Landfill Shed permit application 2014-06-11File # BP-2014-1335
APPLICANT/CONTACT PERSON TRISTAM W METCALFE
ADDRESSIPHONE 142 Main St NORTHAMPTON (413) 586-5775
PROPERTY LOCATION 170 GLENDALE RD
MAP 42 PARCEL 089 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHES::KLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Pennit Filled out
Fee Paid
meofConstruction: TRANSFER STATION IN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets ofPlans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
__Approved __Additional pennits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ _~__~~~_~ ___
Intennediate Project: _____Site Plan AND/OR _~__Special Pennit With Site Plan
Major Project Site Plan AND/OR_ Special Pennit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: '8
Finding __~~~~__ Special Pennit Variance*~_~
____Received & Recorded at Registry ofDeeds Proof Enclosed ___ ~~_
_ ~_Other Pennits Required:
___Curb Cut from DPW ____Water Availability ~___Sewer Availability
~_~__Septic Approval Board ofHealth _~__Well Water Potability Board ofHealth
___]ennit from Conservation Commission ~ Pennit from CB Architecture Committee
_____Pennit DPW Stonn Water Management _~_~___Pennit from Elm Street Commission
_~~~_Demolition Delay
---~---~-----~------------DateSignature ofBuilding Official
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 ofMGL 40A. Contact Office of
Planning & Development for more infonnation.
_____
Version1.7
of Northampton .
uilding Department
212 Main Street
Room 100
L .' J,:,o~hampton, MA 010130 . .
..,.;" PiI.mbina & ~rIfn'@.e4t~.:>A;R7-1240 Fax 413-587-1272 •.
APPLICATION TO CONSTRUCT; REPAIR, RENOVATE, CHANGE THE USE OROCCUPANCY OF, OR DEMOLISH ANY BUILDING
. . OTHER THAN A ONE OR TWO FAMILY DWEL.LiNG .
SEcnON 1,· SITE·INFORMATION:· "', .-' ',.. .' .
. ·Thi$,se~tipn to:be cQmpJet~dl:>y'Office'1.1 Property Address: ____~____._______:-..:...____... _'.
. ---..----.-.. ------..------. . . i . ,Map
Lot .t10{,?(~~aJ-<-.("'pt;( Iftor~IM&f.lc\/;,:.;, q;-"~ 1'} U~it
.',Ov~~I~y! [)Is.~t;iet... !. 7rhk$¥-~' .;".,
u __ • __ t 1.=~'",,' ' .. >: .-.,', _...' .n ~ ;. :~;~~i';i~~~~rf~1~'.: ..~.··.h.· . ,. "~," ..... , .,_-u··
' .. ,
2.1 Owner'of Record:
[~~ ~:};!.~~ ,J
Name (Print)
Signature Telephone
2.2 Authorized Agent:
.--~ . .. ~.
1... :'-;.l_~r.:A,~.~~t1,*~~l~___·_:. ' . 01£.···f1~~;--J;)~;~~-~~-_==1
. ~~~~... .' .---C~_~ejJjn~,.f-ddress: -------'1I A\~2.e" '. :"57?S' _______.1
Telephone'
.
.~.i~6,;i~d~~.'?~~s1;~::;i\,::·tl· .
Item
. 1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5, Fire Protection
6, Total:: (1 +2 + 3 + 4 + 5)
I:jifJo
-
•Offii,iii:ihUse.:,QnlY'....;.;-. -.j':,. -. -"".';:".;.:" .... .,:. " '.:
. 'T~is,SectiobiF.b'~;dffiC:iai:;Us~,0nlv.
-·Il:-'
Building Permit Numb.er. 'I:,"¢?\te,: "
:;;Issaeer
.J~i9D.9.!l,lr.e:__ .
Building Commissioner!1nspedor:oCsuildinQs Date
. Yersion1.7 Commercial BuildmgPennitMay 15, 2000
.S
Interior Alterations' 0 ExistlngWall signs' .0 :Demolition 0 Repairs 0 . Additions 0 .Accessory Building 0
. Exterior Alteratioh·D Existing Gro~n:d.'Sign 0 New Signs 0 Roofing 0 Change of Use D· Other 0 ,
w.u.\.S .. ~Q
0 . A-3 0
/1 D.
iA Assembly 1A
18
2A
2B
2C
3A
38
5A
5B
.~ ~
I'I
0
0
0
0
o o
U Utility Specify: rI~~'U-V'tf-te.!7 t'1A~t(K-47R (2.J;6,!}_" -'---~'l
M Mixed Use . D
S Special Use' a
Existing Use Group:
Hazard Index 780 CMR 34): .'1 pr~oosed Hazard Index 780 CMR
I SECTION 6 BUIL.DIN? HEI(;HiT~ND;AREA .
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION.
Floor Area per Floor (sf)
. '-""'.......-.....~..----~'~-~-.,
51" &"'_ ~ .<1 L__.__~_ _ I 151
~.t::t:Y-:" :zs; ,.,-_____.-J ,:: .,,'i, :;:
2nd 2nd ...JL••__:...._____· __________
3rd, . ,i!\...-.....____.,_..,..,.,___________¥~'''~
3rd ! ,j
. 4th . t ....__....~_____..__.___~__..~...._j
4th i_____.___.________._........j
Total Proposed N~Const~ugio.n {sf)___:
! ! ~__._,_._____,.,__~..__,_,__~.,.~.J
Total Area (sf)
Total Height (ft)
I_··~__~______. __ • ,m __ , ••
7. Water Supply (M.G.L. c. 40, § 54)
Public n Private
7.t Flood Zone Information:
Zone C_. ::1 Outside Flood Zone
, , ' , Version1.7 Commercial Building P~rmit May 15, 2000
-' -' '-";"-:':'-~--' -'~.':':" .
['8., NORT~~T:~~~~~~,~::~I
Lot Size
,Frontage'
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
I Open Space Footage . ,(tot area minus bldg & paved'
: 'parking)
# ofParking Smices'
Fill:
(volume & Location)
Existing
, If
I .
, r--~!'--,ir : ': IR:L-1 ,
r--l,_----I
,I ..~~
---1---, 0 !, __.~!. Yo
'c:J., % . ' '.. " !" .,.... .:..:....;.r'-'~', :.. -
, 1: .. ::~] ...
, Proposed.
j =:Jlf !....
Il II
d j R:k i
C" -1
, Ir=r
"1
Required by Zoning ,
This colmnn to lie :filled in by
Building Department
I~
r-J.'----'
r 1
[....J
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 •DON'T KNOW 0' 0 ; ,.YES
: .:IF):,ES, date issued:
:'~f YES: Was the permit recorded at the Registry of Deeds?
. NOO ' DON'T KNOW 0' YES 0
IF YES: enter Book I t,·, Pagel -l and/or Document # , '____ 1",__",_--,,,,,,,,,,,
B. Does the site contain a brook, body of water or wetlands? NO 0. DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtaihed from the Conservation Commission?
--,.---'~
Needs to be obtained o Obtained 0·';' , Date Issued: I I ~"-.< • . ~~~l
C. Do any signs exist on the property? YES 'NO',0" 0
IF YES, describe size, type and Location: __~~:"'j.,~f~'i1.·==~__==][i~"t_~~t.\~__ ~
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO' e:5'
__'_________I<OW ....
. '
IF YES, describe size, type andlocation: ,. , .' ___,__, ___ .L _______ __~~ ~
E. Will the construction activity disturb (cle?lring, grading, ~"tion, or filling) over 1 acre or is it part of a common plan v
that will disturb over 1 acre? YES 0 .NO . \::J '
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. '. .
Version 1.7 Commercial Building Permit May 15, 2000·
4
SECTION 9.PROFESSI0NALDEsIGN:AND CONSTRtilCT;lQN:!SERVICES'•..FO,R·eWILDIN<§.S:AND·STRUCTURE:S:SLlSJECT TO
,. CONS:T:RUG!JiIOf)l;9qNTRO·l;P,\!iRSUA~t.;tq.:7?o.:ql}ll~;1,~$J::(i~Q!II;tt\i~1.N~:!\!1b.f{E.1fHP.iNi.3'~.~OO'C;J;.:.j:)f.'$~LP'~E:b:,$P~GE)
9.1 Registered Architect:
Not Applicable 0[14s1r~~~, l~ =:: .' ..~,
Name (Registrant):' , ' .
r --.....,. ----~
~tion Number _J ./.
. Telephone
·L"______'--,,,.,~ C.11?-.~~.~~~E~:::-...·--·=]M~ " .. .
Signatlre V
r ........ ._--.---;---;/ j
, j '7IL_.5:1:li...J . Expiration Date
9;2~Professional Engineer(s):
1
,
.j,
"1
'Name' Ic~-"_' .."... , Area of ResponslOlllry.
1
"Mg[EOSl! -_....... ---,.. [!Registration Number
Signature Telephone I Date
/ .. ' -'1'
I iNam~ .... __
I .
Address
.... r
Signature. Telephone
If
I Name
'--Address
, Signature L Telephone
It
Name Area of Responsibility
I foJ
",.....•. ,-''''....'''._-,-_._-
Address Registration Number
I 'I j[,_. -~--Telephone Exoiration DateSignature
9.3 General Contractor
""'I J INot Applicable 0I.L
-t"":1"'I1T"tr"tony Name:
""'l JI' .L,.,..
K6sponSIOIe In Charge of Construcllur
If'.
Annr""", r
Signature ' """'I
1
~1, .. ,
-j
'-I
i
·~1
:.
!
I
-1
!
1
. .
Version1.7 Commercial Building Pennit May 15; 2000
.'
. SEC1iION1
No
I, as Owner of the subject property
hereby _ .___
act on my behalf, in all m~tters'retative to work authorized by this biJliding permit ~pp/ication. -1
I ~
. Signature of Owner . '.' Date
~,============:::=======~=,=:;:::::::;::::::::~:::::::::::-=::::::::=======,--__,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. . " ;, " ' , : ,
'. '--",". , . . '. -". , Si~ed,y.1lgerJb.!tQai!1§...sngJl§J1...?.!tl~!LQ[p,.!7d\l!1:t . . -'.
L .._._.,:. -....,,,,.,...,
PrintName
.'alltV UI '-1"'t;'JI~'=' nUIUt;:'1 :l::!=======================~======d
Signature
Workers Compensation Insuran~e affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the' .... .. '
ned Affidavit Attached Yes '
, Date
o
'." ; ':','
------
, The Commonwealthof;Massachusetts
Dep"artment ofIndustrial AcCitlel1.ts '
, , Office ofInvestigations .........
600 W~;jti;tgton street'
, , Boston, MA0211',
, www.m·a;~.govlditi.
, Workers' Compensationlnsnrance Affidavit: Builders/ContractorslElectricianslPlumbers
Applican.t Information Please Print Legibly
. . . . .
Name (BusjnessIOrganizationiindiiriduaI):,__-,---,~____-,-_____---: ____...,.--_____~__
-4ddress:,__--.:..._______~_---:_.:.....:...:....-...,--~_-:--__________'----_
*Any applicant that checks' box #1 must also fill outthe section below showingtheir workers' compensation policy infurmation.
t Homeowners who,submit,thiii-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 name ofthe sub-contractors and state,whether or not those entities have
employees. lEthe sub-contractors have employees, they must provide their workers" compo policy number ..
1 am an employer that isprovidiitg workers' compensation insuran'c¢ for my employees. Below is thepolicy andjob site
information. " , ,
Insurance Company
Policy # or Self-ins. Lic. '. ' . Expiration
Job Site Address: City/State/Zip:__________
Attach a copy of the ~orkers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGLc. 152 can lead,to the imposition of criminal penalties ofa
fme up to $1,500.00 lI11d/or one-yearimprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fme
of up to$2~O.OOa day against the viotator. Be. advised tliata copy ofthis statement may be forwarded to the Office of
Investigations ofthe DIkfor ins~c~~o';~-;;~g~ ';ermcation. --, ,. - ,
I do hereby certifY under thepailts aiJ,dpenalties ~fperjury that the information provided above is true and correct.
, , Signature: Date:
. Phone#:
Ofjicial use OIl{V. Do not write in tltis area, to be completed by city or town official
-city or-ToWn: ,--.<------,----------.--- , , ,. ,----.'-PermitILicense#_'-_'.._..·_____________
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ________........:...___
Contact Person: Phone #:
City/State/Zip: Phone #:_
Are you an employer? ~heckthe appropriate box:
1.0 ram a, employer with " '.' 4. 0 r am a generalconttactor and I .
. employees (fun ,and/or part:-time).* have hired the sub~contractbr-?
:==o"::,:+:c",,d~c l a.m.a sole proprietoi,or_partner~ _ . listed on the attached sheet. '
ship lind have' no employees .,' . These: sub-contractors nave'
working forme in any capacity. . employees and have workers'
[Ni.fworkers' cOmpo illsurance' "., compo insurance.t",
, ' required. ] .' ,',.., 5. 0 We are a cOIporation and its
3.0 I am ahomeowner doing all work officerS have exercised their
myself. [Nq workerS:' compo . right ofexemption per MGL
, insurance required.]t . ~._152,§lJ4)Jap.d,':Ve hav-e no
employees. [No workers~
,comp.' insurance required.]
Type ofproject (required):
6. 0 New construction
7: ' 0 Remodelfug ,
8. 0 Demolition'
9. 0 Building addition
, 16.0 Electrical repairs or additions
11.0 Plumbing repllirs or additions
12.0 Roofrepairs
13.0 Other