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31B-230 (8)
64 GOTHIC ST G2 BP-2016-1481 GIS 6: COMMONWEALTH OF MASSACHUSETTS Mao:Block: 31B-230 CITY OF NORTHAMPTON Lot. -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPAIR BUILDING PERMIT Permit# BP-2016-1481 Project# JS-2016-002534 Est. Cost: $40000.00 Fee: $280.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: use Group: HARLOW BUILDERS 052460 Lot Size(sq. ft.): Owner: GOTHIC REALTY TRUST-BENJAMIN BARNES&ED ETHEREDGE TRUSTEES Zoning:CB(100)/ Applicant: HARLOW BUILDERS AT: 64 GOTHIC ST G2 Applicant Address: Phone: Insurance: 336 COLES MEADOW RD (413) 586-0465 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:6/13/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ROT REPAIR 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 6/13/2016 0:00:00 $280.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner Version l:7 Commercial Building Permit May 15,2000 Department use only _ :-,) City of Northampton Status of Permit: —1 C uilding Department Curb Cut/Driveway Permit - - 212Main Street Sewer/Septic Availability_,,,, _ I Room 100 Water/Welt Availability Northampton, MA 01060 Two Sets of Structural Plans n«, phone 413-587-1240 Fax 413-587-1272 Plovslte Plans13 _ 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 Properly Atldress. This section to he completed by office 1Ld 604 C �1 Map Lot Unit Gr Zone Overlay District l Elm St District cB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: .� .� C.4 90 tvU ' C,otO© R ttri"` (n4 G -_ S\ Name(Print) Current Mailing Address Signature Telephone 2.2 Authorized Agent SchtC ��l5w 33(r ColRS C� ok..a Name(Print) Omani Mating Address �.��K (`113 SVQ161.46.- Signature im �/�/ „ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to he Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee I 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection �r ``�.��� // // 6. Total=(1 +2+3+4+5) "lO1 an Check Number-39 '/C-3 Y gru0 This Section For Official Use Only Building Permit Number Date Issued s Signatu - �2-< mission espedor. .. ildings Date Version] 7 Commercial Building Permit May 15,2000 ECT $ iON 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wall Signs 0 Demolition Repairs 0 Additions Accessory Building 0 Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use 0 Other 0 Brief posed Work: Enter; a nef son ion here. Of Proposed Work:i SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) , CONSTRUCTION TYPE A Assembly ❑ AA 0 A-2 0 A-3 A 1A 0 A-4 0 A-5 0 113 B Business 0 2A 0 E Educational D � 2B 0 F Factory ❑ F-1 0 F- 0 2C 0 H High Hazard ❑ 3A ❑ 1 Institutional ❑ -.-1-1 0 1.2 a 13 0 aB ■ M Mercantile 0 4 0 R Residential ❑ Ra ❑ R'2 0 R-3 0 5A 0 S Storage ❑ S-1 0 S-2 0 IFR-3 0 U Utility .... ❑ Specify M Mixed Use 0 Specify S Special Use ❑ Specify [, COMPLETE THIS SECTION IF EXISTING BUILDING U ERGOING RENO TIONS ADDITIONS AND/OR CHANGE IN USE Existing Use Group: -. i Proposed Use up -.. . Existing Hazard Index 780 CMR 34) Proposed Hazard Ir.ex 789 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA f/ BUILDING AREA EXISTING PROy'OSSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 17 ii ii / 17 o Total Area(sr) Total Proposed New Construction(NU__ Total Height(ft) Total Height ft -_... 7,Water Supply(M.G.L.c.40,§54) 7.1 Flopd Zone Information: 7.3 Sewage Disposal System: Public 0 Private❑ Zone: - Outside Flood Zone❑ Municipal 0 On site disposal system❑ Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING I Existing Proposed Required by Zoning 0, This column to be filled in by \ Department Depanent Lot Size \ _. • Frontage - A . Setbacks Front Side Rear 5 Bolding lieight --. — Bldg. Square Footage % .._. Open Space Footage pn area minus bldg&Paved paarr #of Parkin Spaces - - FiiP. .-- HI _. _... _... (volume&Location) i_._ -_.. A. Has a Special Permit/Variance coding ever been issued for/on the site? NO Q DONT KNOW YES 0 IF YES, date issued: IF YES: as the permit recorded at the Registry of Deeds? NO DONT KNOW Q YES Q IF YES: enter Book Page and/or Document B. Does the site contain a brook, body of water or wetlands? NO 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 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 NOt IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading xcavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 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 780 CARR 118(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not APPllceble 0 Name(Registrant) Registration Number Address - - Expiration Date Signature TeNphone.. 9.2 Registered Professional Engineer(s): Name Area N Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Reiponsibility Address _.. -. -. Registrabon Number Signature Telephone Expiration Date Name Area of Responsibility Address -.-. .. _... __. Registration Number .-._.._ Signature I elapbone Expiration Cate Name _-- ._. --. -_- .._. Area of Responsibility Address Registration Number Signature telephone Expiation Date 9.3 General Contractor , �,.Q �uckraata - (�l 7U.-J _ Not Applicable 0 Company Name: SC-- tlsv A4--y Responsible In Charge of Construction fl ' CT:1 teS 'S' Ci pe \l>,„? Address 5t -2465` - _ Signature Telephone Version I.7 Commercial Budding Permit May 15,2000 SECTION 10•STRUCTURAL PEER REVIEW(780 CMR 110.11) independent Structural Engineering Structural Peer Review Required Yes 0 No Q 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 aft matters relative to work authorized by this building permit application. Signature of Owner l C�(�/� 1 �( Date I, SC--;""e' Cb)\.1 \ctle-A 1' J ? %1] ga.ffilaU _..1� yyQ s .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 /5 746 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑' Name of License Holder S tW..-0-A b�..� ` License Number 3-M e ("14?-34 ta/A?:34 \ '7 1 t Address Exp ration 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 building permit Signed Affidavit Attached Yes 0 NO cip The Commonwealth of Massachusetts Department of Industrial Accidents ':a.-=co. Office of Investigations n.anni liWiliderithe.'¢' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/'Electricians/Plumbers Applicant Information t� Please Print Legibly Name (Business/Organization/Individual): *car .„ `` t Address: 3 lb C. -ts ti3 , Ei . tbe sk •_ i ?� City/State/Zip: Phone#: (tiI� Sta 0L r Are y9,u an employer?Check the appropriate box: Type of project(required): I. I am a employer with 4,4- ❑ I am a general contractor and 1 6. Di New construction employees (full and/or part-titre)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E 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.insurances required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their, 11.❑ Plumbing repairs or additions • myself.[No workers' comp. right of exemption per MOL I2,_ Roof repairs t G. 152,§I(4),and we have no insurance required.] 13.E Other SLakm 2, aC employees. [No workers' comp.insurance required.] *Any applicant that checks box kI must also fill nut the section below showing their workers'compensation policy in fbrmatl on. Homeowners who submit his affidavit ndinting they are doing all work and then hire outside contactors must submit a new affscIfy t indicating such. tContractors that check this box must attached an additional street?towingthe nano oft e 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. �"}� Insurance Company Name: Srgbe: R((' A 6 21-5 .� k t e Policy#or Self-ins.Tic. #....: o0`3a '�\�')tC )'/ Expiration Date: Job Site Address: (04 .O '-' lsY6` s . , ' nt City/State/Zip: J 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$1500.00 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 cerrtifj'under the :sins and penalties of—duty hat the information provided aboye is I e and correct. mre: / ..%i/. G!., -tG :%'L,/ .... Date: ..._ Phone#: • Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License if Issuing Authority(circle one): • I.Board of Health 2.Building Department 3, City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 150k Address of the work: (eV The debris will be transported by: / 01'4 The debris will be received by: 11d1 11 Xeei Building permit number: / Name of Permit Applicant gcof grA� (—/3-76 'a...dr .i Date Signature of Permit Applicant Harlow Builders 336 Coles Meadow Rd. Northampton,Ma. 01060 (413)374-5326 CSL #52460 HIC # 111205 Submitted to: 6/10/16 The City of Northampton Building Department. I request that you grant a modification to waive the requirement for the control construction for the(Siding Repair) at(64 Gothic St.)in Northampton because the work is of 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. "Mass Amendments, section 107.1 allows for an exclusion from control construction for this project. Respectfully, Scott Harlow Harlow Builders 336 Coles Meadow Rd. Northampton,Ma.01060