44-035 x
'. )VEFIELD ST BP- 2010 -0460
: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 44 - 035 CITY OF NORTHAM
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- 2010 -0460
Project # JS- 2010 - 000632
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD LABOMBARD 055340
Lot Size(sq. 111 36416.16 Owner: RAYMOND JACQUES L & DONNA B C/O RAYMOND REALTY TRUST
Zoning_GI Applicant: RICHARD LABOMBARD
AT: 1 LOVEFIELD ST
Applicant Address: Phone: - Insurance:
119 Park St (413) 527 -7427
EASTHAMPTON MA01 027 ISSUED ON :1111212009 0:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE 10 X 6 DECK, STAIRS & SLIDER FOR
2ND FLR EGRESS
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: .
'nugh: 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 VIOLAT -LON OF
ANY OF ITS RULES AND REGULATIONS. °' y
Certificate of Occupancy Signature:
FeeT_ype: Date Paid: Amount:
Building 11/12/20090:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0460
APPLICANT; /CONTACT PERSON RICHARD LABOMBARD
ADDRESS; PHONE 119 Park St EASTHAMPTON (413) 527 -7427
PROPERTY LOCATION 1 LOVEFIELD ST
MAP 44 PARCEL 035 001 ZONE GI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeo Construction: REPLACE 10 X 6 DECK STAIRS & SLIDER FOR 2ND FLR EGRESS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Build Plans Included:
Owner! Statement or License 055340
3 sets of Plans / Plot Plan
THE FOLLOWING 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 Commission Permit DPW Storm Water Management
Demolit Delay i
26c
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.
�1MMA ANT MESSAE's
FOR
A.M.
DATE TIME 40 P.M.
M
OF
PHONE
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU if WILL CALL AGAIN - -
�WANTS TO SEE YOU l RUSH �
RETURNED YOUR CALL ! l SPECIAL 1kTTENTION
MESSAGE
t
SIGN
FORM 30025
MADE IN U.S.A.
Version 1.7 Commercial Building Permit May 15, 2000
'= Department use a�ly
,
s
City of Northampton Status af'I?ermtt r
N°
Building Department Curb Cut/Dr�siewayPermtt
212 Main Street Sdw"' i r'. epic varia6 y
Room 100 'WaterN I Avatlabil'
_Northampton, MA 01060 Two bets of atructuraC Pfarts;
j $hone 413 -587 -1240 Fax 413 - 587 -1272 i?lot�sate Mans
y
APPLICATION.TOCC)NSTRU , EPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address
This section to be completed by office
1Map Lot Unit
7 4f 1 V A,'� ,t/I Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) �" � .�
r^ �Aev$� /�-) Current Mailing Address
Signaturo Telephone
2.2 A hor' A ent:
Name (Print) Current Mailing Address,
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building /_ D d d a (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
This Sectlon ForOfficial Use Orel
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 ❑ Demolition El Repairs El Additions El Accessory Building El
Exterior Alteration L Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description h ee� re. /� /P
Of Proposed Work: r,�./V0Ic
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly El A -1 El A-2 ❑ A -3 El 1A
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R ❑ R-2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
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
OFFICE USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor (so
_ 1 st
1 st
_. ,.._
... ... .. ... , ., 2 nd
2"q : _ ...... .. . ....... __..._....__
3 ro
3rd_,__._ _.. _........,
_ .... .......... _. 4 m
4 m
Total Area (so Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft_ .
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone F1 Municipal ❑ On site disposal system
Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _. _ . .... . ..._.. ...
Frontage
Setbacks Front
_..,,.. __....: r
Side L .._.__. _.. R: _,_ L ..M_...' R>
Rear
Building Height
Bldg. Square Footage %
Open Space Footage __. %
(Lot area minus bldg &paved
p arking)
# of Parking Spaces
Fill:
(volume & Location) _ ._ _., .. ., „.. . . .......
__.,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was t permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book Page; and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW C) 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a cornMon 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 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
9.2 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
Not Applicable ❑
Company Name: J 1 ��
�".____..___._.
Res In � r Constructi
P
Addre
Signature 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 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, !(AU? ��� /4 4 �� A O / ..,/ ��/tcs�:af.4� -- ?!?#4 � ti�S� `a's Owner of the subject property
hereby authoriz �. _ _ ._. - Ito
my behalf, in all matte elative to work authorized by this building permit application.
V ignafllffe Ol Date
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.,
Print N
Signature of Owner/AgOd Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Lice nsed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Add; e Expiration Date
Signature Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L. c. 152, § 25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial -of theassuance of the - building- permit _ - ---- _ - - - -- -- -_-------------.____----
Signed Affidavit Attached Yes No 0
The Commonwealth of Massachusetts
Department of Industrial Accidents
; _ � - Office of Investigations
Wit- 600 Washin Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers
Applicant Information , Please Print Leaibiv
Name ( Business /Organization/Individual): �« Z *, , ;J ,_ d" ,11. 4 _
Address: zeoL C4wl
City /State /Zip: Phone #: 5 d l l? �Z7
Are you an employer? Check the appropriate bog: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
ployees (full and/or part-time).* have hired the sub - contractors 6. E] New construction
2. F I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp. insurance comp. insurance.T
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. o workers com . right of exemption � ' per MGL P 12. ❑Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
aContractors 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
Investi-ations_of the DLA _for insurance coverage _verification.
I do hereby eerti r the sins and penalties of p jury that the information provided abov is true and correct.
Signature: Datc. , Q
Phone #:
Of 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 #:
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