�- -r
-- Office of Investigations
600 Washington Street
Boston, MA 02111
1 _ www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
nplicant Information Please Print Le2ibl�
Name ( Business /Organization/Individual): CTCo
Address:
City /Sta
Phone #:
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part- time).*
have hired the sub - contractors
2 I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub - contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.*
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
insurance required.
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
"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 isproviding workers' compensation insurance for my employees. Below is thepolicy 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 thepa ins and penalties of perjury that the information provided above is true and correct.
. , � _. — _ (//` . // r�� +A ! //P r /L/ -- l Q
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Phone #:
Permit/License #
City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector