18D-040 REINSTALL
MODIFY 3 BAY
BEVERAGE SINK -\ c„,.......
AREA
II
WALK-IN u n WALK-IN & COOLER LI
FREEZER DUNKIN DONUTS
BEER & WINE STORAGE
I SODA I II
DUMON DONUTS STORAGE
WALK-IN
COOLER
PRIDE STORAGE
SALES COUNTER
. TO BE RELOCATED
'
MEN WOMEN
I INSTALL NEW RELOCATE
DELI CASE - INSTALL MANAGERS
DELI OFFICE
SALES
AREA
DR.BY: INGRAM
FLOOR PLAN ALTERATIONS DATE D BY: OL p ride
CHECKED 1 8 011
375 KING STREET SCALE NONE
REVISIONS: 246 COTTAGE STREET
NORTHAMPTON, MA 01060 SPRINGFIELD. MA 01104
TEL (413) 737 -6992
FAX (413) 731 -5852
• The Comtrmonwealth of Massachusetts
Department of Industrial Accidents
I `) wool = l Office of Investigations
_ ; = 600 Washington Street
. ` Boston, MA 02111
„ 0 www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): PErJ :
Address: ' _ o co' ,.-r: -
City /State/Zip:3 P/2) Nvt%/er ,, /11 il- Oft c Phone. #: ill 3 � ?- 4,
Are you an employer? Check the appropriate box: Type of project (required):
I . ►' am a er w
employer 4. ❑ I am a general contractor and I
p y 6. ❑ New construction
employees (full and /or part- time).* have hired the sub - contractors
2. ❑ 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 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. - right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
.insurance Company Name: -RVTOM UTi UC. l N .D v ” C C 6\c'sr,
Policy # or Self -ins. Lic. #: W L U b °I O Co ..- — C>'i Expiration Date: I - 1.. i1/4(
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: g Date: 7 — //
Phone #: 4t J , 7 . (0 a c
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):
I. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Version1.7 Commercial Building Permit May 15, 2000
• „: •
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11. CO MPLETED
OWNERS AOENT OR CONTRACTOR APPLIES FOR BUI PERMIT
as Owner of the subject property
hereby authorize 1/ 4-ALL_ Lk(' 1 e
act on my behalf, in all ma era relative to work authorized by this building permit application.
-4' 1
• signaure a 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 andyanelties of peauff,
. -
Print Name
'
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION:SERVICES
, .
10.1 Licensed Construction SuoervIsor: Not Applicable 1:1
—..----- .„.
< • - - (. 580)1
Nf License Holder : Aft Ag .
License Number
I 1.9 r 10 1
Address xpiratiori Date
' -73. 7 a■J
Signature 7 Q / Telephone
• .412:1 ..-10 '737 Li91z_
SECTIONIVNORKERW:POMPEISISATAC!Ni
Workers Compensation Insurance affidavit must be completed and submitted with this applicetion. Failure to provide this affidavit will result
in the,denial of the issuance of the bulletin milt_
Signed Affidavit Attached Yes No 0
SOO III ZLZTLI3SCIP XVd 9U:OT 800Z/ZZ/ZT
Version1.7 Commercial Building Permit May I5, 2000
SECTION •9- P O E8SIONAL :DESIGN AND CONSTRUCTIbN:SERVICES - FOR. BUILDINGS AND 8Tf WCTURES SUBJECT TO
• CONSTRUETION CONTROL' RURSUA; NT •TO790:.CMR MORE °T or E.b0 'El4afAED SPA''CC)
9.i Registered Architect:
Not Applicable It
-
Name (Registrant):
I 1 Registration Number
._. ... _..... _.. __......---- - --' .,-- .,....,...�.,�....,...,.. r � —.— __- M.w......_,__...._- _.......
Address _..»»,...,,., — .._. .__.......... ...,......... -...,
r"»"".._ ��_— , Expiration Date
i- i
Signature Telephone
9.2 Registered Professional Engineer(s): r »»_ ».
. Name Area of Responsibility
L
Address Registration Number
Signature Telephone Expiration Data
..,.,....-.... ..... ... »..... .
...,,.....�.....,_ ..- ......». �. -...� - -. - - - -- ,,,-I ��....—_ _, . �, .» » _�...
Name — Area of Responsibility
1 •
Address T _ Registration Number
Signature Telephone Expiration pate
. , ..,,., .,—.-M .,,.»..,,....,..._....w.w. —.. -.
Name Area of Responsibility
i
Address Registration Number
f t
Signature Telephone Expiration (Date
, ,,., �........._.._ .._.,..�_.... .y.....� �. '_
,- ,. . —.. M, , W_ , ! _... ,.
i
Name — Area of Responsibility
.. ..... , �» ,» »..,,_... _....,.......,
1
Address Registration Number !
Signature Telephone Expiration Data
9.3 General Contractor' »
__ Not Applicable
Company Name:
. Responsible In Charge of Construction _ J j
Address --
i
Signature — —
Telephone
_ 17 0011 ZLZTL89017 XYd 99 :OT 8002 /ZZ /ZT
Version1.7 Commercial Building Permit May 15, 2000
. S.:NORTHAMPTON ZONNO.
•
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size F------ 1
_
Frontage L__.
Setbacks Front
Side L:r R:= L__
Rear LJ .TT
Building Height 1 — 1
Bldg. Square Footage %
---4
Open Space Footage
(Lot area minus bldg & paved 77 1 1 --
arkitt
# of Parking
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued: — I
IF YES: Was the 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 er DON'T KNOW 0 Y ES 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 Gr. N° 0
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 common plan
that will disturb over 1 acre? YES 0 NO G
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
C 0 0 [21 %ULM rid 9S:OT 900Z/N/N
. ,
Veraion1.7 Commercial Building Permit May 15, 2000
SECTION gi- DONSTRUCTIONSERV1.4ii0iPROJECTSLESS:THAN351000:
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs 1:1 Demolition ret:pairs El Additions 0 Accessory Building CI
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing El Change of Use 0 Other 0
Brief Description lEnter a brief description here. i 14 c' ' - ' --2D ' ... " C Ac" 67. -1) 674 g ela ‘ cci 4 (2:41
Of Proposed Work: I
g2t,k ..CITP,
SECTION 6 USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable CONSTRUCTION TYPE
A Assembly
El A-1 0 A-2 0 A-3 0 IA 0
A-4 0 A-5 0 1E3 El
B usiness 12r 2A 1:
E Educational 0 . 2B 0
. .
F Factory CI F 0 P 0 2C 0
H Hi! h Hazard 0 • 3A 0
i Institutional 0 I 0 1 0 1-3 0 aa a
M Mercantile We 4 0
R Residential 0 R-1 0 R 0 R 0 5A 0
S Storage El s-1 El 54 El 5B 0
U Utility Li Specify: I '
M Mixed Use Eil Specify:
- --"-
S Special Use 0 Specify: I _ _
COMPLETE THIS SECTION iF,ExisfiN&Oiirsi4000#004.6iaNtAtc*:41) OifIcitislOOrittik:OiliNNuE:ausE
Existing Use Group: LY...1C?eA 1■ IL 6 1 Proposed Use
.... —
Existing Hazard Index 780 CMR 34):1:— I Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT 'AN G AREA
, :•“ : ... ppRICF US E oNLy
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION ' ' ' - — • .
„ • .. .
Floor Area per Floor (sf) :;; .. ' .
/ lit l
2 ? , 2 no 7 ----
; - - ---.
..
rd r v
3rd F i 3 1 _
---1 4tli L 1
4 1 ."------ ___i ---i
Total Area (sf) 1 i Total Proposed New Construction (sfl_ • -•
_I
Total Height (ft) : , . . •
.
r
Total Height ft I 1.
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flop_d Zona _I —
nformation: 73 Sewage Dposal System:
Public re Private 0 Zone L Outside Flood Zone0 Municipal 110'" On site disposal system0
ZOO la ZLZIL92C XVJ 9g :OT 900Z/ZZ/ZT
k
\
— ' RECE
1
, ra,011 6)1131
1 N 6
JUL Z 2011
Version1.7 Commercial Buildin: Permit Ma 15, 2000
7,.• • oli ii• 'r : - • -
, - . tn. -...! .1t5t D...-pis; i gRON#4,51ippgplii,44
,
City of Northampton Ili •-'"At i v i iiii t ori , , , ,
‘ii.z.t.tRifigyaw.leviglithof,t4e-ogst=4640t*
Building Department A
, . , .-- f 4 , ,,, ny - L A L=4 - 21 , , , m..Fts.z.,a.-04, , ,.,,,• 1 4 1 .
.w. • . h
ft .. wvist ,!: rPY.1,11.',,,,r.'rir.o,mq.!..;Arr,,,-.- .1,-,V41.1„04,401i,
212 Main Street ..t. •tti v..ifxz
,..,•-• = ,•- mpiKrtivraiurinnV12
,-. .'inlyig4 4 .',illi,' . 7,:-. • ,,,,; ,, ,... _ , , „ • :,,,,f,,,,, ..,i',:ietill'i
Room 100 WiliNitik...iNitibitiV2.WMT,,__Itg.;,A.11.4.i.4
,....Mi4.Li 0 igY
. Northampton, MA 01060 06(0.'..pplo4.01maupittamcitt.,,,,,,LL"
. phone 413-587-1240 Fax 413-587-1272
PI.M.,,
.61141104Pigtti )14
—
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
i
OTHER THAN A ONE OR TWO FAMILY DWELLING
— - —
, . . .
SECTION 1 - SITE INFORMATION
• • :";::: '' - . ThisOtliontribe'derripIeted•OY...OffIce
1.1 Property Address: /PC/
en .
! e ..r efett(94, Map /(t Lot . Unit
/ 7 1 72 44- ,,,,,zoiiii,. .:o4.0.0
..... .,..,.,:,,,..:.."...,,.,.......:„..,.. : - .. ,...,.... .., . .:.„.,,... :.:;-..„..,,i,:. : •.•.•• : :
.... . .„. „..
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■ .. • • • •--,,-. ....... " !" : ' . • •. •• ''..ca
. . '
SECTION 2 - PROPERTY OWNERSHIP/ADTH0012ED AGENT' , •-.::•:
-
,
2.1 Owner of Record: A bbil
,..„.....,....,_....,„,....._„...,______________ „„... ......, . ..
141.0 ittri:466... s'r. -.e,n3 Lr1.61
Name (Print) Current Mailing Addrta.E..... -....-__......„,.„........_.
I zi'i 5 - 1 115 # 7 - to
Sightture .sa--c-t 0)7 Telephone
--
2.2 Authorized Agape ---- . ___
....-9,__(A,_____---- I ■
. .! ‘/1) 0 C1111 i
t 3)4 tel.,447 -- . -. — __,..,-,........
Name (Print) Currtrit Mailing Address:
■
/ 1 4 / i .-- - '7 3,2:
Signature / "' 1.-- 7 .-4--- ' 1'1;1 ,' f Telephone
tECT164:341ESTIMATED-C_0_115tRUCTION COSTS. :::......‘,
Item Estimated Cost (Dollars) to be . .. • -.: • ,-,•:•,,::,.;•-...„-..:• Otily.
com ileted b oerrnit e • • licant ::::::H ....... •• - • • ..1,i..... 7: 7•••• • ••• . • ,• : . ..... : .. ...- ,: • • • • .
1. Building i ---1 :; ) Bull (rig-Permit 'FM - .,-..- .- -.- - . . .. ., . .. .. ?
. .
i__,____ :.:-.•.',..-..;•.•,:. ••••=,,,,___.:._:,......,,....
...._..... . .,....,„....., .
. ,
1-
2. Electrical . '".- 1 OYE0e9 :,..:....: ci. . :. ..... , • ..,„ „
. CDC. 7 ' ? ----toNtleuetirit,titavi'kai' ." ' • •-•-• 'L4...:.- . _____......1
_. ...___.
_ .._
.. . ........., .
3. Plumbing 1-----"-- /
! 13tillding•Pertrilffe' : . • .. .
Zoo "s
•
4. Mechanical (HVAC) 1 - • t r
— 1 , ' • t/01.050,1 g 1 ' . . , i4
. ... .
5. Fire Protection i __ 53 i •
6. Tota1=(1+24-3 4 4+6) ,
Se ction ,Chdklitmfil).er.... ..-. ...... ":', ... ' ::'..;,:. :.
.. ..
. .. - Settiotf forOffitiall3Se:prili . . ....,.. • • • • • . . ••- .• . • . . . . • . ..
_ . ..... ..
•
Building Permit Number 'Date- .
. .
Issued
. . .
. . .
. . —
Signature: . . ' "
•
.
d i. / .. .. . ..
• Building Commissionertinspectoroll3Uildings Clete
ZLZTLinnti XV,I. 9S:OT 800Z/ZZ/ZT
. .
17 DAMON RD - 375 KING ST BP- 2012 -0091
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0091
Project # JS- 2012- 000141
Est. Cost: $800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BOLDUC 038811
Lot Size(sq. ft.): 42209.64 Owner: Pride Convenience Inc
Zoning: HB(100) //WP Applicant: ROBERT BOLDUC
AT: 17 DAMON RD - 375 KING ST
Applicant Address: Phone: Insurance:
246 COTTAGE ST (413) 737 -6992 Workers Compensation
SPRINGFIELDMA01104 ISSUED ON: 7/27/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL DELI CASE /SERVICE
AREA,RELOCATE OFFICE,MODIFY SODA FOUNTAIN
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: Date Paid: Amount:
Building 7/27/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner