Loading...
18D-040 (4) • • Massachusetts - Department of Public Safet■ Board of Building Regulations and Standards Construction Supervisor License License: CS 74975 Restricted to: 00 STEVEN RIBEIRO 20 RICHARD CIRCLE SEEKONK, MA 02771 Expiration: 7/6/2011 ( misioner Tr#: 20228 • .. . t- The Commonwealth of Massachusetts �'r Department of Industrial Accidents y la t ' " I r - , Office of Investigations • • - i =.: 600 Washington Street Boston, MA 02111 - =� www mass gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information j Please Print Legibly Name ( Business / Organization /Individual): Heine kW/ igtsf/�t� i ? ' i71� . Address: 4 11S s /,ee _c je, City/State/Zip: A4// Pi 4490c277/ Phone #: .SDS C 77- O({0/ Are ou an employer? Check the appropriate box: Type of project (required): 1. [ am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction listed on the attached sheet. _ 7: lIRemodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working or me in any capacity. employees and have workers' g Y P n' # 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowker doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 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. I 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: )44/ %form . ,_ Policy # or Self -ins. Lic. #: • Oct W /37 3 9 3 3 Expiration Date: / ? )– 09 Job Site Address: 3 7.S k// 7C .c .-- t -- City /State /Zip: NorTJ/ m7an 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 . enalties of perjury that the information provided above is true and correct Sil nature: AO ✓ , L_ !, ,r Date: • 7- " 30 ✓OD — Phone . #: ' )O 6 7 7- 0 V/ . 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 b. Other Contact Person: • Phone #: The Commonwealth of Massachusetts D epartment of Industrial Accidents _ — Office of Investigations N ' =` 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly_ Nanne ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. El I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction listed on the attached sheet. 7. ❑ Remodeling 2. El I am a sole proprietor or partner- ship and have no employees These sub contractors have g. ❑ 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 11.0 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. ❑ 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: 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 hnvestigations_oftheD1Afor insurance coverage verification.___ - I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Dutc. Phone #: 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 #: rib. r y 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 I, , «1r1.S1e _ _ SA i? 0 i W/ __ , as Owner of the subject property y P,Q N NA to hereby authorize � (it _��• ������ 1 .._ act on my behalf, in at matters relative to work authorized by this building permit application S' atu z W ' 1 lU�� . ' b� Ye i, 7 _- 11 -,�!!� .. .„ .,,.„ , 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 Name Sign ure of Owne gent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ! � e' f 1� �e _ r ,. �1 F , ci s_. __ - -- . - , License Number 17( ((4ill7 0 C(( ?<L t ..__. _....„ .._._.__,.._._. 7 ., __.. ...._ . Address Expiration Date Ep .. en .. Signature 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 0 No 0 • Apr Version1.7 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 C/0lr(L ,9,✓e) mm �(JIG ._. Not Applicable ❑ Company Name: 57 .,.,,, 47(/36- 1/ ._........ Responsible In Charge of Construction Rt 0 C l?GC ( , .. , � Vie' 1 i4...._.. _ 0471 ! ....' Address 3 4661 Signature Telephone M � Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L..__._ . _.. R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) m ...., .. _ ..., _...... 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 do 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 cp IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 110 NO 0 IF YES, describe size, type and location: t0m/6 5 (C'N 3)(2 AA)0 rifted 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 comiilerl pl8n that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. of -, Versionl.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 ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. k�t4(( an/A/7(`zs , !''t` F e ((c Of Proposed Work: / ?f(,, /� tt/g/(s 12(4. in (47 6 g 1 ot - ,„ SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A I ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: . ,o. -- — . 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): . .......... __.....__ ,__..._r... 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) 1st 3 .z. 1st 2 nd 2 ' 3rd 3rd 4 th 4th Total Area (sf) 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❑ Municipal ® On site disposal system❑ 10 4 Version1.7Commercial Building Permit May15,200 Dep artment use,onlY , - City of Northampton Building Department turb:Cut/Dnve\ivay 212 Main Street Sewe;lSeOtie"Airatiabil(t Room 100 Availability Northampton, MA 01060 1 Plens Two Seta of Structure phone 413 Fax 413 Plot/Si P Pther fy APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE L OR D O W C E C L U L P I A NG NCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 3 :IC /c/1//6 s'Y- Map /IP Lot L I - C) Unit Zone Overlay District 0 OCC c.1 1 ft(4 . Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J /0/ i t / ( ( ./19/7 e7. 4 M) ''11€) 5:41.7'.°/:(' (114/d Name (Print) Current Mailing Address: r 0,7 Signature , . Telephone 4' f_ 0- #6 94416 2.2 Auth° () gent c Name (Print) Current Mailing Address: - d Signature . , Telephone 4/ - 5ZA6 94'76 SECTION 3 - ESTIM • TED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use OnIy completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of if 000 Construction from (6) 3. Plumbing — -6 - Building Permit Fee "(GU Ot Ci` 601 L D. 4. Mechanical (HVAC) 5. Fire Protection 6. Tota?)= (11+2+3/4+5) - Check Number 13() c* ate /14 Thin Section For Official Use Only Building Permit Ndti Date Issued Signature Building Commissioner/Inspector of Buildings Date • File # BP- 2010 -0352 APPLICANT /CONTACT PERSON STEVEN RIBEIRO ADDRESS /PHONE 465 SYKES RD FALL RIVER (508) 677 -0401 PROPERTY LOCATION 375 KING ST 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 i �/ � � 6 Fee Paid ` � Typeof Construction: REPLACE COUNTERS,FLQI R TILES,REFINISH WALLS & RELOCATE BACK BAR - DUNKIN DONUTS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 074975 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: p proved 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 Signature of Building Officia 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. a 4. . BP- 2010 -0352 GIS #: COMMONWEALTH OF MASSACHUSETTS ROO CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate _gory: 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 Address: 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: 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 10/6/2009 0:00:00 $264.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo ' U.S. Postal Service,-. CERTIFIED MAILTM ECEIPT O (Domestic Mail Only; No lemur: , ,,overage Provided) u For delivery information visit o .usps,come ru P ostage $ 4 0 4 . Ar Lri Certified Fe C o p� U, '\' O Return Receipt Fe U' • Q (Endorsement Requirr ov • Restricted Relive L6 t O (Endorsement Rr c, i 1 . E st' ru Total Poi' ,s� N,' < Quo 0 4 a a . AP Sent Tr 0, C e %,,,. a 0� ` a er -1- Q w0 F 0 6 ° . 0 0 4 0 � r \ \%‘ , / ‘'.\\'‘' t -. I 'X / 0 4 py 4 1/ 4 ,1 I e m f r u m <> / i `U O 0 . o b a i • y � , 7 >■•Y 0 o()/ 11, 19%t .1 / el Q`o Secondary to a review of the plans and fire protection narrative that was submitted to me for review, I concur with the issuance of a building permit for this property subject to the following conditions: • A Knox Box is required on the exterior of the structure near the main entrance; the red 120 - candela strobe light that actuates upon an alarm condition is required above the Knox Box. • The suppression system needs to be monitored by a direct connection to the Northampton Public Safety Dispatch as a condition of permit. • A pull station behind service counter to activate an alarm to the fire department that is clearly labeled. • Fire alarm control panel needs to be marked with a red engraved sign with one -inch white lettering on red background "Fire Alarm Control Panel ". • Signage clearly labeling pull station for suppression system 118.4 Violation penalties: Whoever violates any provision of 780 CMR, except any specialized code referenced herein, shall be punishable by a fine of not more than $1,000 or by imprisonment for not more than one year, or both for each such violation. Each day during which a violation exists shall constitute a separate offense. The building official shall not begin criminal prosecution for such violations until the lapse of 30 days after the issuance of the written notice of violation. Mr. Bolduc your failure to receive written permission from the head of the Northampton Fire Department to disconnect monitoring of fire alarm system which was a condition for the operation of a self serve gasoline station at Pride gas station at 375 King St. in our city is a violation of 780CMR and subject to above fines. This letter shall serve as notice that you are in violation and will be subject to the fines allowable by statute. Please contact this office upon receipt of this letter with your plans to reconnect monitoring of fire alarm system at Pride Gas station. Sincerely, Anthony Patillo Building Commissioner City of Northampton CC: B. Duggan NFD, City Solicitor E. Reall City of Northampton 4 1s Massachusetts N .4i D EPARTMENT OF BUILDING INSPECTIONS d b 212 Main Street • Municipal Building s ` Northampton, MA 01060 Building 413 -587 -1240 Commissioner February 8, 2010 Robert Bolduc Pride Gas Station King Street Northampton, MA 01060 Failure to maintain Alarm Monitoring Service Dear Mr. Bolduc, Northampton Fire Department has informed this office that you have terminated the alarm monitoring service for the fire alarm system at Pride Gas Station located at King Street in our city. You are in violation of 780CMR sections 901.3, 901.4, MGL 148 sect 27A and conditions of Northampton Fire Department permit conditions . 780CMR 901.3 States; "901.3 Nonrequired systems: Any fire protection system or portion thereof not required by 780 CMR shall be permitted to be finished for partial or complete protection provided that such installed system meets applicable requirements of 780 CMR. A building permit shall be required for systems installed pursuant to 780 CMR 901.3. 780 CMR 901.3 states;" 901.4 Maintenance: All water based fire protection systems shall be maintained in accordance with NFPA 25 as listed in Chapter 35. All other fire protection systems shall be maintained in accordance with the requirements of the applicable reference standards and standards listed in Chapter 35. The owner of every building or structure shall be responsible for the care and maintenance of all fire protection systems, including equipment and devices, to ensure the safety and welfare of the occupants. No person shall shut off, disconnect, obstruct, remove or destroy, or cause or permit to be shut off, disconnected, obstructed, removed or destroyed, any part of any sprinkler system., water main, hydrant or other device used for fire protection or carbon monoxide detection and alarm in any building owned, leased or occupied by such person or under his control or supervision, without first procuring a written permit so to do from the head of the fire department of the city or town wherein such building is situated in accordance with M.G.L. c. 148 s. 27A." When installations of fire protection systems are interrupted for repairs or other necessary reasons, the owner, tenant or lessee shall immediately advise the local fire department and shall diligently prosecute the restoration of the protection. The building permit was issued with the following conditions from the Northampton Fire Department dated May 6, 2003 which you agreed to prior to issuance of building permit, memo reads; Re: Pride Convenience, 375 King St. From: Duane Nichols Assistant Fire Chief, Northampton Fire Department Date: May 6, 2003 CC: Brian Duggan Version1.7 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 12 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 0 Company Name: Responsible In Charge of Construction Address Signature Telephone • Version 1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved,, 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 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 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 ,Date Issued: C. Do any signs exist on the property? YES NO i IF YES, describe size, type and location: ?,Street, gas canopy and Building D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 0 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 ❑ Existing Wall Signs ❑ Demolition ❑ Repairs GI Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Replace accoutical ceiling system and HVAC equipment Of Proposed Work: SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) _ CONSTRUCTION TYPE A Assembly [171 A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory 0 F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ _ 3B ❑ M Mercantile 12 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B 1 ❑ 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: Mercantile Proposed Use Group: same Existing Hazard Index 780 CMR 34): ,., .. .. Proposed Hazard Index 780 CMR 34): _ SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED kliVrCONSTRUCTION OFFICE USE ONLY RG+ev savrO.J Floor Area per Floor (sf) 1s` 4 400, 1 3156; 2nd 2 nd 3rd 3rd 4 th 4th Total Area (sf) 4 Total Proposed New Construction (sf) 3,156 Total Height (ft) 16 Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public p Private ❑ Zone Outside Flood Zone p Municipal 12 On site disposal system ❑ Version 1.7 Commercial Buildm Permit May 15, 2000 ' City of Northampton Building Department C i€1 ._ }� 10 ' . 12 Main Street 1 Oom 100 ���� 11 Northan ton, MA 01060 phone 43 -540 Fax 413 - 587 -1272 P4* 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 1.1 Property Address: Tills section to be completed by office _. 375 King Street Map Lot Unit Zone Overlay District Etm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Pride Convenience Inc. ;246 Cottage St. Springfield, Ma. 01104 Name (Print) Current Mailing Address: (413) 737-6992 c. Signature / Telephone 2.2 Authorized Agent: David A. Sabourin ,246 Cottage St. Springfield, Ma. 01104 Name (Print) Current Mailing Address: (413) 737 -6992 Signature - ,�_ Telephone Jar SECTION 3 - ESTIMATED CONSTRUCTION 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 $$00.00 _. Construction from (6) 3. Plumbin $400 00 Budding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection $8,000.00 6. Total = (1 + 2 + 3 + 4 + 5) lot 1C % 000 Check Number , /00 14 0 ' This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date