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35-045 O4 jVLAMP�0 a� Crx laf 'Wart 1jaillp foil Z as �resaxraasrtls' — m DEPARTMENT OF BUILDD\TG INSPECTIONS 212 Main Street ' Municipal Building 'e Northampton, Mass. 01060 WGRICER'S COMPENSATION INSURANCE AFFIDA.VTT (IicensecJpermitiec} with a principal place of business/residence at: (phoner�) (stir.ucity/seal zip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compcnsat�on coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration 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) (Insurance Company/PoLicy Number) (Expiration Date) r_ (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date) (attach additiowl short ifneocssary to include inforrneion pertaining to all coatr o ) 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 vihilc homeowners who employ pcxsom to do maintenance,suction or repair work on a dwelling of not mote than three units in which the homeowner reside or on the gr jn&appurtenant tbatto an no(gcoauUy oowukrcd to be employers under the workcez oompcas4ca Act(GL152,vs 1(5)�application by a homeowner for a Gccusc or permit may cvidcnoc the legal ctahra of an employer under the Wackeet Compensation Act I understand the a copy of thin ctatcaumd may be forwarded to the Department of Industrial A=dw&ollioe of Insrusnoo for the coverage verification and that failure to acorn coverago under sectioa 25A of MOL 152 can lead to the imposition Of aiminal pcaakie ooasisting of a fine of up to S1,500.00 aad/or imprison of up to one year and civil pcn&Wcs in the form of a Stop Work OrrSc and a firm of 5100.00 a day against ar- For dgzutmnal use oaty Permit Number II bp#_ — LOt# Signature LicensedPermi.ttee ' r 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......❑ No......❑ SECTION 11-OWNER AUTHORIZATION -TO BE COMPLETED'WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date r 1, wCkrA as Owner/Authorized Agent hereby declare that the statement 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. 0"X\,rck Q yi,J l) Print Name �j V� 07 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number v rv-, 1\ t,i�r�.`7 51s I C Address Expiration Date Signature Telephone 1 ��11JN CQ��tVCtoa� 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 issua.Qce of the building permit. Signed Affidavit Attached Yes....... No...... ❑ ' f 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 92 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 Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone `+ Version 1.7 Commercial Building Permit May 15,2000 7. Water Supply(M.G.L. c.40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ I Zone: Outside Flood Zone ❑ I Municipal ❑ 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: Version 1.7 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 Existing Ground Signs Additions ❑ Roofing ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Qther [ ] ❑ Accessory Building[ ] Repairs [� SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ lA ❑ 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): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY ,. . Floor Area per Floor(sf) St 2nd Est_ 2nd 3rd 3rd 4th �. 4th Total Area (sf) Total Proposed New Construction (sf) ......................... Total Height(ft) Total Height ft ----- - - -------- Versionl.7 Commercial Building Permit May 15,2000 ­,City--: of Northampton � Building Department _r v 212 Main Street Room 100 I JUN 1 3 .007 444 rthampton, MA 01060 e k phone_J13. 87.1240 Fax 413-587-1272 PLICAT F6N F©'CdNSTmT, 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 i" RA Map Lot Untt` �j Zone, Overlay District Eli m St` District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: illlxlr� J�CZc'I!` �1C37 1�{fjG'Aa Name(Print) Current Mailing Address: Signa r Telephone 2.2 Authorized Agent: t�wGe �l?i?U N 13.b E.G.Sl S� (a 1AS3� CA C1 ON Name(Print) Current Mailing Address: Xt� Signature Telephone SECTION 3-- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building , s (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 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building,Commissioner/Inspector of Buildings Date File#BP-2007-1213 APPLICANT/CONTACT PERSON EDWARD QUINN ADDRESS/PHONE 126 EAST ST EASTHAMPTON (413)527-9408 PROPERTY LOCATION 967 RYAN RD MAP 35 PARCEL 045 001 ZONE RR 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: REPAIR SILL PLATES ON GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 055499 3 sets of Plans/Plot Plan VFOATION OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON PRESENTED: ed 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 Signature of Building Of icial 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. BP-2007-1213 GIS#: COMMONWEALTH OF MASSACHUSETTS 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-2007-1213 Project# JS-2007-001936 Est. Cost: $875.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: EDWARD QUINN 055499 Lot Size(sq. ft.): 31842.36 Owner: SLEZEK EDWARD M Zoning:RR Applicant: EDWARD QUINN AT: 967 RYAN RD Applicant Address: Phone: Insurance: 126 EAST ST (413) 527-9408 EASTHAMPTON MAO 1027 ISSUED ON.611512007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR SILL PLATES ON GARAGE 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 6/15/2007 0:00:00 $25.001273 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo