12C-010 (2) NORTH MAPLE ST-SPRING GROVE CEMETERY BP-2019-0269
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block: 12C-010 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT
Permit# BP-2019-0269
Project# JS-2019-000444
Est.Cost: $2000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CITY OF NORTHAMPTON CENTRAL SERVICES
Lot Size(sq.ft.): 1306800.00 Owner: NORTHAMPTON CITY OF SPRING GROVE CEMETERY
Zoning: SR(99)/WSP(99)/WP(3)/RI(0)/URA(0)/ Applicant. CITY OF NORTHAMPTON CENTRAL
SERVICES
AT. NORTH MAPLE ST - SPRING GROVE CEMETERY
Applicant Address: Phone: Insurance:
Memorial Hall (413) 587-1260 ()
NORTHAMPTONMA01060 ISSUED ON:9/6/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 2 DOORS AND 1 WINDOW IN DPW
MAINTENANCE BUILDING
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 9/6/2018 0:00:00 $0.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0269
APPLICANT/CONTACT PERSON CITY OF NORTHAMPTON CENTRAL SERVICES
ADDRESS/PHONE Memorial Hall NORTHAMPTON (413)587-1260 Q
PROPERTY LOCATION NORTH MAPLE ST-SPRING GROVE CEMETERY
MAP 12C PARCEL 010 001 ZONE SR(99)/WSP(99)/WP(3)/RI(0)/URA(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT ARP44CATION CHECKLIST
NCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
Typeof Construction: REPLACE 2 DOORS AND 1 WINDOW IN DPW MAINTENANCE BUILDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INMATION 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
Demolition Delay
_/_ _ 14,� Tdaq
Signatur of Buildmg 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.
Versionl.7 Commercial Buildiry Permit Mav 15.2000
Department use only
R:E::� I / City of Northampton Status of Permit
V Building Department Curb Cut/Ddveway-Permit
212 Main Street Sewer Septic Availability
SEP - 4 2018 Room 100 INater/WellAvailability
orthampton, MA 01060 Two Sets of Structural Plans
h ne 4 3-587=1240 Fax 413-587-1272 PlDt/Site Plans
EPT OF 131JILDING INSPECTIONS Other Specify
ON 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
...._._..---------._.._.........__ M2pI ac Lot 010 Unit
Zone Overla y District
01ob??✓ 1
—� ._. Elm St District CS District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NamC. ..
Signature Telephon _�• _._..._.._,..
2.2 Authori d A nt: •
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED?CONSTRUCTION COSTS:
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /) O� (a)Building Permit-Fee
�i ...._..
2. Electrical (b)'Estimated Total Cost of
Construction from (6)* _.._
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5.Fire Protection _— -....__....._:.._.. ..
6. Total= 0 +2 +3+4+5) lopCheck Number
This Section For Official:Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Version 1.7 Commercial Building Permit May 15,2000 't
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory B Iding_❑
Exterior Alteration
El Ground Sign E] New Signs ❑ Roofing❑ Change of Use❑ Other ''
Brief Description Enter a brieffdescription
�here.
V VJ +
Of Proposed Work: it-%r Q0?0
SECTION 5 -USE GROUP AND CONSTRUCTION TYPE'
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 I ❑
R Residential ❑ 1 R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
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:
Existina 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)
_...__._ 1st
is[
2nd _. ...... .. .. ..._ . ..,-_... 2nd
_........_. .
3`� 3rd
_.....___.. .._... .._ _ 4th.. _......
4t"
Total Area (so Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft
I
7.Water Supply(M.G.L. c.407 § 54) 7.1 Flood Zone Information: 17.3 Sewaae Disposal System:
Public ❑ Privat= ❑ Zone Outside Flood Zone❑ I Municipal ❑ On siie dispesai system❑
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES S-LJBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 1:16(CONTAINING,MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
___...___._._.._.,_....__ -------•-w- •---•--M-------�•--- ': 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
NameArea 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
.....---------- _.......... _- _
1f " Not Applicable ❑
Company Name:
Resp Bible In Charge of nstruction
Addr s
Siona re Teiephone
Version 1.7 Commercial Building Permit May 15, 2000
S. NORTH-kMPTON ZON1.NG
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
LotSize _._ _ -_____ ___ _. . ...._._._ ...........
f -
Frontaae
Setbacks Front
Side L. __ R::--
Rear
::_._...Rear _...._
Building Height _�-....-__._ _._._...._..._
Bldg. Square Footage _..____.: _.___-_.... %
Open Space Footage _ UA
(Lot
—
(Lotarea minus bldg&paved
parking)
#of Parking Spaces
(volume&Location) _. ,,.. _...._. _.. ......_.. .,:,:_._...
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
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 r
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
The Coinin on wealth of Massachusetts
^: Department offndustrial.4ccidents..."
Ofjrce of lnvestigatiolZS
600 Gi'ashina opt Street
=' Boston, MA 02111
www.mass.gov/dia.
VV'orkers' Compensation Insurance Affidavit: Build ers/Contractors/EIectrician SIP lumbers
Applicant Information Please Print Legibly
Name (Business/Oreanization/Individual):
�rlrlr,>cc•
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. E] I am a general contractor and I
employees (full-and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- Iisted on the attached sheet. 7. ❑Remodeling
ship and have no•employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
9. ❑Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. ' right of exemption per MGL
Y �o workerscomp. 12.❑Roof repairs
insurance required.] T c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box T1 must also fill out the section below showing their'workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the nam of the sub-contractors and state whether or not those entities have
emplovees. 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.
Insurance Company Name:
Policy T or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 DLA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjure that the information provided above is true and correct.
Signature: Date:
Phone r:
✓Official use o✓tlh. Do not write in this area, to be completed by city or town ofJiciaL
City or Town: Permit/License r
Issuing Authority(circle one): ..
1.Board of Health 2,B"uilaing Department. 3.Cita:IT.own Clerk EIectrical Inspector 5,Plumb.inQ Inspector.
6.Other
Contact Person: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER'REVLEIN(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
herebyauthorize....- ._.._ _._._.. ..___.........._...............................-. . ._................. ..._ _....._._...- .. ...... . ..._..... ......... ..... ...._.. __...__ to
act on my behalf, in all matters relative to work authorized by this building permit application...___
Signature of Owner Date
�Owner/Aut orized
gent hereby declare that statements and information on the foregoing application are true and accurate,to the best of my knowledge
a d belief.
S r the_. '.a_andpenalties of perjury.
Pr N
Signa ure of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: _....._......
_.._. _......_.__.......__ __ _..._. . . _. .__....._ _ _.._. _ _..__....
License Number
Address Expiration Date
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(S))
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 0
} City of Northampton, Massachusetts
Central Services
Memorial Hall, 240 Main Street
Northampton, MA 01060
David Pomerantz (413)587-1238 Fax: (413)587-1248
Director of Central Services
To: Louis Hasbrouck, Building Commissioner
From: David Pomerantz
Date: August 31, 2018
Re: Construction Waiver
Central Services will be replacing some doors and windows at one of the Spring Grove
Cemetery maintenance buildings. I request that you grant a modification to waive the
requirement for control construction for the project at 05 North Farms Road, in Northampton
because the work is of a minor nature, will not affect health, accessibility, life and fire safety,
or structural requirements. Having construction control is impractical in that the cost of
control construction is considerable when compared to the cost of the proposed work.
Thank you for your consideration.
5
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