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32A-121 (6) Keith Graham Construction 413-210-7717 Dec. 19, 2014 Dear Sir or Madam: I request that you grant a modification to waive the requirement for control construction for the project at 71 King Street in Northampton because the work is of a minor nature,will not affect health, accessibility,life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfull Kei am Keith Graham Construction 16 Corticelli Street Florence, MA 01062 The Commonwealth of Massachusetts 3 Department of Industrial Accidents Office of Investigations t r^_ 600 Washington Street =' Boston, MA 02111 '. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl_/ Name (Business/Organization/Individual): �q Address: / r_Qi"7ZI*Ce°�/% J�/C'e1- City/State/Zip: OrG7Ce A D 6/_-'Phone#: / Z 6 Are you an employer? Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Ix Remodeling ship and have no employees These sub-contractors'have g. ❑Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. o workers'coin right of exemption per MGL y p 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. hnsurance 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 der thepains andpenalties of perjury that the information provided above is true and correct. Sienature: Date: l lrb Phone#: 7 7/-7 F nhv. Do not write in this area, to be completed by city or town offeciaL : - - — - - Permit/License# ority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector [6. Other Contact Person: Phone#: Versionl.7 Commercial Building Permit May 15,2000 4 SECTION 10-STRUCTURAL PEER REVIEW(780:CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 -OWNER AUTHORIZATION-.70.BE COMPLETE.P WHEN.'`' OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _..... _ as Owner of the subject property hereby authorize -/ Y;( ESL act on my beh matter I ve work authorized by this building permit application Signature ner 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 Signatur of Owner/Age Date SEC ION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder: Caf "�AYr,�, _. .._... ___ .�,:: _._ C. 0. t� License Number Addre Expiration Date gnat e- 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 affidavit will result in the denial of the issuance of th building permit. Signed Affidavit Attached Yes No �j 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 Eq.,CLOSED: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 i . ..... .......... ...... ......_. .. _....:.......... ._ ._ F .. Address Registration Number Signature Telephone Expiration Date .. _ .:....__ __._._ _.... Name Area of Responsibility Address Re istration ' 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 _Z _. Address �!l z�6 771 Si nature Telephone Version 1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON.ZONING Existing Proposed Required by,Zoning . This column to 5e filled in by Building Department Lot Size _. ...... ...__.... _µ Frontage Setbacks Front _.....w.. Side L:_.__..._J R.3 .. L__.....__. R. ... ...__ _.. _ _._..... Rear Building Height _...._ ...:.__, Bldg. Square Footage % ----1 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 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 mYES 0 IF YES: enter Book Page and/or Document#, B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. MW 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 ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Ex' ting Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other F-1 Brief Description E e rl hi� T& Of Proposed Work: 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 El 1 g ❑ B Business E] 2A ❑ EEducational ❑ ZB I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 11 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: COMPLETETHIS 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) 151 _ _ .. 1St 2nd 2 nd .. .. ....._ ..._....._._ ..........__....._._,i 3 d 3rd 4th 4th . Total Area(so Total Proposed New Construction(sf) 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 E] Municipal ❑ On site disposal system❑ - Versionl.7 Commercial Building Permit May 15,2000 Departure t use,on)V City of Northampton status at PerrrtEt Building Department Curb Of/Dnveuvay Perrrct .i � 222014 212 Main Street Sewer/Septtc YZI I ROOM 100 Water/Well Availability e ,6 F �N pection orthampton, MA 01060 Two Sets of 5tructuraE-Plans e 3-587-1240 Fax 413-587-1272 Plot/Site Plans 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 Property Address: This section to be completed by office �! �1AW Map Lot Unit .y ✓� - 1 Zone Overlay District -_- Elm St:District' C13 District SECTION 2 'PROPERTY OWNERSHIP/AUTHbRIZED+AGENT 2.1 Owner of Record Name(Print) �� Current Mailing Address Signature Telephone 714 J1. 2 2 Auth ize ent e� :� Name(Print) Current Mailing Address Signature Telephone SECTION 3-ESTIMATk/11 CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official'Use Only completed by ermit applicant 1. Building J (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 _ .......... ..... .... 3. Plumbing G� v Building Permit.Fee A-pop 4. Mechanical(HVAC) _.._......... _„ - 5. Fire Protection _... 6. Total=(1 +2+3+4+5) d Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings i Date File#BP-2015-0682 APPLICANT/CONTACT PERSON KEITH GRAHAM CONSTRUCTION ADDRESS/PHONE 16 CORTICELLI ST NORTHAMPTON (413)582-6890 Q PROPERTY LOCATION 71 KING ST MAP 32A PARCEL 121 000 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out o n .a I � Fee Paid Tyl2eof Construction: REMODEL 2ND FLR BATH New Construction Non Structural interior renovations Addition to Existingti AccessoU Structure Building Plans Included: Owner/Statement or License 075895 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: proved 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 e it' Delay Si re of uil mg O cial 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. 71 KING ST BP-2015-0682 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 121 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0682 Project# JS-2015-001308 Est. Cost: $5500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITH GRAHAM CONSTRUCTION 075895 Lot Size(sa. ft.): Owner: J W INC C/O WHALEN INSURANCE zoning: CB(100)/ Applicant: KEITH GRAHAM CONSTRUCTION AT. 71 KING ST Applicant Address: Phone: Insurance: 16 CORTICELLI ST (413) 582-6890 O NORTHAMPTON MAO 1060 ISSUED ON:1212212014 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL 2ND FLR BATH 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 12/22/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner