32C-003 (2) Louis Hasbrouck
From: Richard Young [byoung @crocker.com]
Sent: Thursday, June 30, 2011 9:23 AM
To: Louis Hasbrouck
Subject: 24 -34 Pleasant St. Northampton, MA
Attachments: img001.jpg
1
Young Roofing Co., Inc. Roofin C
144 Texas
Mailing Ad
Florence,
(413) 584-
(413) 585 -
Date: June 30, 2011
City Of Northampton
Louis Hasbrouck
Building Inspector
Northampton, MA.
Querencia Trust Building
DID Jeff Dwyer
24 -34 Pleasant St.
Northampton, MA. 01060
Mr. Hasbrouck,
I would like to submit a request for a modification to wait
requirement for a control construction form for the above pr
work is of a minor nature, and will not affect health, access'
fire safety, or structural requirements and is impractical in tt
control construction is considerable when compared to the
proposed work.
Cinr■nrcalhr
3
JHMCJ W I r4 I Uri LNW r 1101 tax I:1 I Jbii4110.0 Jun 2A 2U11 11: 2Uam NUU2 /UU1
Contr. Supervisors Ltc. No. 011876
Tel. 413- 584 -1367
�. - J S J ( C 4 4 413 -586 -9167
Fax 413 -585 -0226
P.O. BOX 60056 FLORENCE MA01062-0056
Customer : James Winston Date: 5/21/11
Address: 142 Main St. Suite 1 Northampton, MA. 01060
Job Location
SPECIFICATIONS:
1. Power broom the loose gravel on the main. roof.
2. Apply 1/2 inch fiberboard insulation over all roof areas.
3. Install Carlisle's .045 gauge reinforced mechanically attached roofing system to the main roof,
upper sloped roof, and low inside roof.
4. Flash all walls, edges, and roof penetrations with an approved Carlisle detail.
5. Install 1 -6 inch and 1 -4 inch Zurn -l00 roof drains and connect to the existing plumbing by a
licensed plumber.
6. Upon completion of the work Carlisle will inspect the job an issue the owner a Fifteen (15)
year. Golden Seal Total System warranty.
Alternate No. 1
1.. Install 1 inch polyisocyanurate insulation in place of the 1/2 inch fiberboard. R Value 6.0
Add: $1,070.00
As requescea tty u,tJ AUt,U Vl un sa..vaasss.
Au
material in guerelxeed to be as speciied. Any alterations or deviation from above
apecAioatinne Involving oCra costs wb be eaearned only upon written orders, and Will
beams an extra charge over and above the estimate. All eareemente Conbn5ent upon
strikes. aeddertts or delays beyond our control, Owner to carry lira and other necessary
insurance. Ai accounts not geld wtth'm 30 da a are subject to a e
late crier a of 1 1 �.
per month on the unpaid balance. In the event tnat event action at Inettutee to collect ,
any aces due under tnla agreement. the undersgned agrees to bay at mss incurred including '`-` �
including reeso attorney's lase,
signature R ichard Youu - President
Acceptance of Proposal -mc above 1>r.Ces,sTecifications f
a
rs
nd conditions are satisfactory and are hereby accepted. You arc authorized Sig t -
to do the work as specified. Payment will be made at outlined above.
*"--)
Date of Acceptanoe. — j
4'
Version!.7 Commercial Building Permit May 15, 2000
::SECTION it) STRUCTUI AL,PEER i1EVIEW :CMa:AS0:11)::: ;! :_ .`;:::. ;,;
•
Independent Structural Engineering Structural Peer Review Required Yes ® No do l
• • SECTION :11 = OWNER'AUTHORIZATION.y TQ BE.COMPLETED - WHEN..
