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23B-046 (119) • 4-KN�PTO .�O e LL//((; x� of 'Wart jatlyf ail z BB �lasascf(nsctfa' `b 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. �s�+q A ax^ 4 { ' r A x 3 i ��Y C MUM lm� A-jalb forY ' }u s sy lot .0 Top lot"94yoxygy C '( l 1.. 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