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18D-055 (15) itT t�e°t, ��xtha� pton MA 0 1060 Y c r a Solid Waste.Disposal Affidavit In accordance of the provisions of NIGH. c 40, 554, I acknowledge that as a condition of the wilding permit all debris resulting from the construction' activity governed by this wilding Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined,by MGL. c 'I 11, S 150A. Address of the work: -�-f ZztafolA The debris will be transporter[ by: � ��11�a—S The debris will be received by: Building perm i .number: Name of Permit pplca J Y x £ 2 c r f s ; s r �;2s fy' g "-'-W ................ "S ........... tR Version i.i Corulaercal Building Pafit N1ay 15,2000 g SECTION .PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES.-FOR BUILDINGS AND STRUCTURES SUBJECT T(7 f CONSTRUCTION CONTROL PURSUANT TO 780 GMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) rZd-dress d Architect; Not Applicabi+ nt). _.�..._____.w. Registration Number piration Date Telephone 9,2 Registered Professional Engineer(s).; Name` Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name` Area of Responsibi tty/ Address .•, _ Registration Number Signature gqcptratiOn Date G Name x,„ . Area of Responsibility e Registration Number Address s. r� ra#rrat ` ., Date Wes'• y At rose, r g s a: } y � / version 1.7 Commercial Building Permit N10 15,21100 OrION STUCTURgL PEER REVIEW(�8t}CMR 110.11} ]rde SOCaN 12 S Structural Ersgineering Structural Peer Review Required Yes No AGENT OWNER AURORt ,4TlOK•T3 BE GOMPLE TED WIN OR-CONTRACTOR APPLIES FOR BUILDING PERMIT } to hereby .. _.m_.. _..n .. act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I# as Owner/Authorized Agent hereby declare thatthe staternents and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed'under the pains and pgraities cif perjisr _ _._ Print Name Signature of Owner/Agent' Date n SECTION 12-CON.T.RUCTIQN;3ER1t1OES x blot Applicable 10.1 Licensed C+onstruct�ot �- tdame of I.Icera Halsfsc 4 Lacer q se ttrrttasr _ b a d rM 1 i t • �.. „n � 1 '� vy t� r Nf ,fW c - �--_________- 04(-i ce �� _ " City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 7)7 thou, The debris will be transported by: 'V1 � The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant `- The Commonwealth oflMassachusetts -- _ Department oflndustrialAccidents — � r Office of Investigations 600 TfJ ashin Oj ion Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Afflidayit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibIy Name (B usin ess/Organizati on/Indi vi dual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4. Ej 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. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. 7 We are a corporation and its 10. Electrical repairs or additions D. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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. 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 inform ation. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do.hereby certify under the pains and penalties of perjury that the information provided above is true and correct. S i mature: Date: Phone#: Official use only. Do not write in this area, to be completed by cit)r or town official City or Town: Permit/License# I 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#: i Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No (�f SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN_ OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ..... ....... ---------- 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 .............. 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 und_er the,pgins and P..en.a.lt..i.es of perju ry y ............................... ......................... ......................... ................ ...................... Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder::'.. ................... ... ............................ ...........-1...................... ................... .......... License Number .... ...... Address Expiration Date 167.............................. Signature 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 the building permit. Signed Affidavit Attached Yes 0 No 0 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 M�Telephone' 9.2 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 _. ._._._, , _..._.._ �......... ,..:.._�....�,... ...�_,:.-:.__u.M._....._..__�.,.,_.,�_.. .,.. _.,.. ,..a... .' Not Applicable ❑ Company Name. Responsible In Charge of Construction 0 F-2aX ._. —._ Address qt 3' 5< Signature Telephone i Versionl.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage m.. _.... , _...._._ .., Setbacks Front Side L:.. R., Rear Building Height ---..._ Bldg. Square Footage ....-._----- Open Space Footage —_.-_ (Lot area minus bldg&paved --- parking) #of Parking aces —••----•-_• '° ' Fill: (volume&Location) _...._._.__ ------ A. Has a Special Permit/Variance/Finding er been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Regis 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 �DON7 KNOW 0 YES Q 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 q2r'NO 0 IF YES, describe size, type and location* E. Will the construction activity disturb(clearing,grading, excay ion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO g IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.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 ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ff_�_ Brief Description rater a brief description here. Two ����� Gf ? 0(oor t� Of Proposed Wor k c� /�ed / / n 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 ❑ 18 ❑ B Business 2A ❑ E Educational ❑ I 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-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 S eci ._...w..m.,:.r..._..._.-�_-,....,_.,..._._n..__.,-,�._-,,._..._.� _.._._. P fy 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(so Ist 2nd 2nd - ... __..,... 3 rd 3rd . th 4 th Total Area (so Total Proposed New Con uction(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[] Municipal ❑ On site disposal system[] a� � a -.... Verstonl.7 Commercial Building Permit May 15,2000 'Department use only City of Northampton Status of Permit LUIS SE uilding Department Curb Cut/Driveway Permit 2 "' 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Electric,Plur b,ng&Gas inspections NorthU-npton, MA 01060 N hampton, MA 01060 Two Sets.6f-Structural Plans phone 413-587-1240 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 _......_ _..._..__ _.__.._.__._...__..__....__............. ....._._.._... .._.._... k`_/ Map Lot Unit //�� otoe-,o _ Zone Overlay District _._.._...___._.._. —_....__.___...__._.__..._.____.__..----------------...._..._.__.._..__...___.__ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: _ . .. _ ..__.. . __ ._ .._---- ..... - -/ - ?fcc� _ r Ecrs�� ice' Name(Print)© �S � Current Mailing Address:_ Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a)(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 Signatur . But ' g Commissioner/Inspector of Buildings Date 141 DAMON RD-H BP-2016-0307 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-055 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-2016-0307 Project# JS-2016-000455 Est.Cost: Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SCOTT B DEMOE 095217 Lot Size(sq. ft.): 131551.20 Owner: BOYLE RICHARD R Zoning:_GB(100)/URA(0)/ Applicant. SCOTT B DEMOE AT. 141 DAMON RD - H Applicant Address: Phone: Insurance: P O BOX 2428 WESTFIELDMA01085 ISSUED ON.911012015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD 2 WINDOWS & DOOR TO INTERIOR OFFICE 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 9/10/2015 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner