18D-040 (3) 375 KING ST BP- 2010 -0352
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: BUILDING PERMIT
Permit # BP- 2010 -0352
Project # JS- 2010- 000473
Est. Cost: $44000.00
Fee: $264.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN RIBEIRO 074975
Lot Size(sq. ft.): 42209.64 Owner: Pride Convenience Inc
Zoning: HB(100) //WP Applicant: STEVEN RIBEIRO
AT: 375 KING ST
Applicant Addres Phone: Insurance:
465 SYKES RD (508) 677 -0401 WC
FALL RIVERMA02720 ISSUED ON :10/6/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REPLACE COUNTERS,FLOOR TILES,REFINISH
WALLS & RELOCATE BACK BAR - DUNKIN DONUTS
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: i 0 — 6 — 0 % Xinal: ! O < j J
! J I Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
jz
Final: Smoke: Final:
ls
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS, -
Certificate of Occu • anc E- d r . ► si nature:
ir
FeeType: Date Paid: Amount:
Building 10/6/2009 0:00:00 $264.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
✓s �a '� a��7liadoac�i .ta
I Boa d o .Bis tdingR Lic and Standards
Construction Supervisor License
License: CS 38811
- -p 10/31 /2009 Tr# 10280
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1 1 1 r ROBERT L BOLDCi
49 WOC" & SLEY RD,1-12-7-'.E,_, j' -� �`�
LONGMEADOW, MA atlas- Commissioner
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11 i + `' '�' ce r :`7447,* >'_,��w
$- The Commonwealth of Massachusetts
Department of Industrial Accidents
P ` Office of Investigations
'� : �� 600 Washin Washington Street
Boston, MA 02111
'4c
4c-1" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business /Organization Name: //,& /2t Cscm./ ✓/g 4/Cc /.✓e
Address: Y 6 CO 7'7,.g -s 6 Sr
City /State /Zip: J l2 024 p / /D`l Phone #: Y/ 3 'J' ‘i'€
Are you an employer? Check the appropriate box: Business Type (required):
1. 0 I am a employer with PO D employees (full and/ 5. g Retail
or part- time).* 6. ❑ Restaurant/Bar /Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]* '
4. ❑ We are a non - profit organization, staffed by volunteers,
11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
* *If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: /9' rh077V& /A446'7744 Co'' '
Insurer's Address: �D 7' j /AdSul.- e. ,o 6,)x 3 6 .0 0
City/State /Zip: we T Vii° /`l7 4 214- ' , O / — 360 - O
Policy # or Self -ins. Lic. # C- 00 9,04S 07 Expiration Date: /ot 3/ -0?
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 par • and penalties of perjury that the information provided above is true and correct.
.1'. S i • nature: - Date: ,%
--e
Phone #: F / 3 7 3 ? 0 l __
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. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
•
www.mass.gov /dia
Version1.7 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 el
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Robert L. Bolduc
I, , as Owner of the subject property
hereby authorize David A. Sabourin o
act on my behalf, in a matters relative to work authorized by this building permit application.
;08/17/2009
Signature of Owner Date
Robert L. Bolduc , 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.
; Ler— - L. gold-
Print Name
08/17/2009
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . Robert L. Bolduc
License Number
49 Woodsley Rd. Longmedow, MA 01106 112/31/2009
Address Expiration Date
(413) 737 -6992
Signature / /i /� 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 ® No
r i
File # BP- 2010 -0206
APPLICANT /CONTACT PERSON ROBERT BOLDUC
ADDRESS /PHONE 246 COTTAGE ST SPRINGFIELD (413) 737 -6992
PROPERTY LOCATION 375 KING ST - PRIDE CONVENIENCE
MAP 18D PARCEL 040 001 ZONE HB(100) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out n (� /
Fee Paid /0O -/ 9 / / 7 o $ 6° --
Typeof Construction: REPLACE ACCOUSTICAL CEILING SYS & HVAC EQUIPMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 038811
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION PRESENTED:
A 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
Demolition Delay
/ — 8 Z l7• e
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.
7,1 G ST - PEE CONVENIENCE a BP-2010-0206
GIS #: COMMONWEALTH OF MASSACHUSETTS
t‘Mati:H1ock: 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: BUILDING PERMIT
Permit # BP- 2010 -0206
Project # JS- 2010 - 000253
Est. Cost: $10000.00
Fee: $60.00 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: 375 KING ST - PRIDE CONVENIENCE
Applicant Address: Phone: Insurance:
246 COTTAGE ST (413) 737 -6992 Workers
Compensation
SPRINGFIELDMA01101 ISSUED ON:8/25/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE ACCOUSTICAL CEILING SYS &
HVAC EQUIPMENT
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 8/25/2009 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo