12C-010 320 NORTH MAPLE ST-SPRING GROVE CEMETERY BP-2017-0113
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I2C-010 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2017-0113
Project# JS-2017-000185
Est.Cost:$12700.00
Fee:$0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: LAROCHELLE CONSTRUCTION INC 069121
Lot Size(sq. it): 1306800.00 Owner: NORTHAMPTON CITY OF SPRING GROVE CEMETERY
Zoning: SR(99)/WSP(99)/WP(3)/RI(0)/URA(0)/ Applicant: LAROCHELLE CONSTRUCTION INC
AT: 320 NORTH MAPLE ST - SPRING GROVE CEMETERY
Applicant Address: Phone: Insurance:
7 WESTERN VIEW RD (413) 781-5651 WC
HOLYOKEMA01040 ISSUED ON:7/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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:
FeeTvpe: Date Paid: Amount:
Building 7/27/2016 0:00:00 $0.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Versionl.7 Commercial Buildin&Permit May 15,2000
• Department use only
RECEIVED City of Northampton Status of Permit
Building Department Curb Cut/Priceway Permit
212 Main Street Sewer/Septic Availability
JUL 2 7 2016 Room 100 Water/Wel Availability
orthampton, MA 01060 Two Sets of Structural Plans
parr.CF mNNNG —s —e 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans
xontwisnon,NAs
Other Specify
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISf ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: n1 /lThis section to be completed by office
. r20
6,01a pte. Map 'drIV Lot 0/0 Unit
IVf irp1rAt PIV_OMfe Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OW ERSHI UTHORIZED AGENT
2.1 Owner of Record: 1
Cribof 1'br'v twpEmti ala Main St-, Yb O mono
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
C_44•3 o� -\)r pL ck )ol'1C42xtrc 19s- coc &s4 .
Name(Print) QAC' \4 . ln Current Mailing Address:
v J 7•A� ll_ 0041,044WItM Vrat 01191
Signature Telephone LIG 517 Icto
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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)
Fire Protection 11 a,AtAgc-e-
5.
6. Total=(1 +2+3+4+5) 4 1;00`Ce° Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/inspector of Buildings Date
Version!.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 0 Repairs Additions 0 Accessory Building
Exterior Alteration 0 Existing Ground Sign 0 Neeww Signs 0
Rp%000fingX Change
h_ange�of Use❑ Other
Brief Description Enter a brief description her'/^` V ( KJ L+
Of Proposed Work: rs �... 7
SECTION 5-USE GROUP AND CONSTRUCTION TYPE /J'pV fu`
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 (71 A-2 ❑ A-3 ❑ 1A 0
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A 0
E Educational 0 2B ❑
F Factory ❑ F-1 0 F-2 ❑ 2C 0
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 0 1-3 ❑ 38 0
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 0 R-2 0 R-3 0 5A 0
S Storage ❑ S-1 ❑ S-2 ❑ 5B I ❑
U Utility ❑ 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): 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(sf)
1"
2 d 2nd
3rd 3.e
4 4n
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 Sewage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone El Municipal ❑ On site disposal systems
Versionl.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 L: R: L: R:
Rear
Building Height
Bldg.Square Footage °a
Open Space Footage
(Lot area minus bldg&paved
parking) I
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Sp ial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO Cc
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exca tion, or filling)over 1 acre oris it part of a common plan
Othat will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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:
Nat 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
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractorlo
‘4.612614C._14C._ Coy\9cktoN Not Applicable 0
Company Name:
`inn VATOLbeAtt.
Responsible In Charge of Construction
to m U 1C4) .• lAa 1(4061%V O M l°
Address
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 O No 0
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 2111 W�Oa- vF1W ^E– s-e"0`l"k "-- to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 11 -- _1 1^ - Date
I, n t xGo ,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.
`U7(n aa-
Print Name
'f-
7 t
Signature of Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not�Applicable 0
Name of License Holder: -nah La
�"' License Number
tAkatk Pv\ U Leto Qd . ot ta.o w-io to 1I 3I ff
Address Expiration Da e
413 4-5.61
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 thebuiling permit.
Signed Affidavit Attached Yes No 0
The Commonwealth of Massachusetts
=,,11Department oflndustrialAccidents
='dill_ tOfce of Investigations
I Congress
f! - Street, Suite 100
-, _ a_
' _lil[i Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `_ Please Print Legibly
Name (Business/Organization/individual): L,',r�ppk_ Coaski �
✓Lq-vv
Address: 11lrkk
1I (n
U1Pu) SFT
City/State/Zip: k t nuM0 Phone #: Litt 711--qcsi
Are youyoan employer? Check the appropriate box: Type of project(required):
I.Igl t am a employer with & 4. ❑ I am a general contractor and I
employees (full and/or part-time),'
6. ❑New construction
have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 9 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 9 We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12Roof repairs
insurance required] ' c. 152, §1(4),and we have no
employees. [No workers' 13.9 Other
comp. insurance required.]
*Any applicant that checks box k must also fill out the section below showing their workers'compensation policy infomiation.
t Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors 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. n
Insurance Company Name: ..zirktotiktic `rapkrap tAOt\
Policy#or Self-ins. Lic. #: t4 0-$03 ADS -Of —Q'f (S/7 Expiration Date:
Job Site Address: 3X 1.1 Ma J(Q Sk W yvyyApll[r/r•-_ City/State/Zip: I1 ( 1/4„.. O/Doiry
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 5250.00 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.
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: _ Date: 7- �J—
rr
Phone#: (t1•I ` adS1
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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#: