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DEPARTMENT OP BUILDING INSPECTIONS _=
• 212 Main Street Municipal Building
Northampton, Mass. 01060
WORKER' COMPENSATION INSURANCE Ai+•1r`IDAVTT
Pioneer Contractors
(Li censee/permi ate)
with a principal place of business/residence at:
P.O. Box 1145 Northampton, MA 01061 (phone) 586 5491
(st rceticity /sta telyp)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following worker's cornpeusation coverage for my
employees worming on this job:
Assor�iatPrl Employers Insuraan c cg 5 0 059570120C ( p 6/30/1
(Insurance Company) (Policy Number) (Ex-pirarron 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) (Lnsu ance Company/Policy Number) (Fxpuntion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) •
(Name of Contractor) (Insurance Comp.any/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (xpiration Date)
(attach additional rlicet iFnn .ry to include information pertaining to all ooafrncLor3)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: plaec be aware that while homeowners who employ persont to do maintenance oouuruoion ar repair work on a dwelling of
not more than three units in which the homeowner roida or oa the grounds appurtenant thereto arc not generally ooesidered to be
employes under the worker's cempe ration Act (GL152,an 1(5)), application by a bomeowocr for a Liceme oc permit may cvirie-a e the
legal statue of an oaoployec under the Wod ca & Compe nation Act
I understand that at copy of this eta temect may be forwarded to the Department of Industrial Aoadasts' Of oo of lnszuwoo for the
coverage verification and that failure to aoatre covcrago under section 25A of MOL 152 can had to the imposition of criminal pcati ice
consisting of a fine of up to S1,.500.00 and/or imprisommem of up to one year and civil penalties in ibc form of a Stop Work Ordc' and a
fine of 5100.00 a day against tnc.
r For 'peen ! use only
te, Permit Number
A Al t f ,�� Map4 Lot #
Si. u tlrre of LiccnuxJpermi • • / L
•
Version!.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
Josephine Cavalari , as Owner of the subject property
hereby authorize Pioneer Contractors
to
act on my behalf, in all matters relative to work authorized by this building permit application.
04/08/2011
Signature of Owner Date
Pioneer Contractors
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
04/08/2011
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : David A . Claxton 017890
License Number
P.O. Box 11 5 Northampton, MA. 01061 01/19/2012
Address Expiration Date
xi, (413) 586 -5491
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
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 i nZi
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
Pioneer Contractors Not Applicable ❑
Company Name:
David Claxton
Responsible In Charge of Construction
P.O. Box 1 5 Northampton MA 01061
Address � �i�
4 i , (413) 586 -5491
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
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)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 DON'T 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 0 NO
IF YES, describe size, type and location:
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 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.
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. Repair of Existing Roof Top A/C Platform 3 tX, (
Of Proposed Work:
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 -4 ❑ A -5 ❑ j 1B ❑
B Business 151 , 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A 0
I Institutional ❑ I -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 ❑
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: Business , Use Group: ame
Existing Hazard Index 780 CMR 34): Low Proposed Hazard Index 780 CMR 34): Same
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1 St
1
2 nd
2nd
3 r d
3 rd;
4 th
4 th
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 p Private El Zone Outside Flood Zone p Municipal p On site disposal system ID
411(rtk" ,
VII WO ma
P
Versionl.7 Commercial Building Permit May 15, 2000
%�, e art t nt us e. ��
/< iv r G � / /G�� /iii/ ii/ . �
City of Northampton fete ��'!� %� "'' %r�x
Building Department Cu � � Ve � mitft "�� " � %;4
212 Main Street �11'�b "Yifi,� CI Room 100 fateri3,, - �i �_ +'rthampton, MA 01060 T`w �� 0f tr rarria v , � �ti ��,4, % i i�4P /r > g�4i / g r ,00, File Pl X87 -1240 Fax 413- 587 -1272 an � , � �� ; ��� NSTRUCT, 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
� Map 1 Lot 1 5 Unit
151 Main Street
Zone Overlay District
Elm St. District GB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Josephine Cavalari
Name (Print) Current Mailing Address:
(413) 527-7944
Signature �y' Telephone
g
4r
2.2 Authorized Agent:
"Pioneer Contractors P.O. Box 1145 Northampton, MA. 01061
Name (Print) Current Mailing Address:
(413) 586 -5491
Signature `onv Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $2,000.00` (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
6. Total = (1 + 2 + 3 + 4 + 5) Check Number /441 $ J C
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
p ;
File # BP- 2011 -0813
APPLICANT /CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586 -5491
PROPERTY LOCATION 151 MAIN ST
MAP 31D PARCEL 145 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out I / , J /�
Fee Paid 6 '7 L
Typeof Construction: REPAIR ROOF TOP A/C PLATFORM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017890
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
t/ 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
c— y r
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.
151 MAIN ST BP- 2011 -0813
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D - 145 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP- 2011 -0813
Project # JS- 2011- 001335
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 1481.04 Owner: JOE -MAE REALTY ASSOCIATES GENERAL PARTNER, JOSEPHINE F.
Zoning: CB(100)/ Applicant: PIONEER CONTRACTORS
AT: 151 MAIN ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586 -5491 Workers
Compensation
NORTHAMPTONMA01061 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: REPAIR ROOF TOP A/C PLATFORM
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 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner