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23B-008 (15) 04 ° LL ±� N 'f}Jai1Tpfon ' = # =o ,... _,. ... AtAi q.v.{ .: J 4( RC Rb Ct td —mip �W'=— DEPARTMENT OF BUILDING INSPECTIONS • S2.411 ' • , 212 Main Street • Municipal Building Northampton, Mass. 01060 '" r" WORKER'S COMPENSA'nONN INSURANCE AFFIDAVTT I, a,t ( 7 p l_. � �S T � G __,E- (licensee/permittee) with a principal place of business/residence at: S //if /e ST Lt,e) /o� �, � 0/ (Phone #) .//3 5 `» 25& (street/city/state/zip) do hereby certify, under the pains and penalties of perjury, that: / 'f I am an employer providing the following worker's compensation coverage for my employees working on this job: 81 AIV7W /f L ' wiz kP1fL5S7 7bve p 1 (Iris ance 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: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) , r. (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 if ccnary to include information pertaining to all contractors) ( ) I a a sole proprietor and have no one w m orking for me. . ( ) I am a home owner performing all the work myself • NOTE: plcaae be aware that wtrilo homeowners who employ persons to do matnt ., conslruction •or rcparwork on a dwelling of not tnoco than throe units in which the homeowner resides or CO the grounds appurtenant thereto arc not wally oocoid red to be employers under the w veneer compensation Act (GL152,n 1(5)), application by a homeowner for a Iiccnsc or permit may cvidcnee the legal ctabia of an employer under the Woriceet Compemation Act. I understand that a copy of this statcmmi may bo forwarded to tbo Dcpartarcot of Iii al Aocidcacf Offioo of luwrsnoa for the coverage waif cslioo and that failure to secure coverage) under section 25A of MaL 152 can lead to tho• imposition of criminal penalties , . oomisiing of a fine 'of up to S1,500.00 and/or impzisoamctst of tip to coo year and civil pmattics in the form of a Stop Work. Order and a fine of S100.00 a day agp.iast me. ------------Tp For dc ntcol uio oalY Permit Number _.... a? --,.�� 2-/2-a.170 mad Lot 4 Signature o iccnsee/Pcrubittce Ikit.e Versionl .7 Con Building Permit 1 \ 1 D ' . , i i'; SLCTION ,O- STRUCTURAL PEER REVIEW (780 CMR 110.11) ir Structural Engineering Structural Peer Review Required SECTION II- .OWNER' AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTPACTOR APPLIES FOR BUILDING PERMIT H A- 6 LI< b L ce__, , ____ _ , j ` r -uthorize Q - 0d R , lio u / e C 0/2 s r7 ) 0 - X101? _.,7 1 C - 1 i� , ^, a!II t ' authorized by [his buildin g l el.a a. ,. y' permit application. � l . L ," r _ / / Si nature o Ow'er Uu - te Q�0 .•l ____ ga • /r ,,(.> /COhS T�ucTio -z C. �' hereby dec a th :'• the statements and information on the foregoing application are true and accurate, to Ine be knowledge and belief. I 1ioned under the barns and penalties of perjury. T a Th S. P //e / ier 'r;r,t (Jame _..vim , Z i or 7 ignaIure of Ow -t:'_'", Ren Date SECTION 12 - CONSTRUCT10NSERV'10ES I 10.1 Licensed Construction Supervisor: n �'.00 : :ci, �7 Name of License Holder : - - 72�a7 - j S, 8 //e , / e f "_ __ t ? / _----- - - - - -- 1pcoose r !mbor 5 _ / /efS Z UC//o4/ /9 d/O56 1 1 07-(27-2.0.11 d e<<. pi r,. on - ,--- •arAr-..1 7 <g :7 / 01: 21(!ila.....frr 4 - 5 7- Soo t 7, Telephone I SECTION 13 - WORKERS' - COMPENSATION I'NStJRANCEAFFIDAVIT (M.G.L. (. 152, § 280(6)) r..-s Compensation insurance affidavit must be completed and submitted with this aboii_atTn =a ;,I , : : result in the denial of the issuance of the building permit. - red Affidavit Attached Yes K1" No ❑ Version 1.7 Commercial Building Permit May 15, 2000 • SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FORBUI AND S TRUCTURES SUBJECT TO •C©NSTR CTIO U_N CONTROL P1IRSUANT 70i7.80CMR 116-(CONTAINING MORE THAN , 35,'000'3C F OF EENCLOSED'S,PACE) 9.1 Registered Architect: Not Applicable ,S 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 ? R , ii /e - 6i15Tf v _.1 G Not Applicable ❑ Company Name: //gtorA Responsible In Ch6rge of Construction : / /et S% `� /o��� (-// .cC Address 7/3 - 5 — 7 - 0.50 0 Signature Telephone • 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 ❑ 1 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 DONT KNOW A YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT 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 ° - the e any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: Versionl.7 Commercial Building Permit May 15, 2000 =SEC IO 4 CO LESS T 35 ,� ' CUBIC =FEETOF IN C LOSEDSPAC E 4 - r l Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building [ ] Repairs [ ] BRIEF DESCRIPTION J4 7 eft, L.7/ 6 //c e / � T7 /CC e, ,,7 i;/' 1 4yPJ'.oi C9 '1?e 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 ISi 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I -1 ❑ I -2 ❑ I -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B 14 U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: __COMPLETE THIS SECTION II XISTING BUILDING UNDERGOING €RENOVATIONS, .A.DDITIONS,'ANDJOR CHANGE IN USE Existing Use Group: a Proposed Use Group: 13 Existing Hazard Index 780 CMR 34): 2 Proposed Hazard Index 780 CMR 34): g SECTION 6 BUILDING HEIGHTAND AREA . .. #' , . {)F FEI CEIEB ONLY .. Y pit BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION b t „", z O C V L .