18D-004 (45) May 00 03 01:27p
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Versionl.7 Commercial Buildipg Pctmit May 15, 2000
- --
- -- Qtly- ot'Northar.:pton r , , .' ' ' t a �Y T
:( Buildrrg Department t,, 4,a� . r ;rt
r .. ' ._ _ -- . ._.__.. _ 212. Maw Street • .1 � - J r f ( mac " sf -,, ROOM 1 00 t,*�R �c?F{ 'f 1 : �- ' x ", 7 �•.•. � { � a -
APR 2 9 4 -_: - ;, ,
f� rtharripton, MA 01060 h� s ;,1, 4 -- ..--
phone 413.5 / -1240 fax 41358 - 1 272 Y. 3
�r 6 ...L"rel� sy
Y.* 4 a . - Jk zT�.:.._""'T �-.§_ L rh
APPLICATION CONSTRUCT, REG74 RENOVATE, CHANGE T E USE OR OCCUPANCY OE, OR DEMOLISH ANY BUILDING
OTMiER THAN A ONE OR TWOfAMILY DWELLING
1 SECTION 1- SITE IM MA t
1.1 Property_ Address t ry 5 ' tit �F * 0 ' ,r -
I04 6 , ki �. . ,- � { tki-
4.5 '47=',''- .0.�y,+r"' ,,
Z .-. a t, ` 0!R! it i W i„ ,F :
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
-- — 1
1 1 Owner ' Rums!: _ 1 t
Name (Print) Curren; M sling Address,
V CZ :~ 60.3 - 35 - 1- (o 33 I
Signature Telephone J
2.2 A horized AAgent: f
Name (f , t) ~ -„ ' t Y CurrE ailing Address: I
r � _ ` tf 3) 5- ICr - 6 O ✓4 i
S�gnattue Teleorone ///
t
.CTlON_3 - ESTIMATED'CQNSTRV TION COSTS
Item - - Estimated Cost (i ?oflars) :o tre C�td+siai �I Qslfy.
ll
coeted by per_m:t applicant
1 Building c� (a) &iiid ng PermiLfee — —
I
2 Electrical
Est +mated Total Cost °Of
f -- Construction Itom)
— s
3 Piumbrrg J` � ^ Building Permit Fee
4. MuChao Cal (,NVAC)
5. rite Protection �f �e-
b. Totat =- (1 +- 2 + 34 4 S) I 7z i t iC ) + tJV Check Number 3 176, X47 {
Tfii Section =for Official Use Only ._
Building Permit Number ' Date lss -Jet: _ ___._—
Signature _ — — �
Building Commissioner /Inspector of Buildings Date , —
I•d
enl.: nn cn J n Reu
- 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 El No ❑
S TION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1
I , c\ LLCM-g-0 PCSO■&■,\O-ACI
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.
Sid ed under the pain nd penalties, of perjury.
k l (.. -(-1 G Vt\A.,t . r, is
P f Narr , -:.
j) ' ' QQ-01.4,1.
.
Sig ature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Su ervisor: } Not Applicable ❑
Name of License Holder : ' T I><,J ;,nt !C - "' , 1 7 i) 3 -D
License Number
.,i.,.7 SC\c kl 1 40(((sI, -L / /61 A q
Addre Expiration Date
6 5 6 3
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 ❑ No j
C�
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
92 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:
Responsible In Charge of Construction
Address
Signature Telephone
O . a itiAA1P 2 .
a � A:4% til
4 Crxi� iif rt lttttt�r rat � __t, A JO 6 �s"� j' B asaxchnsctta '
iU e DEP OF B UILDING INSPECTIONS t11---
' 212 Main Street • Municipal Building
Northampton, Mass. 01060 y `'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee&permittec)
with a principal place of business/residence at:
(phone #)
(strect/ci ty /state/21p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
t • (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
•
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
•
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneecreary to include infocmatioo pertaining to all oocttraetnrs)
(a sole proprietor and have no one worljng for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that while homeo wners who employ persons to do mamtrna - construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto are not generally coo:noel al to be
employers under the worker's ecatpeasation Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal stabs; of an employer under the W oriox's Compensation Act.
I understand that a copy of this statement may be forwarded to the Department of Industrial ADadu#>' Moo of Insrusnce for tha
coverage verification and that failure to secure covet under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a ,
fine of S 100.00 a day against ax.
For dgastarreal use only
�.,„\\ Permit Number
n "� 4 ., ',JM *' M Lot #
Wm
o a o Date Liccnsee/Permit .ce
Versionl.7 Commercial Building Permit May 15, 2000
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 ❑
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: L: R:
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
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
No
IF YES, describe size, type and location:
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 Existing Ground Signs Additions El Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [) Change of Use [ ] Other [ ]
4;1J.— _ Accessory Building [ ] Repairs [ ]
wr DE c W -Tr'% ‘ 11.1bLkO ve ` Cctxrt F)k()-k k)t i(- 6(. I( -( ev.,) ,. c)lye... 0 4 - - f (71 ,,,i- i,„
SECTION 5'- USE GROUP AND CONSTRUCTION TYPE 1
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 1 A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business 1- 2A El
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1 - 2 ❑ i - 0 3B El
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 El 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 U
it 1, : ‘--,,
Ya
Floor Area per Floor (sf) 1 st ' : ka
H
2nd
1st ai?` fir
3 rd pr , t
2nd
4th
3rd
4tn
Total Area (sf) Total Proposed New Construction (sf) ( ' _ '
Total Height (ft) 1 - ;1
Total Height ft
Versionl.7 Commercial Building Permit May 15, 2000
1
pity of Northampton < l':::::,- `
_. t( _ "' . Building Department ' �
212 Main Street r , .g" � .
Room 100 Wa e try
APR 2 9 c ,
,
rthampton, MA 01060 Tvzq is o u. . , l4 sk: 1
phone 413 -5$7 -1240 Fax 413- 587.1272 Pith / . A, , ;..,_,... r _ i_ �t 4 i
■ d r b
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 Property Address: This to be completed by office
1 ,
$ 3 ( 6 1 i n.c» J Ct Map Lot ' Unit
'1
Zone 4;li.,________,:f. D t
Elm St. District ,, CB District
t SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
r 2.1 Owner of Record:
v
- 1
Name (Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent: - (, 7 )
(z: LC iti ��
Et X �li G ...c \- s ik ck (k `c � l GPI A- .
Name ( i t) d Curre ailing Address:
k_ r,,(! C'.�' 1 4 � t � �1 3 � ���� (e 3 •
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (t, (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 1
6. Total = (1 + 2 + 3 + 4 + 5) (0C�)�) u>1 Check Number 3 / 7l, 025
This Section For Official Use Only
Building Permit Number: 03 -- 9 i�o Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2003 -0986
APPLICANT /CONTACT PERSON BAYSTATE WINDOW & DOOR
ADDRESS/PHONE 87 SHATTUCK RD (413) 549 -6824
PROPERTY LOCATION 104B DAMON RD
MAP 18D PARCEL 004 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid W76. A `"'—
Typeof Construction: REMOVE GARAGE TEMPORARY BLOCK WALL BACK TO EXISTING OPENING
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License 125626
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFG NATION 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 Commi
7
- o l / • -� 2 c9 7
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.
104B DAMON RD BP- 2003 -0986
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D - 004 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2003 -0986
Project # JS- 2003 -1586
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BAYSTATE WINDOW & DOOR 125626
Lot Size(sq. ft.): 87120.00 Owner: MOCK WILLIAM D & EVELYN F
7_onine: GB Apj licant: BAYSTATE WINDOW & DOOR
AT: 104B DAMON RD
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549 -6824
HADLEYMA01035 ISSUED ON:5/12/03 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE GARAGE TEMPORARY BLOCK WALL
BACK TO EXISTING OPENING
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: OK R_ q.- c 3 v
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ON OF
ANY OF ITS RULES AND cY REGULATIONS.
Certificate of Occu p an 7, 7 ature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/12/03 0:00:00 3176 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo