23B-046 (119) • 4-KN�PTO
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060 �~
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
Pi Con Inc./Pioneer Contractors
(Ilcenseelperuuttee)
with a principal place of business/residence.at:
p n n f�orthar�ogt��-1�P�: 8181 (phone#)
(street/ci ty/statrla p)
do hereby certify, under the pains and penalties of perjury, that:
(X) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
`.
Li') t P4iihml Tnquranre C VJC1_31S-491822-0501 6/30/02
Pr
r, (Insurance Company) (Policy Number) (Expiration Date)
rl`
( ) I am a sale proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
k�
e (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compairy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additional shed ifntcenaxy to inchude information peru6ning to all o.atrnciors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whim homeowners who employ person to do mx bAra acr,construction or rzpair work on a dwclliag of
not more than tbme units is which the homeowner resides a on the V=Xh appurtenant thercto arc oot gcoaahly ooandercd to be
employers under the wcxkees coanpcas4ca Act(GL152,sa 1(5))"application by a homcoviW fora Gccnx or Permit may evidcaoo the
legal ctatua of an employer under the Worker's Compamation Ant.
I undastaad dirt a copy of this sxatcmear may be forwarded to tho Doputnca2 of Industrial Accido a&Offroo of lnsuraaoe for the
covaage vaificaum and that failure to&Dante coverago under socUoa 25A of MOL 152 can lead to than imposition of criminal penakics
comistiag of a fine'of up to S1,500.00 axdllor imptisoo of up to one year and civil pcnzWc3 in the form of a Stop Work Ordcr sad a
fmo of S 100.00 a day agniv A M
1 For d�nl wo Daly
Permit Number
M� Lot#
Signahrre of Liceirsc e/Permittee
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW'Q80,:CMR 110.11)'
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11! OWNER,AUTHORIZATION!-TO;BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING''PERMIT
I, Cooley—dicl<inson Hospital as Owner of the subject property
hereby authorize to act or
7S,iVare ehalf, in all otters rela ive to wor au honzed by this building permit application.
cgy Apo 1-/T
of OWner Date Z Z 0 2
I, Pi nnpar f'nntrartnrc 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 th:ra pe ti f p rjury.
Print Name
David A. Claxton
Signature of Owner/Agent Da e
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Pig,Pr I sntr-2.t 017890
License Number
P.O. box 1145 Northampton, HA, 01051 1/19/04
Address Expiration Date
X/ 5RA-5491
Sig tur 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 affidavi'.
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9=PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -',FOR BUILDINGS,AND STRUCTURES SUBJECT TO
CONSTRUETION;C,ONTROL PURSUANT T0;780 CM 116(CONTAINING MORE THAN 35;000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Fcil�arrl I lanrlr)i A �}„� Gf^�
Name(Registrant): KiA • Yr
Registration Number
Heal thCnrP llrrhhi farf , IpQ
Idd ;,re rt:h m 11A. 01060 4 P Expi ion Date
Telephone
92 Registered P f Sion AL14g ineer(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
' Versionl.7 Commercial Building Permit May 15,2000
• 7.Water�lipply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage.�isposal System:
Public t� Private ❑ Zone: Outside Flood Zone ❑ Municipal 8 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:
• Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET`'6' NCIOSED;SPACE"
InteriorIterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs [ ]
n
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 ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
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 ❑
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):
SECT10N;6,131JILDING HEIGHT AND AREA
OFF GE-.USE",' `f
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) Sty
1 ? qtr
k
2nd
f -•`"E.
I St
3rd
2nd
3rd 4th
4th
F
> Total Area (sf) Total Proposed New Construction (sf)
------------- --------------------- 5 ,
Total Height(ft)
Total Height ft --------------------
Y Versionl.7 Commercial Building Permit May 15,2000
C* ampton ;
k
� ul artment
+, 212 i Street
u FEB 2 5 2002 R oo rte
Northam ton, MA 01060 U, 8 �
oEphtbmAdl, i Y 40 Fax 413.587-1272 Site
►oRTHAMPToN,M.A OIC60 �
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 b6 completed by o ffice
3
30 Locust Street !ao� Map Lot` Unit
Cooley-Dickinson 'ioSDital Zone Oyrerlay btstrict°
Elm St. District CB`District
Radiology Rm. 4;3
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
—Name °a' gnitalgnital S3mp AG Ahova
Name(Print) Current Mailing Address:
�11 (Facilities\
Signature Telephone
2.2 Authorized Agent:
Pionpp��ntr @stars r HA. 01061
Name(Print) Current Mailing Address: 9
586 54l9l
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official`Use Only
com feted by ermit applicant
1. Building (a) Building Permit Fee
20'00g 00
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
N;/A
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 +-3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Po a` '" Date Issued:
Signature:
Building,Commissioner/Inspector of Buildings Date
File#BP-2002-0729
APPLICANT/CONTACT PERSON Pioneer Contractors
ADDRESS/PHONE PO Box 1145 (413)586-5491
PROPERTY LOCATION 30 LOCUST ST-FLUORSCOPY G203
MAP 23B PARCEL 046 001 ZONE M
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RM G203 -CEILING&PARTITION ALTERATION&SOFFITT
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 FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Commis n
i
Z L� 264 2---
Signature of Buil ing 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.
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