- - , .' if:: V v Floor Area per Floor (sf) /1 9 v ,f0 i 0 r %, 7 '4 z H ,' yr : i;1,e 4'e ' - u�`i x 'W. Y k .%,5 b:. •fel yip a.. , 'c 1st , s,F., N �. ,.=g a 3 r,�Z ia;', r4 , 7 'sort -iV'� s 2 nd 3 4 HAAA ' t a a 3 rd 1 :.�.tf 5 � S - V'� ?: V s, yr 4 s w J1'-' ' 5",t. '*' ti y ,� w. 4 th a F k s ,,.•r" m s Total Area (sf) Total Proposed New Construction (sf) t k y , a t w Total Height (ft) . 4 € rte Total Height ft. r `� Versionl.7 Commercial Building Permit May 15, 2000 City of Northampton ' �- � � s , � � r� :- Building Department "''','',.'-$:-., ,e r , ;;M'','" . - r Q , . -' - ,. i : 212 Main Street Room 100 4 , - �4 . Northampton, MA 01060 � 1 t -F phone 413- 587 -1240 Fax 413 - 587 -1272 M," ;�� '',""77''' ,-,t - 1 ,, .. , -� , ` ' ` s ue =�, 'a"`1';%=1- %� APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING - n, j n [01,(1 SECTIONS .SITEixNFORMAT _ 1.1 Property Address, �� 4 1#a ,,Thgs. ectlon to;3e�COmPleted i .o ice * `` .. _ r a n. S / L 4 � / // l 5 e 3 � c 7r 1 f) ,, mad` � *, * 4 0 ' X 14 ,4kA3t1l� ' " ti ;z^ 267 Lc . /ofe/ c /1 ,4 . -one i � m a.x e,riay u ct~ t e - 'St astnct • SECTION 2 :PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ` �// IA S : t / � /4 4. /2. , ?oX cod 2 f" /0(e4IG-e /a/A /06 Name (Print , / �`/� / .�._t. _ � Current Mailing Address: i3 S g ` — 3 Sig . 7 Telephone 2.2 Aut • 40.6c- k o - � 4s 7 - 1 c � SNIi /4C s T Lvi/e7w /f� / Name Print) Current Mailing Address: / / '/� ����.h � I /1�Ar � ' �S ?— 2 -5'( , �• ' �� yip y Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION °CO Item Estimated Cost (Dollars) to be Official -Use Only completed by permit applicant 1. Building oo :_(a) Permit :Fee 2. Electrical /C D (-9c2 • {b) Estimated Total Cost of :-Consttruction'from'(6):--= 3. Plumbing OC�C?. Building m PerltFee.: . / 4. Mechanical (HVAC) 3 c / a? ®Q 5. Fire Protection 6. Total = 1 +2 +3 +4 +5) / 3 7 / /$. _ Check Number 3 Th is Section For Official Use Only Building Permit. Number: - _ - ' _ . Date Issued: Signature: Building Commissioner/Inspector ofBuildings Date File # BP- 2010 -0732 APPLICANT /CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS /PHONE 5 MILLER ST LUDLOW (413) 547 -2500 0 PROPERTY LOCATION 267 LOCUST ST MAP 23B PARCEL 008 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �j Fee Paid / / r�► p"5 -7 Typeof Construction: RENOVATE INTERIOR OFFICE SPACE(BLUE SECTION - DR ROCKWELL) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: �j� Owner/ Statement or License 066227 /f / � l� }`T/ 3 sets of Plans / Plot Plan ` THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 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 r Signature of Building Of icial 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. 267 LOCUST ST BP- 2010 -0732 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 008 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0732 Project # JS- 2010- 001087 Est. Cost: $1371 15.00 Fee: $822.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Group: B RAYMOND R HOULE CONST INC 066227 Lot Size(sq. ft.): Owner: NEW SILK MILL LLC Zoning: Applicant: RAYMOND R HOULE CONST INC AT: 267 LOCUST ST Applicant Address: Phone: Insurance: 5 MILLER ST (413) 547 -2500 () Workers Compensation LUDLOWMA01056 ISSUED ON:2/25/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE INTERIOR OFFICE SPACE(BLUE SECTION - DR ROCKWELL) POST THIS CARD SO IT 1S VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: � .. ervice: Meter: J Footings: Rough3 - u / Ir / House # Foundation: ' Driveway Final: Final: t j y .nal: 2 -j ( -/ u 3 1$ 1 C'? (16-1A1 Ln - Rough Frame: OJ J Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation:`�� ► " J Final: Smoke: Final: OK � ' © l l l THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES ANI) REGULATIONS. Certificate of OccupancyyY)------ L l Signature: FeeType: Date Paid: Amount: Building 2/25/2010 0:00:00 $822.00 LI MC S F y kcr wq( 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo