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. • \
•
•
•
•
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• •
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