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23B-011 (6) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4-N www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (B usin ess/Organ izati on/Ind i *Al 4__ _ Address: a /l% ^/ / f 7g > 4l - S City /State /Zip: / © / Phone #: a `f 2 —7S-7 6 Are you an employer? Check the appropriate box: Type of project (required): 1. [ a employer with I" 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- 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. required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3. ❑ I am a homeowner doing all work 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. r 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: dG iC Policy # or Self -ins. Lic. #: u! C L .S 3 at), y O/ (AO 0 3 Expiration Date: `7// 40 Job Site Address: /' cf City /State /Zip: ,/1 ;y /o, ,, O/ D 6 6 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 penalties of perjury that the information provided above is true and correct. Signature: `rit7 Date: f / /S' / Phone #: cf 2 — G6 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 #: ,\ 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 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT rtf , as Owner of the subject property hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. 7d/0 Signature of Owner 144— ( CA--\---\ >-''"'" -- 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 tbesains,and_genalties ofsetiury. ___________ _ Print Name -- -- Signature of Owner/Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : L 0 6626 License Number 41 4101_4 1.4-e-rt( c,/ed? 1 L Address Expiration Date (421/J cR Cf:? 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 (1,1/' No 0 Versionl.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): f i Name . Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility _ _ - -"'I Address - Registration Number Signature Telephone Expiration Date Name Area of Responsibility _ M L Address Registration Number Signature Telephone Expiration Date --1 i —.__. _ __. t Name Area of Responsibility Address Registration Number i Signature Telephone Expiration Date 9.3 General Contractor _ � 19-sf -¢ , av, /L-- 'a Not Applicable ❑ Company Name: __j old . 1 Responsible In Charge of Construction .a � -.wG2K __ Sr ._ -� - ora I Address Signature Telephone • . . , 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 _____.1alC 7 - -.- -- --------- :-----; Frontage Setbacks Front t _ Side L:i..6-42,-J R:' L: • 0 i R:L(PAI L..,-P:o_M ag Rear L a - 7 1 i VO Ch L /fAiter Building Height FIAT riA ! ("NG, 5143e, y ;Jo Bldg. Square Footage 0::3 Eat % 1=7 1737 ,- . , Open Space Footage , % (Lot area minus bldg & paved - CV ' L.,32 &PINS" r37 1 , parkin /71 i 7 F 1 L # of Parking Spaces Fill: (volume & Location) L_ _ ...j A. Has a Special Permit/Variance/Finding ever been issued for/on the site? - NO 0 DONT KNOW YES 0 1 I IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW OV YES 0 IF YES: enter Book 1 i Page 1 and/or Document # B. Does the site contain a brook, body of water or wetlands? NO er 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 0 , Date Issued: j 1 mi C. Do any signs exist on the property? YES r NO 0 I -- IF YES, describe size, type and location: /L-14141-- 3 .-S ' gleie, Zt . 7 4,LC 2 I/ 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: i 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 .,...----- IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE / 1 � Interior Alterations [Ex LWl isting 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. /v— C4' a ri 7 Q d/`j` vic�` -� it-d-- v Of Proposed Work: i y ..1'4,41 oC' s t / 4.4/ 1_410t., , 3 - -r / s- Y " 6 L^p dvi j lAd r. .5 ._: SECTION 5 - USE GROUP AND CONSTRUCTION TYPE " '' USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A ❑ A -5 ❑ 1B I ❑ B Business li, 2A ❑ E Educational ❑ 2B r r ❑ F Factory ❑ F - ❑ 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 P 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: ,_� e0„ s 5 ,,.._ Proposed Use Group: / e5 v 55 _ ...1 t Existing Hazard Index 780 CMR 34): I Proposed Hazard Index 780 CMR 34): I wI SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) st ..._ - -_- _ _ --__: 1u i < � - ; 1 _70 y3 _ f rr _ s- > t 2nd ...__.._ _-- __.--- -_.._. 2 nd 1 ' rd t 4t" 4t' ! 1 4 ' ` Total Area (sf) C) v 5 I Total Proposed New Construction (sf) 'sa. - -Y S .& Total Height (ft) r j Total Height ft i, „„ _87 „ _. 1 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public itg./ Private ❑ Zone _ Outside Flood Zone- Municipal TY On site disposal system❑ Version1.7 Commercial Building Permit Ma 15, 2000 _.-p -- �� o Northampton m \\ � ding Department h i g y f , _�� J 2 M ain Street ewer a e > $ 4 j 04 , oom 100 � ; '' A:44-,,,---: 2. 2 01 0 Nort am MA 01060 g " \- phone 413 40 Fax 413- 587 -1272 0 p �` APPLIC TO C QNSTRUC T REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: / P3 CvS 1- C fi E Map Lot Unit J ! Zone? Overlay District . _____ 4 Eim;St: District CB. District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ _ Name (Print) ii°-"7-7----- (I Current Mailing Address: Signature L. at. Telephone 2.2 Authorized Aq nt: o ra? / ✓�t - % /. Name (Print) Current Maili Address: -__ y Signature Telephone --4t--- SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building - e ° ..._.., __ (a) Building Permit Fee i -..�� t _ 2. Electrical / ��, — (b) Estimated Total Cost of I: Construction from (6) _.v......__._...__.. ._, 3. Plumbing /..,./.. dv U - Building Permit Fee 4. Mechanical (HVAC) --- -_ 5. Fire Protection -,5000 6. Total = (1 + 2 + 3 + 4 + 5) (, g doe Check Number L cOg 3O it9d 57 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date r` ■ The Commonwealth of Massachusetts Department oflndustrialAccidents UPI. — b -r7 Office of Investigations r ' ' 600 Washington Street Wi n ; r.�' n , • 77:774 ✓ Boston, M14 02111 www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plunibers Anoli Call t Information Please Print LezibIv Name ( Burines /Organization/Inaividual): ,O/VIq,SP.., OJ4', ar, , Address: 'di Ai- 4. 14 S r - City/State /Zip: e- Z. .�7 f Phone.#: d, 6 6 G Are you an employer? Check the appropriate box: I 1. Type of project (required): i [ I am a employer with 4. ❑ I am a general contractor and I � l ih � 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. fl Remodeling shin an have „o e loyees These sub - contractors have S. 0 Demolition working for me in any capaci employees and have workers' Y t3' 9. ❑ Building addition No workers' comp. insurance comp. insurance.: required.] 5. We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3. ❑ I am a homeowner doing all work l 1.0 Plumbing repairs or additions myself [No workers' cow. right of exemption per MGL Y �`' 12.0 Roof repairs insurance required J t c. 152, § 1(4), and we have no employees. (No workers' 13.0 Other I comp. insurance required.) I 1 I *Any applicant that checks box #1 must also fin 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 contactors must subunit a new affidavit indicating such. Z that check this box must attar -hed 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' camp. 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. #: 1,4 S ©Cy 3 G,,Z cr d /A0 a 3 Expiration Date :. 7/////0 Job Site Address: l / 3 L a`. .d 'T ' T City/State/Zip: Aft/4 le " 0 / 6 66 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 imprsonment, as well as civil pens Ities in the form of a STOP WORK ORDER and a f+e 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 DLA for insurance coverage verification. I do hereby certify render the ains and penalties of perjury that the information provided above is true and correct Sisnatire: Date: / t/� !J Phone T: c K ?-1)---X644. - — Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License T Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: k Versionl.7 Commercial Building Permit May 15. 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) I Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,L /) z '-t-l? + ,- s ., ' r ! , as Owner of the subject property hereby authorize Om, to act on my beh in all matters relative to work uthor by this building permit application. Signature of wner 7Date i � � ��'''�► 3 r /� , 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. (�� / .i - sI,� Print Nam Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ ,�d O 5 44 Ovc� ? . 3 Name of License Holder : ( - - License Number 1 t 1L 5r ff ( af ./2 ....c /U //°// Address - Expiration Date 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 0 Versionl.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 Q/tAirt-i /4 l✓ �' �`� Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing I Proposed Required by Zoning This column to be filled in by Building Department Lot Size 11 A Gr 4c- ,,U a 64, rAif c Frontage 9% .S . L 3 N a c 4. 9. 7 0 Setbacks Front •? 3 Side L: V. R:.,,(= yi,t L: R: Rear ad. ; Buildin Height O .w S r� ,/ /16 6 4 a � C Bldg. Square Footage -76 y3 3 % e-41.,/-z- Open Space Footage (Lot area minus bldg & paved Q y7V 3 A-'' C SC parking) J/� # of Parking Spaces (9 - Fill: (volume & Location) 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 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 0 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 t NO 0 IF YES, describe size, type and location: 3 kS' frz e/ D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 NO Q-- IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version] .7 Commercial Building Permit May 15, 2000 I SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations f Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign 0 New Signs ❑ Roofing Change of Use ❑ Other ❑ Brief Description Enter a brief description here. /ot-i SA' . r 6,d, 7 d cc, c .FNt Of Proposed Work: .f � , , r4„t j X &A SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ . 1B ❑ B Business V( 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A 0 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ I -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S-2 ❑ _ 5B I L'r . _, 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: 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 USE ONLY Floor Area per Floor (sf) f� 1st '7 1` / 0L-1 2 • 2 3rd 3 4 th , th Total Area (sf) — 704(3 Total Prnpnsad 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[�' E/On site disposal system❑ Version1.7 Commercial Building Permit May 15, 2000 Department use only /�. City of Northampton Status of Permit „ ( Building Department Curb Cut/DrivewayPermit L. 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability v Northampton, MA 01060 Two Sets of Structural Plans phone 413 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify 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 section to be completed by office • C ?3 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: s _ 7O 0 Si A ' / / Ad Telephone 2.2 Autho 'zed Agent: Name (Print) _ Current Mailing Address: d l'7 - 44‘ G Y7c5 GAG cc // Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building > (a) Building Permit Fee • S a 2. Electrical (b) Estimated Total Cost of j cd' Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) 6j r�au Check Number 6" ,g This Section For. Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File BP- 2010 -0702 APPLE. AN I CuNTACT PERSON ROY OMASTA ADDf [SS,1'110NE 21 North St HATFIELD (413) 247 -5666 PROPERTY LOCATION 193 LOCUST ST MAP OB PARCEL 011 001 ZONE SI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZO \INC FORM FILLED OUT Fee Paid Pur Permit Filled out Fee o tier'‘— Fee Paid �// d T ..,', :1' Con, t! .;c I ion: CONVERT BILLING OFFICE INTO 4 EXAM ROOMS /BATHROOM & ADD 3 X 15 BU\IPOUT fO EXISTING STRUCTURE New(construction Non Structural interior renovations Addition to Existing i ces:,ury Structure Building Plan_ Included: Owner; Statement or License 006763 3 sets of Plans / Plot Plan THE FOLLOWING AC N HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION ENTED: 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: § 25-o �. C f Finding Special Permit Variance* ,vo,r✓ 0 ,., r.c.. , _ Received & Recorded at Registry of Deeds Proof Enclosed �y , ,, Other Permits Required: 5- ^" ` 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 1 — / Zltj Sign,.Lt,Lof ;uuclingOfficial Date Not, : 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 ar, granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planr:l & 1 rc "lopment for more information. File # BP- 2010 -0702 APPLICANT /CONTACT PERSON ROY OMASTA ADDRESS /PHONE 21 North St HATFIELD (413) 247 -5666 PROPERTY LOCATION 193 LOCUST ST MAP 23B PARCEL 011 001 ZONE SI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out � 93) //061 � �/ Fee Paid 0C/ / p Typeof Construction: CONVERT BILLING OFFICE INTO 4 EXAM ROOMS/BATHROOM (/' O /�(2 rf I c T New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 006763 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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 /fp 4 7 7-7 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. 193 LOCUST ST BP -2010 -0702 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 011 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 -0702 Project # JS- 2010- 001044 Est. Cost: $68000.00 Fee: $408.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROY OMASTA 006763 Lot Size(sq. ft.): 39465.36 Owner: 193 LOCUST ST ASSOCIATES LLP Zoning: SI(10 Applicant: ROY OMASTA AT: 193 LOCUST ST Applicant Address: Phone: Insurance: 21 North St (413) 247 -5666 Workers Compensation HATFIELDMA01038 ISSUED ON:2/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:CONVERT BILLING OFFICE INTO 4 EXAM ROOMS /BATHROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: �,� Meter: q ,� Footings: /� e '' ✓ House # Foundation: Rough:,,w; !!Y - FB I �,�'"� Rough: (rt��,j`�,;�,;1 �� Or p ,ven ?if j / Driveway Final: Final: „t - 10,4 6inal: ,..513/462 �l Rough Frame: 0 i 9/ i al 0 10 ti' S Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: e- 3 J d i d 4f ;; Final: Smoke: Final: OK S' f ' I 'o f _ . � THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy 400 Signature: FeeType: Date Paid: Amount: Building 2/23/2010 0:00:00 $408.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo