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17C-245 (5) Page 24 of ProForm Magna User's Manual I ManualsOnline.com Part No. 195331 R0303A 11/2/14 6:45 AM Printed in USA©2003 ICON Health & Fitness, Inc. Page 2 of 2 James Mailloux 55 Main St. 2nd Fl. Florence, MA 01062 CS L-081694 Job RE: 85/87 N. Main St. Florence Hi Louis/Chuck, A short note with regards to the property above and the Building Permit i am looking to get granted on removing/rebuilding a new porch in the front. I request that we can grant a modification to waive the requirement for control construction for the project in that the work is of minor in nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of controlled construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, Jim Mailloux r` 11110/2014 —(2448x3264) http://web.mail.comcast.net/service/home/—/?id=331800&part=2&auth=co&disp=i 1/2 4r v 1+ 111, x 4� t 3 # L , f „k hFl- N "4 s 5 � 4 £� r MOM � - a � .s_ � 7l►i ,.M d. gra x � a ; � x tt t G r° " a t _ VJ' q5 X16 OKI pe C4 ` y d4 f The Commonwealth of Massachusetts 7, Department of Industrial Accidents — = Office of Investigations , 600 Washington Street J Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Name (Business/Organization/Individual): Address: S-s /77.41"V f 2A,,P City/State/Zip: !�/'��� /fit A14 ✓/0�,, Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. D I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. [ New construction listed on the attached sheet. 7: ❑ Remodeling 2.91 am a sole proprietor or partner- _ . -- - - These sub-contractors have g. Demolition ship and have no employees working for me in any capacity. employees and have workers' 9 D Building addition [No workers' comp.insurance comp. insurance. 5. 7 We are a corporation and its 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right myself. [No workers'comp. , exemption per MGL 12.D Roof repairs insurance required.] t c. 152, §I(4),and we have no employees. [No workers'. 13.D 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 thepolicy 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 t/xe ains andpenalties ofperjury 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 1::1) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNER AUTHORIZA7 ON-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FORiSUILDING PERMIT I, ........... ..:.... . ......... _:__ .w............___ _..._,_ ___ .._:___ ___ _..,_. _._ __.:_ __._.....___. _ ,as Owner of the subject property hereby authorize act on my behalf, in all matters relative to work authorized by this building permit application. i Signature of Owner Datemm 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 _........ .........._______..._. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ . `,.j l Nameof License Holder..!.__...._d..____.,,.__�.._..w._.._„w_.,,m.�._.._- __�V..�._ . �..._._................... ,,. ._ __....._.. _..... ._. ..__.. License Number Address Expiration Signature Telephone SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L.c.152 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 Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION.S ERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION.CONTROL PURSUANT TO 780 GMR,1.16(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 9.2 Registered Professional Engineer(s): Name Area of Responsibility —------------ ..................... ......... ......... Address Registration Number Signature Telephone Expiration Date .......... ................... Name Area of Responsibility Address Registration urjjLE�_ Signature Telephone Expiration Date .......... ......... Name Area of Responsibility Address Registration Number ................. ............. Signature Telephone Expiration Date ---------- ....... ........................................ ............ Name Area of Responsibility Address Registration Number .......... Signature Telephone I 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 8. NORTHAMPTON ZONING Existing Proposed Required by honing . This column to re filled in by Building Department Lot Size _..__ ._.,..... mM. _. Frontage Setbacks Front Side L ...._? R. m J' L:,' v _ Rear Building Height s Bldg. Square Footage Open Space Footage _ (Lot area minus bldg&paved parking) #of Parking Spaces l ....... ..... . . . ......... _,_...__..._. _._._ _ Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page, and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO DONT 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 0 NO I IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 part 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. Version 1.7 Commercial Building Permit May 15,2000 J i SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 1 CUBIC FEET OF ENCLOSED SPACE -" Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ - " m Brief Description Enter a brief description here. fir"UX�S�i n /��"�� ✓��N �C� i kl trc� Of Proposed Work:_ SECTION 5-USE GROUP AND'CONS.TRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly El A-1 El A-2 ❑ A-3 ❑ 1A A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B - r ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H-Hi h Hazard ❑ 3A ❑ Institutional El 1-1 - El 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 t ..-........ M Mixed Use ❑ Specify - V � V S Special Use El 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(so q. 1 St # 1st _..._. 2nd 2"d ....__...__ rd 3 3rd th - 4 Total Area(so Total Proposed New Construction sf) w,mw Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system E_] Versionl.7 Commercial Building.Permit May 15,2000 � -, Department use;only �____.__ City of Northampton status pf Permit ��� 02014 �`i Building Department eirrh cut/Dnrreway Permr 212 Main Street Sevier/SeptcAvailabr[Ity Gay �nspect'cns Room 100 WaterMfep Rvailability Electric,Plump t� c hampton, MA 01060 Two`Sets ofi Structural Plans Nc;?hU r." phone 413-587-1240 Fax 413-587-1272 Plof/Site Plans ' '7777 7777� Other Specify 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 PropertyAddress This section to be completed by office Map 1-702, Lot �q� Unit M,4 Zone: Overlay District - - EIm St.District' CIB District SECTION 2-:PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: .r�/LCJ62: _.. _ __._ (�'j•�+�N f C tin J iF (r� fit, Name(Print) Current Mailing Address: _ Signature � Telephone 2.2 Authorized A en .. . ..........._ . __.. Name(Print) Current Mailing Address:W, _. .._.....__.__.__ Signature Telephone SECTION 3'-ESTIMATED:CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (6)'Building Permit Fee 2. Electrical (b),Estimated Total Cost of L. / I Construction from 6 _.... ..._.._.._r__... 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection _/�.✓., �.c/a/_. _..., _..._.: 6. Total=0 +2+3+4+5) Check Number This.Section For Official.Use 0nl Building Permit Number Date Issued Signature:__ Building Commissioner/Inspector.of Buildings Date File#BP-2015-0541 APPLICANT/CONTACT PERSON JIM MAILLOUX ADDRESS/PHONE 55 MAIN ST-2ND FLR FLORENCE (413)563-4654 O PROPERTY LOCATION 85 NORTH MAIN ST MAP 17C PARCEL 245 001 ZONE URB(100)/ 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: DEMO&REBUILD FRONT PORCH(,SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 081694 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO!jMATION 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 Commission Permit DPW Storm Water Management l' ' n Delay 1 Signature of Building fficial 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. 85 NORTH MAIN ST BP-2015-0541 GIs#: COMMONWEALTH OF MASSACHUSETTS MW.Block: 17C-245 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0541 Project# JS-2015-001019 Est.Cost: $10200.00 Fee: $61.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JIM MAILLOUX 081694 Lot Size(sq.ft.): 15681.60 Owner: MAILLOUX JAMES Zoning-: URB(100)/ Applicant: JIM MAILLOUX AT. 85 NORTH MAIN ST Applicant Address: Phone: Insurance: 55 MAIN ST - 2ND FLR (413) 563-4654 O FLORENCEMA01062 ISSUED ON:11/14/2014 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO & REBUILD FRONT PORCH (SAME FOOTPRINT) 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 11/14/2014 0:00:00 $61.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner