23B-011The Commonwealth of Massachusetts
p_ Department of Industrial Accidents
Office of Investigations
�Ny 600 Washington Street
w -A Boston, MA 02111
4`N www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organizadon/Individual): 6%14,6-1
Address:
Citv/State/ZiD: Phone #:
Are you an employer? Check the appropriate box:
1. ['Lam a employer with �
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. [1I 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. r-1We are a corporation and its
�. ❑ 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'
coma. insurance reauired.l i
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.❑ Roof repairs
13. ❑ Other
'Any applicant that checks box #1 must also fill out the section below showing thea 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.
;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 is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: ur C L �Dd 3 a y opo r� 3 Expiration Date: `7/// /%0
Job Site Address: ��13 L��—✓ �f City/State/Zip:O/ D 6 v
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: ls'�—�ri� Date:
Phone #: �g c-( 2 GG '
Official 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 #:
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 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _ _....._.. ..... _.: T-. _w...o _ <<. r�✓ ,. _.._ ._ _._ ____�_._.. _ ..� ..__. .__ .... . , as Owner of the subject property
hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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 andDenalties ofe 'u�
Print Name — - -- - --
Signature ol Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Not Applicable ❑
Name of License Holder : ? ��
pa7�3 i
License Number
- - ----
Address
Expiration Date
Signature—� Telephone
SECTION 13 WORKERS' COMPENSATION....INSURANCE AFF.:IDAVIT (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.
Sianed Affidavit Attached Yes No 0
Versionl.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--
Signature
��
Telephone
Expiration Date
9.2 Registered Professional Engineer(s):
Name
Area of Responsibility .__..__-
Address
Registration Number
Signature
Telephone
Expiration Date
NameArea
---Y
of Responsibility
Address
Signature
Telephone
Registration Number
Expiration Date
Name
Area of Responsibility
Address
Signature Telephone
Registration Number
Expiration Date
t
Name
Area of Responsibility
Address ~
Signature Telephone I
Registration Number
Expiration Date
9.3 General Contractor
Not Applicable ❑
.
Company Name:
Responsible In Charge of Construction
Address
Signature i ( Telephone
Version 1 Commercial Rni1dinv Permit Mav 15 ?000
S. NORTHA.MPTON:ZONING::._
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front"
Side
L� R.'?
L:4E R:!_.
Rear
}
A10 64V'v1C—
Building HeightIja-
N19*%,41
AJOG
Bldg. Square Footage
%
%
L.,_ -
Open Space Footage
area minus bldg & paved
RIMY
%(Lot
parking)
# of Parking Spaces
Fill:
i
(volume &Location
...w...,.._�....
._.�._.."...,.,......�
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 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued.
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: 3"4- 3 S u jp��
.._.. ...._ _.._ .......... .....
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 common plan
that will disturb over 1 acre? YES 0 NO (D,,'^
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESSTHAN35,000
CUBIC FEET OF ENCLOSED SPACE / 9
Interior Alterations [Existing Wall Signs ❑ Demolition ❑ Repairs 0? 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: 1 dP%►S g`
Y 7`6 f�i�1i. r Snf✓. sv2 P
SECTIONS -USE GROUP AND CONSTRUCTION TYPE"''
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A AssemblyE3A-1
E3A-2
A-4 ❑ A-5
11A-3
❑
❑
1A
1B
E3
❑
B Business
2A
2B
2C
❑
❑
❑
E Educational ❑
F Factory ❑
F-1 ❑ F-2 ❑
H High Hazard
❑
3A
3B
❑
❑
1 Institutional ❑
1-1 ❑ 1-2 ❑ 1-3 ❑
M Mercantile
❑
4
❑
R Residential
❑
R-1 ❑ R-2
❑
R-3 ❑
5A
56
❑
S Storage ❑
S-1 ❑ S-2 ❑
U Utility
❑
Specify:
Specify:
M Mixed Use ❑
S Special Use
❑
Specify:
COMPLETE THIS SECTION: IF EXISTING BUILDING UND
Existing Use Group: .S `N
Existing Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
Proposed Use Group: f5'
Proposed Hazard Index 780 CMR
BUILDING AREA EXISTING I PROPOSED NEW CONSTRUCTION
Floor Area per Floor (sf)
4
to ,
1 st
2nd......_..__.___._.._._...,__._._.._..�_.�..._.'_'-_-.~..~,3
3rd
Total Area (sf) Total Proposed New _Construction sf)
Total Height (ft)
r
Total Height ft
i AND/OR CHANGE IN`.USE
7. Water Supply (M.G.L. c. 40, § 54) 17.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public �/ Private ❑ Zone Outside Flood Zone Municipal 22-o" On site disposal system❑
Versionl.7 Commercial Buildine Permit Mav 15. 2000
1.1 Property Address:
This section to be completed by office
�9 Cv5r J
Map Lot Unit
`
Zone Overlay District
i
--- - -
Eim;St District' CB. District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print)
Current Mailing Address:
r....�...-.
Signature
Telephone
2.2 Authorized AgAnt:
Name (Print)
Current Maili Address:
Signature
Telephone
SECTION 3 -'ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use pnly
completed by permit applicant
1. Building
(a) Building Permit Fee
«j
2. Electrical
/ —
(b) Estimated Total Cost of
Construction from 6
3. Plumbing
/ dv --
i
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+5)
(o �ldd"—
Check Number&1 goli
This Section For Official Use: Only
Building Permit Number
Date
Issued
Signature:
Date
Building Commissioner/Inspector of 136ildings
The Commonwealth oflassachusetts
Deparrrtent of Industrial Accidents
Office oflnvestig ations
600 Washington Street
Boston, AL4 u2111
✓/
www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Dolicant Information Please Print Le4ibh
dame(P•usiness/Organization/Inaividual): �/VIq�7P.� OJ4', �.�>t �
Address: J / 14 5,—
City/State/Zip: Phone.T: d, `t/ 2—, 6 G
Are you an employer? Check the appropriate box:
1. [�Kam a employer with �J
4. ❑ 1 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
shm n i have „o emplo; ees
These sub -contractors have
working for me in any capacity.
employees and have worxers'
[No workers' comm. insurance
comp. insurance.*
required.]
5_ F_� We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself [No workers' coma.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. (Ivo workers'
insurance
Type of project (required): i
6. ❑ New construction
7. ❑ Remodeling
S. Demolition
9. Building addition
10.0 Electrical repairs or additions
I LEI Plumbing repairs or additions
12.0 Roof repairs
13.7 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' cornnensation policy information.
t Homeowners who submit this affidavit indicating they are doing aD work and then hue outside contractors trust submit a new affidavit indicating such.
Cont -actors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employe -.s. If the sub -contractors have employees, they mast provide their'workm' ramp. policy number.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insu=ce Company Name:
Policy # or Sells ins. Lic. 1,4C 5 00 3 " L(d /,A c: a 3 Expiration Date:
Job Site Address: I / .3 L a`- ✓iT S T City/State/Zip: /V tlzyy�%z
Attach a copy of the workers' compensation policy declaration page (showing the poficv 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 imprsonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
Ido hereby certify�render�the aims and penalties ofperjury that the information provided above is true and correct
Signat ire: ��" l✓� Date:
Phone T:
Official use only. Do not write tit this area, to be completed by city or town offic iaL
City or Town: PermitlLicense T
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical,Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Versionl.7 Commercial Building Permit Mav 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes
No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
�-
"to
hereby authorize
act on my beh f,in all matters relative to work thorized by this building permit application.
Signature of wner
Date
VMA
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 Nam
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Not Applicable ❑
`�
Name of License Holder: V / .-( �'
License Number
Address
Expiration Date
Signature Telephone
SECTION 13 -WORKERS' COMPENSATIONINSURANCE 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
Versionl.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:
Expiration Date
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Signature Telephone
Expiration Date
9.2 Registered Professional Engineer(s):
Area of Responsibility
Name
Name
Area of Responsibility
Address
Registration Number
Signature Telephone
Expiration Date
Name
Address
Signature
Telephone
Expiration Date
Area of Responsibility
Name
Registration Number
Address
Telephone
Expiration Date
Signature
Area of Responsibility
Name
Registration Number
Address
Telephone
Expiration Date
Signature
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
� Non 1, 5 ' i/may,. � � � k"
Address
Sionature Telephone
U
Version l_7 Commercin] Riiildinv Permit Mav 15 '1000
S. NORTHAMPTON ZONING
Existing
Proposed
Required by Zoning
This column to be filled in by
Building Department
Lot Size
l s �-
G'✓9N C
Frontage
Setbacks Front
•7 3
Side
L:V. R:
L: R:
Rear
tiL
v c
Building Height
`
Ivc. c 4w v. c
Bldg. Square Footage
--70`13
%
Open Space Footage
(Lot area minus bldg & paved
o y7Gf
%
_3
OV U
C SC
parking)
# of Parking Spaces
Fill:
(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 (D,— YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: j X S' L./o J ltrz "tl
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 common plan
that will disturb over 1 acre? YES 0 NO Q—
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 3? Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing El Change of Use ❑ Other ❑
Brief Description Enter a brief description here. (3 4)' ' a it FNt
Of Proposed Work: q X,1
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑
A-1 ❑ A-2 ❑ A-3 ❑
1A
❑
A-4 ❑ A-5 ❑
.1B
❑
B Business
2A
❑
E Educational ❑
2B
I ❑
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-1 ❑ R-2 ❑ R-3 ❑
5A
5B
❑
S Storage ❑
S-1 ❑ S-2 ❑
U Utility ❑
Specify`
Specify:
M Mixed Use ❑
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)
"'7 / �
1 ` / 0 vl -3.
15f
2nd
nd
2�
3`d
3rd _ ..
4e,
`7 ..
Total Area (sf) p y
Total Prnpnsecl NPw Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L, c. 40, § 54)
I
7.1 Flood Zone Information:
7.3 Sewage Disposal System:
Public Private ❑
Zone Outside Flood Zone
Municipal Z2/On site disposal system[-]
Versionl.7 Commercial Building Permit Mav 15, 2000
SECTION 1 - SITE INFORMATION
Department use only
/�. City of Northampton
This section to be completed by office
Status of Permit:
„ ( Building Department
Curb Cut/DrivewayPermit -
�- 212 Main Street
Elm St. District CB District
Sewer/SepticAvailabiliity
ToRoom 100
2.1 Owner of Record:
Water/Well Availability'
Northampton, MA 01060
Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272
Name (Print)
Plot/SitePlans
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 PropertvAddress:
This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print)
Current Mailing Address:
Signature Z�Z'
Telephone
2.2 Autho 'zed Agent:
Name (Print)
Current Mailing Address:
cl'? F7-3-4666ct//
_G
Signature
Telephone
SECTION 3 - ESTIMATEDCONSTRUCTION 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. Firu Protection
6. Total= (1 +2+3 +4+5)
j rJcu
Check Number G I
sL!
This Section For Official Use Only
Building Permit Number
Date
_
Issued
Signature:
Date
Building Commissioner/Inspector of Buildings
File t3P-2010-0702
AI111L,(A;1 I �,uNTACT PERSON ROY OMASTA
ADn[yFSS,'PlJO E 21 North St HATFIELD (413) 247-5666
PROPERTY LOCATION 193 LOCUST ST
MAP 'ZB PARCEI- 011 001 ZONE SI(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZO`,t'NJ FOR:) FILLED OUT
Fee Pail
Buil(liug Permit_ I illed out
Fee Paid _
ronf.tn.ic_1ion: CONVERT BILLING OFFICE INTO 4 EXAM ROOMS/BATHROOM & ADD 3 X 15
BU\IPUUI 't o EXISTING STRUCTURE
New ( construction
Non Structural interior renovations
Addition to Existing
_ r'wces�oi y Structure
Buildim-, Plans Included:
Owneri ,Statement or License 006763
3 sets of Plans / Plot Plan
THE FOLLOWING AC NHAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION ENTED:
-- Approv ed _�J Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
t nterme:diate 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
Septic Approval Board of Health
Water Availability
Sewer Availability
Well Water Potability Board of Health
cG
/,f or-- —r— xis
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Sign,.Lue ol' i;uiiding Official Date
5s cAGr Z /9-, C-
Not,: 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.
* Va; ianees ar, -,ranted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Plarr:u� & I )!"% lopment for more information.
File # BP -2010-0702
APPLICANT/CONTACT PERSON ROY OMASTA
ADDRESS/PHONE 21 North St HATFIELD (413) 247-5666
PROPERTY LOCATION 193 LOCUST ST
MAP 23B PARCEL 011 001 ZONE SI(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
Typeof Construction: CONVERT BILLING OFFICE INTO 4 EXAM ROOMS/BATHROOM'
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
Septic Approval Board of Health
Water Availability Sewer Availability
Permit from Conservation Commission
Well Water Potability Board of Health
Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
y' i' 0
Signature of Building Official Date
Note: Issuance 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.
193 LOCUST ST BP -2010-0702
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map�Block: 23B - 011 CITY OF NORTHAMPTON
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 -2010-0702
Protect # JS -2010-001044
Est. Cost: $68000.00
Fee: $408.00
Const. Class:
Use Group:
Lot Size(sa. ft.): 39465.36
Zoning: Sl(10I
PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
ROY OMASTA 006763
Owner. 193 LOCUST ST ASSOCIATES LLP
Applicant: ROY OMASTA
AT. 193 LOCUST ST
Applicant Address: Phone: Insurance:
21 North St (413) 247-5666 Workers Compensation
HATFIELDMA01038 ISSUED ON:2/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK. -CONVERT BILLING OFFICE INTO 4 EXAM
ROOMS/BATHROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Meter:
.//�� '� ,"fz✓ House#
Rough: --w !!Y -F �� ''� Rough:
F��po'ae, Driveway Final:
Final:- �(7�� inal:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Building Inspector
Footings:
Foundation:
1
Rough Frame: 0 i � i 0i' / ` � to u' S
Fireplace/Chimney:
Insulation: O � 3
Final: p K 5 ISPO
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy
SS , " Si nature:
FeeType: . Date Paid: Amount:
Building 2/23/2010 0:00:00 $408.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Building Commissioner - Anthony Patillo