17C-220 (6) R.C.1 ROOFING
40 MAINE AVE,
P,0. Box 309
EASTHAMPTON, MA 0027-0309 ((==ES TZ MA TE-,)D,)
PHONE (413)627- 477 S low
FAX (4-13)527'4WS ---- -, .
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DEPARTMENT OF BUILDING INSPECTIONS
212'Main Street a Municipal Building '
Northampton, Mass. 01060
WORRER'S COMPENSATION INSURANCE AFFIDAVIT
(1i r=M* )
with a principal place of business/residence at:
Z46 fna0rtti . wit- � � a��.,a\c�� �\a• 0A0Mhone# 1'u
( •ty/staW2ip)
do hereby certify, under the pains and penalties of perjury, that:
(VK1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
6)C\31 S•31T IS-611 10-5-0�
ansumace 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:
_ t
R; (Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PaUcy Number) (Expiradon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shod ifaw=uy to ind. 6&cmatioa pertaining to au oodraclocs)
( ) I am a sole proprietor and have no one working for me.
( ) I am a homeowner performing all the work myself.
NOTE:please be aware tilt vrhilo bomoownea who employ pc=m to do maiamsaoe,coosuvwoa•ar r cPair wort:on a&XIling of
nog an"than tbroe units is which the hoamwocr raida or m the grounds VVAdeoLaiberoto an oot geoerally 000sidcmd to be
c*oY=uada the worker's compeasatim Act(GL152 fs 1(5)),applimtioa by a homeowoir for a Gant•a permit nay evWc=the
Iega1 status of an employw under the Wockar's C,oaVpozWm Alt
I understand that a oopy of this suLecocat array be forwarded to the DcpacCnaos of Induatriel AoeidaW OXoe of 1—iry w fa dw
eovcrago Wrificd1w*ad that failure to&•nine coverage under soctim 25A of MOL 152 an lad to the inlpo oar of aimiasl peaaltia
oomistiag of a fine ofup to S I,300.00 sadly impeisoamwt of tip to ooe yt sad Civil penalties is the form of a Stop Walt Older and a
ter»of 5100.00 a day against tae
For drat use coty
Permit Number
Map# Lot#
Version 1.7 Commercial Building Permit May 15,2000
G !
4*ifr`
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
s a s r e
I, '18M Ow SS d SP1WLC'& 'No—t , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative tow k authZded by this building permit application.
aLa0-ho-d 9 13103
Signature of Owner Date
I, r' ����F _ K �_ —C' . 9�4:Lk n , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing applicati re true and accurate, to the best of my
knowledge and belief.
signed under the pains and penalties of perjury.
r
Print Name
Signature of Owner/Agent Date
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: � \ )� \\S��� o-1 Ll S� a1-4
License Number
,A() '5- O� �- O Jf
Address Expiration Date
Signature Telephone
SET
C6
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....... ❑ No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
f
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 lY
Company Name:
Responsible In Charge of Construction '
Address
Signature Telephone
Versionl.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 ❑ 1 Zone: Outside Flood Zone ❑ Municipal ❑On site disposals stem ❑
S. 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
Interior Alterations Existing Wall Signs Existing EPIgns Additions ❑ FRool'!ng
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ .]
❑ Accessory Building[ ] Repairs [ ]
ish - ES
4SE T 0 S G pU
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 213 ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I 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:
ri .®
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
$4CT O 6
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(so 1:t
1st 2nd
2 nd 3rd
3rd 4th
4 th
Total Area (sf) Total Proposed New Construction(s f)
Total Height(ft)
Total Height ft--------------------
,i
-
1 EI ��?#aY�x'�ii^a75$fbsf64�sc?iet,l�J� -.
City of Northampton <� paf?
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Building Dep6rtmeht t
212 Main Street
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ortham
ptbn, MA 01060
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2. Electrical
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4. Mechanical(HVAC)
5. Fire Protection
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I7.NORTH MAPLE ST BP-2004-0254
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mpp:BBlock: 17C-22P CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0254
Project# JS-2004-0374
Est.Cost:$10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 074334
Lot Size(sg. ft.): 10410.84 Owner: VALLEY PROGRAMS INC
Zoning: GB Applicant: RCI ROOFING
AT. 17 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P 0 BOX 309 (413) 527-4775 Workers
Compensation
EASTHAM PTON MAO 1027-0309 ISSUED ON:915103 0:00:00
TO PERFORM THE FOLLOWING WORK.REMOVE EXISTING SLATE - INSTALL NEW
ASPHALT SHINGLES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Foy;;"alas:
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 Ci"l'� OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/5/03 0:_' ): ?„ 4451 $50.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo