18D-004 (51) 104 DAMON RD BP-2017-0749
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I8D-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit BP-2017-0749
Project# JS-2017-001164
Est.Cost:$30000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class_ Contractor: License:
Use Groupe LIZOTTE GLASS INC 072931
Lot Size(sq.ft.): 87120.00 Owner: MOCK WILLIAM D
Zoning:G13(100)1G1(0)/ Applicant: LIZOTTE GLASS INC
AT: 104 DAMON RD
Applicant Address: Phone: Insurance:
390 RACE ST (413)532-2737 Workers Compensation
HOLYOKEMA01040 ISSUED ON:72j9/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVAL OF EXISTING GLASS &ALLUMINUM
STOREFRONT ,INSTALLATION OF NEW STOREFRONT MATERIAL & GLASS
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 Ftreplace/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 12/9/2016 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-13uilding Commissioner
File#BP-2017-0749
APPLICANT/CONTACT PERSON LIZOTTE GLASS INC
ADDRESS/PHONE 390 RACE ST HOLYOKE (413)5322737
PROPERTY LOCATION 104 DAMON RD
MAP 1RD PARCEL 004 001 ZONE GB(100)/GI(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERM„T APPLICATION CHECKLIST
/// ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ��
Fee Paid
Bui ,,,ing Permit_Filled out
Fee Paid
Tvpeof Construction; REMOVAL OF EXISTING GLASS&ALLUMINUM STOREFRONT,INSTALLATION
OF NE,W STOREFRONT MATERIAL&GLASS
New Construction
Non Struc .1 interior r: ovations
Addition to Existing
Accessory$$mature
Building Plans Included:
Owner/Statement or License 072931
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demoli on I- y
Signa n e of Building O'ictal 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 l.'Commercial Butfdine Permit Ma‘ L.2000
Department use only
City of Northampton Status of Permit:
IBEG .. 5 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
_ .J Room 100 Water/Well Avaaabiny
OFr
Northampton. MA 01060 Two Sets of Structural Plans
phone 413587-1240 Fax 413-587-1272 PbtSite 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 Property Address'. This section to be completed by office
104 DAMON ROAD Map Lot Unit
NORTHAMPTON. MA
Zone Overlay District
Elm St.District Ca District
SECTION 1.PROPERTY OWNERSHIP/AUTHORIZED AGENT
J 1 Owner of Recorj
WILLIAM MOCK k Po C° x +411t—I,Eut+t{tr/e icwr AHI clot,
Name(Print) Current Mating Address
Yj
•SignaNre 4✓Yl °lea— \Tekanpna 4- /3 5-66-'f 437
2,2 Authorized Anent:
LIZOTTE GLASS /SHAWN LEBLANC 390 RACE STREET HOLYOKE.MA
Name{Prion Cmient Mailing Address.
(-113) 532-2737
Signature /� TeesPane
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
corn detect b ermit at•Scant
1. Building 530,000.00 (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 'y f1
6. Total=(1 +2.3=4e5) Check Number 01 q J 4610
This Section For Official Use Only
Building Permit Number Date
Issued
Signature.
Sue/ft Cemmissionernnspector of Ettedings Date
Version1.7 Commercial Building Penult May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs ❑ Demolition 0 Repairs Additions 0 Accessory Building 0
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Rooting❑ Change of Use❑ Other 0
Brief Description REMOVAL OF EXISTING GLASS AND ALUMINUM STOREFRONT
Of Proposed Work: INSTALLATION OF NEW STOREFRONT MATERIAL AND GLASS
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) _ CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 0 A-3 ❑ 1A 7—Cr
A-4 0 A-5 0 18 I 0
B Business 0 2A 0
E Educational 0 28 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 I-1 ❑ 1-2 0 I-3 0 3B ❑
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 0 R3 0 5A 0
S Storage 0 S-1 0 S-2 ❑ 58 1 0
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Spedal Use 0 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 8 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1s,
2
244
3,a 3`°
4L 4m
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 0 Private ❑ Zone Outside Flood Zona❑ Municipal 0 On site disposal system❑
Version).7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Depanment
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage °io
(Lot area minus bldg&paved
parking) _
q of Parking Spaces
FiB:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES Q
IF YES: enter Book Page and/or Document tt
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location: TYPICAL NON LIGHTED APPROX 5'X 3'
D. Are there any proposed changes to or additions of signs intended for the property? YES (3 NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that wilt disturb over I acre? YES O NO 0
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 CMR 116(CONTAINING MORE THAN 35,600 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect
N/A Not Applicable 0
Name(Registrant):
N/A Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
N/A
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 'IIExpiration Date
9.3 General Contractor
LIZO 1 1 E GLASS INC
Not Applicable 0
Company Name:
LIZOTTE GLASS
Responsible In Charge of Construction
390 RACE STREET HOLYOKE, MA, 01040
Address
(413) 532-2737
Signature Telephone
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 , & 150A.
Address of the work: 7fr,rron ,/
The debris will be transported by: Loge_ (21,06.5
The debris will be received by: --gitkvIt/i& pA4G &ewe<
Building permit number:
Name of Permit Applicant 424. --ZOc,s c'c...
til-N2b/6 4 c
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
r l ' Office of Investigations
gel_ 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ([iusincssiOrganizationindividuan: LIZOTTE GLASS INC.
Address: 390 RACE STREET
City/State/Zip,HOLYOKE, MA Phone#: 413-532-2737
Are you an employer?Check the appropriate box: Type of project(required):
IN I am a employer with 20 4. 9 I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers comp.insurance Comp.insurance"
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required] c. 152,§1(4),and we have no BioR[FltgJt kE.in nCEreErvT
employees. [No workers' 13.[x]Other
comp. insurance required.]
'Ano applicant hat checks box k I must also fill and the section below shaving their workers'compensation policy intormatiotr_
'fiemeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must suborn 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,
1 am an employer that is providing workers'compensation insurance for ray employees. Below is the policy and job site
information.
Insurance Company Name: AIM MUTUAL INSURANCE
Policy R ar Self-ins. Lie.#: MCC20002872015-MA Expiration Date: 1/112017
Job Site Address: 104 DAMON ROAD NORTHAMPTON, MA. City/State/Zip: 01060
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
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa 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 cenify and /ties of'er'ury that the information provided above is true and correct.
Signature: Date: 12/1/2016
Phone tt: ' 1 —..... L-� ✓
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#:
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
WILLIAM MOCK. ,as Owner of the subject property
hereby authorize to
GLASS INC. to
act on my behalf,in all matters relative to work authorized by this building permit application.
12/01/2016
Signature of Owner Date
THEODORE LEBLANC LIZOTTE GLASS 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
12/01/2016
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not
Applicable� E] /
Name of License Holder '" 4g �-y ee•-• et- 5 - V 7 J y 3 j
Ave, r1 I A License Number
ter, vcjI A 42 & aI 1 ,'&4 ole '5 y - B/�
Address Expiration Date
inn 9,3 3% '76tk
Sign!): Telephone
SECTION 10-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
/'L1
Signed Affidavit Attached Yes No 0
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-072931
Construction
GA Supervisor
50 ROOSEVELT
AVE
60 Ar
WESTFIELD MA 61085 `
L
•
•
x-
�� Expiration:
Commissioner ' 04/08/201*
•
Construction Supervisor
Restricted to.
Unrestricted-Buildings of any use group which contain
less than 35,000 cubic feet(991 cubic meters)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation or this license.
DVS Licensing information visit:wWW MASS.GGY1t1pS
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