' OWNERS AGENT OR;CONTRACTOR; APPLIES FOR BUILDING:PERMIT;'s:
I I .• ___ '�• , as Owner of the subject property •
hereby authorize Ito
act on my behalf, in all matters relative to work authorized by this building permit application. • � „,_.� „
Signature or Owner ( Date
•
1 ,i i , () I / .G , 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. •
Si ned under th _ fns eraalti s of o . ! } cv —--- �--�—
•
1 1��1(IVLL V
Print Name %� s . f ..• M ... ,._. �.�..� �, _.... .
Signature 'Owner /Agent Date •
SECTION.T2:= CONSTRUCTION SERVICES •,: :
10.1 Licensed Construction Suaery , o : Not Applicable ❑
ram° of Wen°° Holder : - License Number
Expiration Date
Address
Signature f Telephone
.
SEOTIOfJ13= WQEtKEitS! CO INSUI�ANEE A FFIDA V I'1•- . ( M.G,L :; c. ; 157 ; § 25 1 ; 6)): .:: ,`•:•
Workers Compensation Insurance affidavit must be completed an sub 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
•
. ,
• Yersionl.7 Commercial Building Permit May 15, 2(100
at:c a PRUFE$elUNAL.• ESIt3N'AND GdnSTRUGTION.5ERYIGES =FOR U1L'DINOS STRUCTURES. SUBJECT TO •
CON9TR CONTRO �fN
PIUR3UT-TO 770 GINR 1ie CONTAINING; NIO AN,00
REiTN'300_C:FJrOF ;ENCLOSED 9 C
0.1 Regis te r e d d
Not Applicable CI
Name (Regiatnmt):
Registration Number
. Address
' Expiration Date
• Signature Telephone
8.2 Registered Professional Engineer(s): --°
Name Area of Responsibility 1
[ I C. _. ww_ 1.1
Address Registration Number .
I------I I------I
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
IL 1
Signature Telephone Expiration Date .
I I
Name Area of Responsibility
Address I Registration Number • I
Signature Telephone Expiration Date
•
1 .......___,.........______1 I
Name Area of Responsibility •
Address Registration Number
1 1E L
-
Signature Telephone Expiration Date •
11.3 General Contractor
Not Applicable 0 .
• Company Name: .
Responsible In Charge of Construction
L
Address I
SlgnatUle Telephone •
•
{g_ QP> �T
Yersionl.7 Commercial Building Permit May 13, 2000
a-
Existing Proposed Required by Zoning
ml, column to be filled in by
Building Department
Lot Size I I I I I
Frontage 1 I I ----_ I I
. Setbacks faug = 1 1
,Side L :1 I RI I Li I R:I=1 L_._.J
f 1 11 f 1
Building Height t - °�-- j I I
Bldg. Square Footage [J 1=1 ° ri r I
Open Space Footage a/
minima bldg & paved I I 1_1 I = I 1
# of Parking Spaces I I I I
Fill:
(volume & Location) �_ ..�..�._.M......._.......� �.._. w._.,.-.._... _»M,............,...,.....w.,._ _,_ � .
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: ( 1
IF YES: Was the permit recorded at the Registry of Deeds/
NO ® DONT KNOW YES
IF YES: enter Book I Page ' ] and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® - Obtained 0 , Date Issued: I__.__.!
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: f
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 pert 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.
•
- .
Yersion1.7 Commercial Building Permit May 15, 2000
..,
•
. . . . . . . . . .
SECTION it•tONSitUCTIGN SERVICES FOR PROJECTS LESS THAN aa,boo: .
FEET.b SPACE. • : : ; :; •• • :.• ...:: • : • .: : • .E :.:::..
interior Alterations El Existing Wall Signs 0 Demolition 0 Repairs 0 Additions 0 Accessory Building 0
Exterior Alteration 1:3 Exisfing t3round Sign 0 New Signs 0 Roofing* Change of Use 0 Other 0
Ada Description Enter a brief description here. See
Of Proposed Work:
. . . .
. .
.. ... . . . .. •
SECTION O USE prtowlmi5.con5fRucfpfribipEi
I
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 0 A-1 0 A-2 El A-3 0 1A 0
A-4 0 A-5 0 _ 18 0
B Business 1111 2A 0
E Educational 0 2B El
F Factory 0 F 0 F 0 2C El
N Nigh Hazard L3 . 3A 0 ...
I Institutional 0 1-1 0 1 0 1 0 38 El
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 CI R-3 D 5A 0 ... ,.
S Storage 0 S-1 0 S-2 0 5B • 0
-•— -- 1
U Utility 0 . Specify:
. 1
M Mixed Use 0 Specify: -
- • -
S Special Use 0 Specify. ....._ . _
. E.----------- —
. . i
. . . . . . . . ... .
. • ". COMPLETE:iiii&SEOlION IP busTiNfi I30ILOINO UNDEROOINd tieN(WAfi.oNs; ADDITIONS 6No■ciFf:GHANGE IN USE
. . . ... . .. . . .. . ..
Existing Use Group: 1 1 Proposed Use Group: I I
Existing Hazard Index 7130 GMR 34): I 1 Proposed Hazard Index 780 CMR 34): 1...._____ _I
•
SECTION: 0 Afib AREA. .... ...]
. . .. . . . ...
- . - :'...•'.,(DEF,ICE:.USEIONLY.......:
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
1;•;'::. f.'.;f '':•.:i.
Floor Area per Floor (et)
J:..i.',......= :• F ; e i i . ".9' ,' Z'A - iii - ,!'-: : ',.;- • '-' • -i . .. : :::f1Y..*:•:;' - .;'.' . '
•
,.. ..... : , 1-4 •.c: ;: 't... '•'.. — •!...i '
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,
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2" I 1 2"d 1 ..4 .;;;'
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i 3 ,4 (2 --------------- "=: " ...,-; ''.- l' ''' ' " i' 'Llt,r"ii'.' i•,, :t.....J.: , .
3rd I I ...:ii:i•.Y,'. .: .,*
- .1 , , , ir..:::: : :4.f:',...w.A. - 4; :: ::: , -:;1:-74F:F , :+7 , -, -. fc.- .....,...: A •:.'
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:.;:. Tr. -..,.,. • ', :i.r.. ..; ':: .1 :,-' :. -
,..,!'!"?.,.;!..,..j.:q. .'/;-:. :" ...••••.. '
Total Area (sf) L I Total Proposed New Construction l..e :•: ;• ,:•/. f...
1 ':::i'..-::....:.:!:•:....;;:l'•:',;::!g•'.....,Y.'1•1'.1V.,;• '',.:' '.', ...; • :.; •••
Total Height (II) I 1 - ----,
Total Height ft 1 ------- ...._ j •-•'.•,:-; i ',;::: ; .::47,12.V.,1:".„ 1 -,*r:..'H2.x.c., ,, .7.1,4:..:".':'. : '','-'.-,--- -I. ,''. ... •
". ''''''''.1041-:;2."'''';:fr. '.. '! 1 f i 1. 2 C ...,... ,: ; . . ;.... • .. :, ■
'..,...i•!, .-.; t'l: OW! ' ' , % . 7T ,. 0 . 4 1 : . V: '..... :....,,*;. ..: ..: ' • . •'.. ' '. '..
• : .::..„,•,i...-:.;: :•;,:•;;;;S4.i..ag.41 -, '' ' ...: 1 • .- • •
7. Water Supply (M.G.L c. 40, § 54) 7.1 FlogslignajnforrnatIon: 7.3 Sewage DIsposerSystem: - -
Public 0 Private 0 Zone I 1 Outside Flood Zone Municipal 0 On site disposal systemEl
• .
... ,
•
•
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1
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,
• _ D Versionl.7 Commercial Buildin. Pennit Ma 15 2000
'ty of Northampton , •
40 2- 9 : ilding Department
'12 Main Street
- • Room 100
v ' o ampton, MA 01060
• phone 413- 587 -1240 Fax 413 - 587 -1272
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 provertvAddress; , ' 4, ; '' 1 'This'l;ef�tion:td:ls cvt'ifple ed -.,:.
�. E by bfficl}
`'^ vyV� , J )f.iViifi �iN + �.4M- t 'ee' tl i �e't,'} , r�'g , �h �r � r .
/ V Lr! y (.0 LL/ � v) S - - � '�' F ,`; �rr3t �.' .� c`�T, " r -o+" �' ` .�. `� r` at t �.
�. i }1 l:bfhi'1; t.
I y, ., M(Ai>"1 Si-. k C a i s + r f r yi ' °" 'teag 1 a r n 7 +
Ai � �.. I f.. � 1/11 � j' of t - i is t u » ;+ . 4 . ;" i 7• t! � �.r r. - s ' t rt 7.
r+• ill M I ones t Overia is�r)� t r,�,x
:}�; S {'t blbtrCt l if fY t�1�(id' t GIS^ ":.,10
. t 3�
SECTION 2 - PROPERTY OWNERSHtt' /AUTHORIZED - AGENT,
•
2.1 Qyvner of Record:
1 n i iL lj� per_ M4
Name (Print) Current Melling Address:
-/3 ?/ -1110 .
Signature Telephone
tt. ed. et .
Name (Print) , 1 Current Mailing Address:
Signature ��� Telephone
: SECTION 3'�E CONS U CTION COSTS • • : l
Item Estimated Cost (Dollars) to be • ... Official Use Only::. ::
completed by permit applicant ::. .
1. Building a Buildin Permit Fear:: ` �
_ ""�"""
, I 1`� 000 .:f) g ..
2. Electrical (b) Estimated Total Cost of; • - : :-
. :..Construction froln 0 :::..:... :. : :::'.
3, Plumbing ( y
4. Mechanical (HVAC) 1
5. Fire Protection
6. Total = 1 +2 +3 +4 +5 4 9• ow. 00 �- ! (
• ...•'..: this , SeCtion For Official Use Only ::: • •• .. .--..... .. .. .
Building Peiniit Number,: D at e
:.:•:.::.:.:: :: •:•. issued'
Building CommissioryeF /Inspectorof Buildings : . . . . . : . . . : : D a t e
File # BP- 2011 -1107
APPLICANT /CONTACT PERSON YOUNG ROOFING CO INC
ADDRESS/PHONE P 0 Box 60056 FLORENCE (413) 584 -1367
PROPERTY LOCATION 142 MAIN ST
MAP 32C PARCEL 003 001 ZONE CBU100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out %7y /I//
Fee Paid (!� a
Typeof Construction: INSTALL CARLISLE ROOFING SYS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 011878
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN, F ATION PRESENTED: —
lNA ;
Approved Additional permits required (see below) �/ Ca7 fi �' N' f (lA t
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
63t/
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.
142 MAIN ST BP-2011-1107
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP- 2011 -1107
Project # JS- 2011- 001783
Est. Cost: $19000.00
Fee: $114.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: YOUNG ROOFING CO INC 011878
Lot Size(sq. ft.): 4835.16 Owner: WINSTON BENNETT LLC
Zoning: CB(100)/ Applicant: YOUNG ROOFING CO INC
AT: 142 MAIN ST
Applicant Address: Phone: Insurance:
P 0 Box 60056 (413) 584 -1367 Workers Compensation
FLORENCEMA01062 ISSUED ON:6/30/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL CARLISLE ROOFING SYS
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 6/30/20110:00 :00 $114.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
•
M e t c a l f e A s s o c i a t e s architecture & interior design
142 Main St. Northampton, MA, 01060 Tristram W. Metcalfe III, Ma. Reg. 5393
Phone number > 413 586 5775
Cell number > 413 569 8200
Email >
NCARB, NYS, MA, CT
registrations
WMAIA
AIA
April 16, 2010
Louis Hasbrouck
Building Inspector City of Northampton
Puchalski Municipal Building,
212 Main Street, Northampton, MA 01060
RE: Add a room to Suite 2 @ Winston building
142 Main St, Northampton, Ma 01060
Dear Louis,
This is a statement of my 780CMR Sect 16 involvement in above project to add a small room
in the corner of Suite #2 at 142 Main St. It is for the new tenant Dr. David Hammond, who is
moving his therapist office there.
This is a very small project in the 2nd floor space. It will be similar 2x4 wood and gwb
construction to existing in this fire protection sprinkled building with its wood frame construction
within masonry walls. The existing sprinkler layout works perfectly with the new wall location.
I am acting as the permit holder for the owner and tenant. There will be another 36 wide door
installed in the small 7ft x 10 ft room.
* Applicable codes will be adhered to;
780 CMR: Massachusetts State Building Code, 7th Edition
521 CMR: Massachusetts State Building Code Architectural Access
NFPA 101 Life Safety Code
All with amendments, as promulgated by the state board of building regulations and standards.
I will provide any information as requested.
Sincerely,
Tris Metcalfe, ' _„00.
Ma Reg Archt #539
The Commonwealth of Massachusetts
• Department of Industrial Accidents
Office of Investigations
~ � -1.+ 600 Washington Street •
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/Contract ors /Elese P nt Le G
Plea Pri Leg ibl er y
A. .licant Information
—
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. E1 I am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub contractors
listed on the attached sheet. 7. ❑ Remodeling
2. n I am a sole proprietor or partner-
have ors - contrac
These sub-contractors h Demolition
ship and have no employees 8. ❑
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ET We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. ❑ Plumbing repairs or additions
3. ❑ I am a homeowner doing all work
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.
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
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: Date:
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 #:
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) I
Independent Structural Engineering Structural Peer Review Required Yes Q No Q I
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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 the pains and penalties of perjury , e e _ m _ �.. ... . ...
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
License Number
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 0 No 0
Version1.7 Commercial
City p f Building permit Ala
BUilding Department y is 2000
212 partment : tat s nt use oniy
Main vt Perrt urb'Cu t/Driu
Room 1 C ut/Drivewa y
Nort hampton, O
Sew er/Septic � rtnrt
Phone 413 -587_ MA 01 060 Water R trc,gyarlab i jlty
1240 Fax / eligvarrabrtity'
413 587 - 1272 Tw Sets of S
'N TO CO NSTRUCT , Plot/Site plans, cturaj plans
RUCT, REPAIR,
HER OVATE' CHANGE Other Specify
OT THAN THE USE
E INFO A ONE OR TWO FAMILY OR OCCUPANCY OF
OR DEMOLISH ANY BUILDING
INFO RMATION
D WELLING
ress:
Map
... ._ .............................
This
rn
section to be completed by office
Lot
Unit
Zone
'RN OWNERSHIP/AUTHORIZED Overlay District
AC, ^ Elm St District
ENT CB District
‘" ,
"t 1-S
cj edr e ,
Current
Mailing Address:
T elephone
Gol c.r
— 42
Current Mailing Address' '°
_e. s
__.__._......__._______CONSTRUCTION elephone
RUCTI C
Osrs
Estimated Cost
Estima C (Dollars) to be
ermit a • ••Ilcant Official Use Only
` �Dt7 (a) Building Permit Fee
(b) Estimated Total Cost of
w :.
Construction from 6
O Building Perm
U
Check Number 5 ` tP ,5
°�ialtlse ___
40isrionsimoirmomesonewiwolow."
lit
V ersion1.7 Commercial —ui i . 1c1'ng
Permit May 15, 2000
CTURES
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION-SERVICES - FOR BUILDINGS AND STRU
IN
CONSTRUCTION CONTROL PURSUANT TO 780 C MR 116 (CONTAING MORE THAN 35,000 G.F. OF ENCLOSE
9.1 Registered Architect:
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9.2 , egistered Professional Engineer(s):
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Address , tration Number
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