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25C-251 (99) 54 FAIR ST BP-2017-1381 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block:25C-251 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:demolition BUILDING PERMIT Permit# BP-2017-1381 Project# JS-2017-002301 Est. Cost: $100.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: use Group Homeowner as Contractor Lot Size(sq,R): Owner: HAMPSHIRE FRANKLIN& HAMPDEN AGRICULTURAL SOCIETY Zoning:SCOOPYURB(1)/ Applicant: HAMPSHIRE FRANKLIN & HAMPDEN AGRICULTURAL SOCIETY AT: 54 FAIR ST Applicant Address: Phone: Insurance: P O BOX 305 (413) 584-2237 0 NORTHAMPTONMA01061 ISSUED ON:6/1/20/7 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMO OF OLD VENDOR STAND - 10X16 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 6/1/2017 0:00:00 $50.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner File# BP-2017-1381 APPLICANT/CONTACT PERSON HAMPSHIRE FRANKLIN& HAMPDEN AGRICULTURAL SOCIETY ADDRESS/PHONE P O BOX 305 NORTHAMPTON (413)584-2237 O PROPERTY LOCATION 54 FAIR ST MAP 25C PARCEL 251 001 ZONE SC(10O)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST • CLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Ake); Fee Paid 7' TvpeofConstruction; DEMO OF OLD VEND() - • D- 10X16 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: (Mier/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION 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: § FindingSpecial 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 Demolition Delay B/11 Sig tire of Building Official 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. Version1.7 Commercial Buildin_Permit May 15,2000 DePadmentuse only City of Northampton Status of Permit Building Department Curb Cut/DrivewayPomut U I 212 Main Street SawerSepdcAvatledMy .JI Room 100 Water/Wen Availability ,L� c,FPi r-fTloNS orthamPton, MA 01060 Two Seto of StructuralPlans �=cry¢:,maeo p one 413-587-1240 Fax 413-587-1272 Plot/Ste Plans Otter Spa/iffy 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 54 Fair Street Map o?5 C Lot 1 Unit Northampton, Ma Zone Overlay District Elm St District CS Diseict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Hampshire, Franklin and Franklin Agri. Soc. 54 Fair Street,Po Box 305,Northampton Ma Name(Print) Current Mailing Address: (413)584-2237 Signature Telephone 2.2 Authorized Agent: Bruce R Shallcross Po Box 305.Northampton, Ma 01360 Name(Print) Current Mailing Address: (413) 584-2237 Signature Telephone 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) 5. Fire Protection / - - 6. Total=(1 +2+3+4+5) Check Numbed' a �2 4 (co This Section For Official Use Only Building Permit Number Dale Issued Signature: Building Commissioner/Inspector of Buildings Date Version 1.7 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 El Demolition Repairs Additions 0 Accessory Building Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing Change of Use 0 Other 0 Brief Description Enter a brief description here. Demolition of old vendor stand. 10'x 16'no interior partitions Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 0 A-3 ❑ 1A 0 A-4 0 A-5 0 18 ❑ B Business 0 2A 0 E Educational 0 2B ❑ F Factory ❑ F-1 ❑ F-2 0 2C 0 H High Hazard 0 3A ❑ I Institutional ❑ I-1 0 1-2 0 1-3 0 3B ❑ M Mercantile ❑ 4 0 R Residential ❑ R-1 0 R-2 0 R-3 0 5A ❑ S Storage ❑ S-1 0 S-2 0 58 0 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 MID AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1" 160 2 a 2n° 3m 3'd 4" 4m Total Area(sf) 160 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❑ Municipal 0 On site disposal system❑ Version1.7 Commercial Building Pennit 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 Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O 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 O 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 O 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 will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 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: Not 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 Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I• ,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 un r the pains penalties of perjury. PrintlR Name '`� . . epJ pG , Sha.\Lca oC7 c) 901 1 11. Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Dale Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 O No Q • • • • Al. • \ • • • • , • • • The Commonwealth of Massachusetts n_-= Department of Industrial Accidents =1.1i a Office of Investigations _,_ I= =It= 11 1 Congress Street, Suite 100 Boston, MA 02114-2017 a 441;VA wwtamuss.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Hampshire, Franklin and Hampden Agricultural Society Address:54 Fair Street City/State/Zip:Northampton, Ma 01060 Phone 4:413 584 2237 Are you an employer?Check the appropriate box: Type of project(required): I.. I am a employer with 7 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- These on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 9 Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurances required.] 5. 0 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 MGL 12.9 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.9 Other ,v comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. It Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoutracmrs 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 subcontractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:A.1.M. Insurance Company Policy#or Self-ins. Lie,#:awe-400-7035317-2017a Expiration Date:02/04/2018 Job Site Address: 54 Fair Street City/State/Zip:Northampton,Ma. 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 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 of perjury that the information provided above is true and correct Signature: 8t t4 I. ' Date: x),24!17 Phone#: 413 584 2237 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#: NOTICE , (* NOTICE TO �, TO EMPLOYEES h _ EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required.by Massachusetts General Law,Chapter 152, Sections 21, 22, & 30,this will give you notice that 1 (we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC-400.7035317-2017A 02/04/2017-02/04/2018 POLICY NUMBER EFFECTIVE DATES 8 North King Street Suite R 1 Webber&Grinnell Ins Agcy Inc Northampton, MA 01060 (413)586-0111 NAME OF INSURANCE AGENT ADDRESS PHONE Three County Fair BX 305 54 Fair Street Northampton,MA 01060 EMPLOYER ADDRESS 02/23/2017 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 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 150A. Address of the work: 544 FR.ye. S T zeut The debris will be transported by: 1/4,u p. Sic MVprn+tltae The debris will be received by: W A s-r6 r(\fataisternRwt Building permit number Name of Permit Applicant I-1 A ' r" CI-41 CavAtl 1 2 14 AnApet° /34R. c.. 1.— -fl4L s, c ,'eor S/301j. a Date Signature of Permit Applicant