17C-031 (2) 4(tt�Pp
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060
WORI{ER`S COMTENSATTON INSURANCE AF AAVIT
with a principal place of business/residence at:
OF
,n (phonell)
(stmt/city/stairJ7ip)
do hereby certify, under the pains and penalties of perjury, that:
(� I am an employer providing the following worker's compensation coverage for my
employees worming on this job:
C�)Lam T—n�s - -
(Insurance Company) (Policy Number) =60A Dare)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
y;.
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Comparfy/Poliey Number) (Expiratioa Date)
4,
(N ame of Contractor) (Insurance Company/Policy Number) (Exp iration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(ana ch additional sheet if neo=ary to i och,6&infornoatien pertaining to all contractors)
( ) 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 dod VAWo homoawacrs who emptoy persons to do ammAcmaot,coastrudion or rcpaw work on a dwcllia of
not more then throe uaits is v*h the hon"wacr resides or ea the grovads appurtanantthetdo arc cot gmoralty oonsidcmd tc be
employers under the--ictes compensation.Ad(GL152.=l(5)),application by a homoo�far a Gccase or patnd may Vn&Wo the
leSd crams of as awptoyer anderdw Woslr z Compemation Act_
I undassarid that a.copy ofthis uatcmeat may be foramrded to the Depwmw=at of lndnahid Accidw&Olfioe of Iawranoa for the
eovaaw vetifieation and ttut faikiwe to scam covaw trader suction 25A of MOL 152 can lead to"imposition of rrimiad pestaltia
consisting of a foe of up to 11,500.t?0 andlor impr6onwa t of rip to ace ycw and civil penalties in the fora of a Stop Wait order and a
fine c(3100.00 a day aping tae.
/ For dgnatusxtal um OMIY
l �
' r Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL:PEER REVIEW(780 CfVIR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11-OWNER AUTHORIZATION 70BCICOMPLETED WHEN
OWNERS AGENT`OR CONTRACTOR APPLIES fOR BUILDING PERMIT
de as Owner of the subject propert
hereby a one 1 to act
my be I tterh 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.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION'SERVICES
10 Licensed Construction Supervisor: ( Not Applicablee�❑ '
Name of License Holder:C`•i(-U-<� I'�4 �Yl'1 Cpl L�� %"t t 4'`"6 in
License Number
�- D,1
Address Expirat onn D ttee
Signature Telephone
SECTiO 13=WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION -9=PROFESS IONALDES IGN AND CONSTRUCTION SERVICES- FOR BUILDINGS AND,$TRUCTURES SUBfECT TO
CONSTRUCTION CONTROL PURSUANT TO'78iO 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.Wafer Supply(M.G.L.c.40, 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ 1 Zone: Outside Flood Zone ❑ Municipal ❑On site disposal system C
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 %
(Wt 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
Na
IF YES, describe size, type and location:
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-C7NSTRUCTION'SERVICES FOR PROJECTS LESS THAN;35,006
CUBI£ FE"F0 ENCLOSED SPACE `
Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] -Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs
Bogy DESK P"7 L_C
"SECTIONS-`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 O F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential W 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 ANWOR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6',BOILDWG HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION E(� W
Floor Area per Floor(sf) 1st : ;
2nd
4'"
3'd
$x„
4ei
Total Area(sf) Total Proposed New Construction(sf)
_-------- --------------------
Total Height(ft)
Total Height ft----•---------------
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
Building Department
212 Main Street �
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 411-587.1272 o hSe r
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDIN(
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prop Address: ;z This'section to be completed�by•Office
55 ' �, 1„ _� 1� Map Lot Unit
�`'1�t �� Zone 'Overlay District
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name i Current Mailing Address:
Signa Telephone
2 2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building (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&l
Buildingg Permit'Number, Date Issued:
Signatifre:`
661)dingC6mmissioner/inspect6r of Buildings Date'
s ALE ST BP-2003.0106
GIS#: COMMONWEALTH OF MASSACHUSETTS
17C-031 CITY OF NORTHAMPTON
Lot: -001
Permit: B u l I d i nl?
Category_ BUILDING PERMIT
Permit# BP-2003-0106
Protect# JS-2003-0209
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Cyrus Newman 064690
Lot Size(s4. ft.): 13808.52 Owner: OLANDER FREDERICK G&KAREN W
Zoning:URB Applicant: Cyrus Newman
AT. 85 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:7130102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/30/02 0:00:00 3287 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo