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��f s 1 i� ���� -- ��`�'� �� MAN s �-��� ��� � ����
Richard Cross
Lic#CS-098014
request that you grant a modification to waive the requirement for control construction for the Verizon
Wireless Zone at 180 Main St. Northampton, MA 01060 because the work is of a min, )r nature,will not
affect health, accessibility, life and fire safety,or structural requirements and is imprijctical in that the
cost of control construction is considerable when compa-red to the cost of the propoiuRd work.The
proposed work is installing 120 If of partition wall with steel studs,sheetrock 2 sides, paint, minor trim,
Flooring, and paint. Electrical to be done at a later date.Thank you for you consideration. "Mass
Amendments,sections 107.1 allows for an exclusion from control construction for th is project."
Respectfully,
Richard Cross
kU �
Richard Cross
129 Pleasant St
Granby,CT
01033
The Commonwealth ofMassach.usetts
Department of hidus'trial Accidents
Nh ,
Office of LzveO,-ations
r-r _ 600 Washington Street
Boston, MA 02111
www.mass.a,ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information rr Please Print Leaiblv
Name (Business/Organization/Individual):
Address: /2 1 fecjc,-�
City/State/Zip: rC_ . X. Al Phone#: G S (f 7
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I a a employer with 4. ❑ I am a general contractor and I
ployees (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. emodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working or me in an capacity. employees and have workers'
g y p �'• $ 9. E] C,addition
[No workers' comp.insurance comp. insurance,
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work ❑
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 131-1 Other
comp.insurance 7equired.]
*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 the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
i
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 certifyudeerr theme pains d penalties ofpeijtu07 that the iinformation provided above is rue and correct.
Signature: L/ J C� Date: �L `1 X1
Phone#:
Of use only. Do not write in this area,to be completed by city or town official
City or Town: Permit) icense#
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
a - t
Versionl.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
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, --- - 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.
......
- r
Signat a of Owner Date
I, Tf�J1 .� 1 � 11( Fore ��z2JI1fJfiEt ., .Lp 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 10ye
Signature Owner/Agen r�h5le ¢/' Date
SECTION 12-CON CTION SERVICES
10.1 Licensed Construction Su ervisor. Not Applicable ❑
.....
Name of License Holder: Y v J.._ )
icense Ntqber
Address ) 1 c� S• . Expiration Date
NO3
Signature Telephone
------ - -in 7
SECTION 13-WORK RS'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 b ilding permit.
Signed Affidavit Attached Yes No 0
r
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICE-FOR BUILDINGS AND STRUCTURES SUBJECT TO
M
CONSTRUCTION CONTROL PURSUANT TO 780 CR 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
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
.....
......_......I. .. . ......_.... ..... _.._........ _.......
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
i
i
I
f
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
Setbacks Front
Side L::. R: L: R:
Rear
Building Height ....
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
.......__..
arlan )
........................
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page, and/or Document#.
B. Does the site contain a brook, body of water or wetlands? NO e---'DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
._._........_.............
Needs to be obtained I Obtained , Date Issued: E
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavatio 1 ing)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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 ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description E er a br*ef description
Of Proposed Work: �^--
1 .
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 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A P111- I
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile Rr I "' :vic--S (so 3. 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility F-1 Specify:
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): Propo'ed 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)
1 St 1 Si
2nd 2nd
._._ ..__._ ....___ .._._..__.. ...._._. .......... ..,.. . __... ...._. ....
3rd 3
rd
4in 4r
........ .........................._....._....! _.
Total Area(sf) 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 Sewag�posal System:
Public Private ❑ Zone:- Outside Flood Zoneg Municipal On site disposal system E]
I
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Version 1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton Status of Permit:
DEC 2
Building Department Curb Cut/Driveway Permit..
212 Main Street Sewer/Septic Availability
i
{ Room 100 Water/Well Availability
o ` ' ''��-� orthampton, MA 01060 Two Sets of Structural Plans
13-587-1240 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
Utz `zo�- ; This section to be completed by office
1.1 Property Address: W zGti^t.
�� Map Lot Unit
"V��t L-`''��A `—� �✓�
! ` , ,� 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:
.........
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed 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) ( C Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0834
APPLICANT/CONTACT PERSON RICHARD CROSS
ADDRESS/PHONE 129 PLEASANT ST GRANBY01033
PROPERTY LOCATION 180 MAIN ST-VERIZON
MAP 3 1 D PARCEL 162 001 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
Fee Paid
Typeof Construction: CONSTRUCT PARTITION WALLS FOR OFFICES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 098014
3 sets of Plans/Plot Plan
THE FOLL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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
Demolition Dolav
Signature of Building Of icral 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.
180 MAIN ST-VERIZON BP-2016-0834
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31D- 162 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0834
Project# JS-2016-001412
Est.Cost: $8000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD CROSS 098014
Lot Size(sq. ft.): 1873.08 Owner: BERMOR LIMITED PARTNERSHIP
Zoning: CB(100) Applicant: RICHARD CROSS
AT. 180 MAIN ST - VERIZON
Applicant Address: Phone: Insurance:
129 PLEASANT ST
GRANBYMA01033 ISSUED ON:11412016 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT PARTITION WALLS FOR OFFICES
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:
FeeTyne: Date Paid: Amount:
Building 1/4/2016 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner