11C-056 410 NORTH MAIN ST BP-2016-1411
GIS COMMONWEALTH OF MASSACHUSETTS
Map:Block: 1IC -056 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-2016-1411
Project p JS-2016-002276
Est.Cost: $60000.00
Fee:$420.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DOUGLAS GOODNOW 082188
Lot Size(so. ft.): 11979.00 Owner: MIAS SETH I
tonin_. 11B(34)/URAn6)/ Applicant: DOUGLAS GOODNOW
AT: 410 NORTH MAIN ST
Applicant Address: Phone: Insurance:
225 OLD CHESTERFIELD RD (413) 296-4387
WILLIAMSBURGMA01096-9318 ISSUED ON:5/31/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE RESTAURANT INTO CATERING
BUSINESS - NO STRUCTURAL CHANGES
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 14 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 5/31/20160:00:00 $420.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1411
APPLICANT/CONTACT PERSON DOUGLAS GOODNOW
ADDRESS/PHONE 223 OLD CHESTERFIELD RD WILLIAMSBURG (413)296-4387
PROPERTY LOCATION 410 NORTH MAIN ST
MAP I IC PARCEL 036 001 ZOE HB(34)/URA(16)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �a�u
Fee Paid G�# 3(y ((O W
Building Permit Filled out
Fee Paid
Tvoeof Construction: RENOVATE RESTAURANT INTO CATERING BUSINESS-NO STRUCTURAL
CHANGES
New Construction
Non Structural interior renovations
Addition to EBisting
Accessory Structure
Building Plans Included:
Owner'Statement or License 082188
3 sets of Plans/Plot Plan
ri
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IIs
PRESENTED:
Y Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With She Plan
Major Project:_ Site Plan AND/OR _Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Findine Special PermitVariance*
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
•emsliti•I Delay
ArlieH
rzor
S c . ure of Building Offi 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.
Version I.i Commercial Buildise Permit May I5,2000
- - -
- Department use only
-City of Northampton Status of Permit-
...i 3uilding Department Curb CuUDnve vay Permit — -
' ' 1 i xsiaiwo'4 212 Main Street Sewer/Septic Avauebilfty" '" Room 100WaterlWell Availability
NOrthampton, MA 010617 Two Sets of Structural Plans_phbt 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 Pro a Address: This section to be completed by office
�.,tao fr rt/r M AdA../�"h--f Map Lot Unit
Lyaik 5 t 41 Zone Overlay District
-- -- --- ---. - - - ---. Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.i Owner of Record:
Name(Pnn Th _ Current Makin Address --
tj}k )i\ .. La oc U$ mac&
Signature " ti Telephone
2.2 Authorized Agent:
✓o„ b �s225 olJ_ sfr { } .r
Name(Prat) Gummi Marling Andress q
//�`.�{',[,,� kW ret n„$ bur; , '4t t4 O[ O 7 6
Signature y/- 1 ,,;: Telephone
SECTION 33-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building j ../(5-0°61j (a) Building Permit Fee
V/.
2FIe"tricai /� da o @)EstimaConstruction of
from(6)
3. PlumbingD a Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection ,,r
6 'total=(1 +2+3 +4+5) GOr a Jn - Check Number 3 (ty _ yr1,0 -�
_. This.Section-Eor-OfficiaLUse-Only. — -
Budding Permit Number Date
Issued
Signature:
Building Commissioner/inspector of Buildings Date
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 0 Demolition 0 Repairs Additions Q Accessory Building❑
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other❑ '
Brief Description Enter a brief description here. ff?j _tia r�"x 'Z� rrt.
n
Of Proposed Work /I4U4�e ()SLY j4cK S& -r�LS i. 7n 7c (y��frr�y pvj 1,-pJ$ fPr'ra in �
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) r CONSTRUCTION TYPE
A Assembly Q A-t ❑ A-2 0 A-3 0 IA ( ❑
A-4 0 A-5 0 1B 0
B Business ❑ 2.4 0
E Educational 0 2B ❑
F Factory ❑ F t 0 F-2 0 2C ❑
H High Hazard 0 - 3A 0
I Institutional ❑ I-1 0 1-2 0 1-3 0 3B 0
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 ❑ R-3 0 5A ❑
S Storage 0 S-1 0 5-2 0 5B I ❑
U UtilitySpecify'
M Mixed Use Q Specify:
S Special Use ❑ Specify
COMPLETE THS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDIOR 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(s@
1" ..._. _.. . 1s _. . _..
.... 3.e .._. _. .._..
4m .. ....___.__.._ ._. 4+ _. _....
Total Area;sr) -- - ictal Proposed New Canstrudon(st)
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 ZoneD Municipal On site disposal system[)
Version l.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ---- -
Frontage
Setbacks Front - –
Side
Rear
Building Height - ----
Bldg. Square Footage – / --- ------
Open Space Footage
(Lot area minusbldg&paved
part ng)
N of Parking Spaces
(volume&Locaron)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document q
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
-'- IP'YES,—describe sizeTtype and-location: -- - -
E. WII the construction activity disturb(clearing,grading,excavation,or filling)aver 1 acre or is it part of a common plan
that will disturb aver 1 acres YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 730 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Regstranl) __._ _
- - - --- - Registration Number
Address
...__.---._... ____._-. Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
, _
Signature Telephone Telephone -. ... . Expnatan Cate
Name Area of Responsibility
Address Feg st2bOn Number
Signature Telephone Expiration Date
Name -.... _ Area of ResponsrbSity
Address Registration Number
Signature Telephone Exp raton Dale
_
Name -_. --- -.. .... __-._- -�__. Area of Responsibility
Address Registration Number
Signature Telephone Expiration Dale
9.3 General Contractor
/ /-
(. cs ano mi _c<J evs Not Applicable ❑
--Company-Name: - _. -._
Do ifr.14,I 66 " -/
Responsible In Charge of Construction
d? 01 k rk.
Add res
�..�. yl =spa 1341
Signature Telephone
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 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Seyw�' J +' --- 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 Z Date
I, ..,.,t9` .- ..-.._. __._ __ ,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 penury
Pnnt Name
;pay-2,C 7/
Sig e of Ow rlAgent ._
Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed ConstructionSupervisor: Not Applicable El
of 0
Name License Holder OD 0) (w5.. U`S'4r aJ -_ CS- 6EG)- I
License Number
Address \ Expiration Date
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
build 9B'permit.
Signed Affidavit Attached Yes No 0
The Commonwealth of Massachusetts
Department of Industrial Accidents
�
��, Office of Investigations
'tT:'leBeia ; 600 Washington Street
Boston,MA 02111
www.mass.,;ov/dia
Workers' Compensation Insurance Affidavit. Builders/Contractor/Electricians/Plumbers
Applicant Information �p 7" Please Print Legibly
Name(Business/Organizatiot/Individual): GOr�dh'(7 n 'S
Address: 0)2S 01 A Cie-Yr a 1 LA. if ,
City/State/Zip: t I '�^^Y 7`'r 414 Phone#: VJ 3 t{8--cid 6
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. [] I am a general contractor and 1
ptoyees(full and/or part-time).* have hired the sub-contractors 6. (�New construction
2. I am a sole proprietor orpartner-
listed on the attached sheet. 7. E Remodeling
ship and have no employees These sub-contractors have 8. U Demolition
workingfor me in anycapacity. employees and have workers'
[No workers' P Y 9. 0 Building addition
iredj comp.insurance comp.insurance.'
required.] 5. ❑ We are a corporation and its MO❑Electrical repairs or additions
3.❑ I am a homeowner doing an work officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. tight of exemption per MGI.,
12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.] 1
`Any applicant that checks box tl must also fill out the section'below showing their workers'compensation policy information.
t Homeowners who submit his affidavit indicating they are doing all work and then hire outside cocbuctors must submit anew affidavit indicating such.
iConeacmrs that check this box must an hod an additional sheet showing the narm of the sub-contractors and state whether or not hose entities have
empiayees, if the sub-contactors have=playact,they must provide their workers'coop.policy nuSer.
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.Lie.#: 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 the pains and penalties oJ'perjury that the information provided above is true and ccorrect.
Signature: / - _. Bate: S/C2/ 16
Phone#: L/'1 ` rr i g t —__—
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitiLiceose#
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#:
greofreArc ,_5444,7 1-70, (,k_
0 �wn S - 7 0 0 P
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