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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#: