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17A-287 (2) 344 BRIDGE RD BP-2018-1020 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-287 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: demolition BUILDING PERMIT Permit# BP-2018-1020 Protect# JS-2018-001849 Est.Cost: $2500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group, THOMAS AQUADRO 083682 Lot Siu(sg.ft.): 90604.60 Owner: FITZGERALD HAROLD RJR C/O ALICE FITZGERALD Zonis:RI(100)/RR(86)/URA(14)/ Applicant: THOMAS AQUADRO AT: 344 BRIDGE RD ApplicantAddress: Phone: Insurance: 38 LINSEED RD (413) 348-4444 WEST HATFIELDMA01088 ISSUED ON:41"018 0:00:00 TO PERFORM THE FOLLOWING WORK.DEMO 40X40 METAL BLDG AND 20X22 WOOD FRAME BLDG 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: FeeTvue: Date Paid: Amount: Building 4/9/2018 0:00:00 $50.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Versionl.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit: Building Department Curb CUVDriveway PermH 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site 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 (0 zit 7.1 Property Address: This section to be completed by office ) r Map 1�/-1 p Lot 759 Unit Zone Oveday District )-6Nc2 /r - - - - EIm SL District G6 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f-etiC. e -IL, Name(Print) / ,��/44.�unenr Mailing Address: c�C3 �rg .333s Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building PermH Fee 4. Mechanical(HVAC) 069 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature'. 14J-6-1 Building Commissioner/Inspector of Buildings Date C- X77 al/., Version1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESSTHAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repaint❑ Additions ❑ Accessory Building El Exterior Alteration ❑ Existing Ground Sign❑ Naw Signs❑ Roofing❑ Change of Use❑ Other['T Brief Description Enter a brief description here. /'t�'/yI,Q,L,(�a AA/-d- djl17es e �l©X),/0 6itYWA61c, OF Proposed Work: 't /4N l J- 1� l l f� _A46- SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A AssemblyElA-1 11A-2 ElA-3 El 1A 11 A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A S Storage S4 cff S-2 ❑ 5B Q/ U Utility ❑ Speciry. 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 NEN/CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 1. 1:' 2ne Zee _. 3"' 3b _ Total Area(so Total Proposed New Construction(sf) Total Height(ft) _.. .. Total Height it 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone_-nformation: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone. Outside Flood Zone[-] Municipal ❑ On site disposal system❑ Versirxi Commercial Building Permit May 15,2000 S. NORTHAMPPON ZONING Existing Proposed Required by Zoning This column m h fii1N m by Building Depznment Lot Size Frontage Setbacks Front Side L:-R:_... L: R. Rear Building Height Bldg.Square Footage In Open Space Footage % (Lot area minus bldg&paved lsve) #of Parking Spaces - (volume&Lawnov) ....__ A. Has a Special Permit/Variance/Fin(ding ey�r been issued for/on the site? NO O DONT KNOW (2 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registsyvf Deeds? NO O DONT KNOW �n YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW © 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 Q-/ NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E, Wil the construction activity disturb(clearing, grading.excavate ,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O 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: _._. ...... . ..._._ _. Not Applicable ❑ Name(Registrant) _ e g Registration Number Address Expiation Date Signature — Telephone 9.2 Registered Professional Englneer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Dale 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 Telephones Expiretion 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR : APPLIES FOR BUILDING PERMIT I, /LPL 6 Q 1'y�Z C/'e�Cb(LL2 as Owner of the subject property hereby authorize �tlt :mA /u . © !!#1 _ to c 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 under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supennsor: Not Applicable ❑ Name of License Holden Trt 0 /N1.4 C' /4. /" U Ll./D An- _ L _,6,sa License Number 3iyseed ! 1 _ _lnJzsr;/VA � , < / , 111tz AE/-2j 2tVA Address Ex i2h Dat 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 issuanceof the building permit. Signed Affidavit Attached Yes No O 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 !. � �tt The debris will be transported by: Z�Ijj akcZ 11AAek11A091L':�'Y SaN} The debris will be received by: Building permit number: � q Name of Permit Applicant _�' riLyt 6 . A5 /P, >r`q 1e A n.P v 2 Z'6 Y Date Signature of Permit Applicant The Commonwealth of Massachusetts Department ss Slre s Suit ccidenis 1 Congress Street, Suite 100 Boston,MA 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Appheant Information Please Print Legibly Business/Organization Name: - -)n MA < Al �n l Address: 3 $2 ,G r/V S PP d 4l City/State/Zip: 4-,) EST Phone#: Y/7-3 �'g - -9y�� Are you an employer?Check the appropriate box: Business Type(required): 1.❑ 1 am a employer with employees(full and/ 5. ❑Retail _�4fpart-time).; 6. ❑Res;nmmnt/Bar/Eating Establishment 2 0?'tam am a sole proprietor or partnership and have no 7_ ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required) g. ❑Non-profit 3.❑ Weare a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per a 152,§1(4),and we have 10.❑Manufacturing uo employees. [No workers'comp.insurance requireA]' 4.❑ We are a non-profit orgadlation,staffed by volunteers, 11.❑Health Care with no employees. [No workers'comp.insurance req.] 12-❑Other 'Any apphi that checks box#1 mart also fill out Mesection belowsbovivgtbeirarorkeri compensationpolityud uom "nNe evemped themselves,bur thecoryomdou has other employaraworkers'compmsatim policy is rslui dand suchan organiution sM1OWd checkbox 5l. lam an employer that is providing workers'compensation ins ranee for my employers Below is the polity information. Insurance Company Name: insurer's Address- City/State/Zip. Policy#or Self-ins-Lic.# Expiration Date: 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 cer6�r the pains and pcookies ofperjury that the information provided %above is true and correct Sten Phone#: 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.Licensing Board S.Selectmen's Office b.Other Contact Person: Phone#: w -ues.gov/iia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an emplojwe is defined as"._every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and me oiling the legal representatives of a deceased employer,or the receiver or marme of an individual,partnership,associatio:a or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apa-tments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every stare or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states`Neater the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to tie cumacting authority." Applicants Please fill out the workers' compensation affidavit ccmpletely,by checking the boxes that apply to your situation and,S necessary,supply your insurance company's name,aidress and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited LiabilityParmerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Han LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or roam that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed leldbly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used es a reference number.In addition,an applicant that most submit multiple perreaMicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of me affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bumleaves etc.)said person is NOT required to complete this affidavit. 7Le Department's address,telephone and fax number: The Commonwealth of Massachusetts Department.of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE Fns#617-727-7749 www.mass.gov/dia Form Revised OMM5