32A-177PTS
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DEPARTMENT OF BUILDIhC INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 �4
WORICER'S COMPENSATION INSURANCE A -F ITDAVIT
I, Pioneer Contras ors
(licenstdpermitiee)
��rith a principal place of business/residence av
p, 0, BOx 1145 Nn wtn n10.61 _Pboner) _5491
(strrxc/ci ty /staLe.�zi p )
do hereby certify, under the pains and penalties of perjury, that.
(4 I am an employer providing the follo`ving workers coMpensauon coverage for my
employees worming on this job:
Wcc 50059570120C1Z 613n/&
AGcnni a teA FnInI nxz�'Y z nsttranrg C ----- —
(Insuranca. Company) (Policy Numl:�er) (_xpimdon Date)
() 1 am a sole proprietor, general contractor or homeoNvner (circle one) and have tired
the contractors listed below who have the following worker's compensation policies:
(Name of Conuraetor)
(Insuranec Company/Policy Numbcr)
(E irntion Date)
(Name of Contractor)
(Insurance Comparly/Poliey Number)
(E-l'piradon Date)
(Name of Contractor)
(Insurance Company/Policy Number)
(Expi.tabon Date)
(Name of Contractor)
(Insurance Company/Policy Number)
(B4iratioa Date)
rt -ch ad&ticaal shoct ifnc:x c to mclks-& infonnalion pcxtaining to sll wcrtractor�)
() I am a sole proprietor and have no one working for me.
() I am a home owner performing all the work myself.
NOTE: plemw be aware dai while homcowncm who employ pctsous to do m irdcna � oomstrL ion or tcpair work on a dwelling of
not to (v than throe units in wWch the bomoowocr midcs or oa (bo grounds appeuteaat tbucto arc act &,nanny ooaaid,; d to be
cmploym under tbo ivorkru's.00wpa soon Act (GL152fs 1(5))� application by a hoaloo9mcr for a Uccwc a permit may cvn'kmc the
lcgar ctsuuo of an employer under the Workoes compomation AAA-
I undcrsssad &xt z copy of thu ctztcwoat may be forwarded to the Dcpwlm of Inchts l A=dca& OPhoo of luau— for the
aovemsc vcr&cation and that G.ilure to town coves&, undo stiction 25A of M01, 152 can Icad to tbo imrposifion of ---Xl p -a -
oomistiag of a fine of up to S1,500.00 angor inpris of stp to one year and civil pcUIWcs in the fosrn of a Slop Work Ordr and a
dW of S 100.00 a day a&ninsl Mc,
Foc darxi17ninti c°h'
Pcrmit Number
/✓,�i�3P
Signdt= of LiccnsceRcrmi e --
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 0 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Unique Lodging, LLC. as Owner of the subject property
Pioneer Contractors to
hereby authorize
act on my be inZllatters relative to work authorized by this building permit application.
.F OS/ 17/2013
Signature Own Date
David Claxton/Pioneer Contractors asAAVW/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.
Signedunder th pins and pe altie pe jury., _..
tolp�
Print Name
05/17/2013
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
Not Applicable ❑
David Claxton
CS 017890
Name of License Holder:
License Number
P.O. Box 1145 Northampton, MA. 01061
01/19/2014 11
Address
Expiration Date
(413) 586-5491
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 issuance of the building permit.
Signed Affidavit Attached Yes No 0
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:
Name (Registrant):
Address
9.2 Registered Professional Engineer(s
Name
Address
Telephone
Name
Address
Name
Address
Name
Address
Telephone
9.3 General Contractor
Pioneer Contractors
Not Applicable ❑
Registration Number
Expiration Date
Area of Responsibility
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Not Applicable ❑
Versionl.7 Commercial Buildine Permit Mav 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
Rear
L:' R:
L. R:,_
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 DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW Q YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO ®i
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.
Versionl .7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Il
Interior Alterations ❑ Existing Wall Signs ❑✓ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs [I Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. Selective interior removal of wall & floor coverings
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable)
CONSTRUCTION TYPE
A AssemblyElA-1
E]A-2 ElA-3 El
1A
A-4 ❑ A-5 ❑
1B
❑
B Business ❑
2A
2B
2C
I
❑
❑
❑
E Educational ❑
F Factory ❑
F-1 ❑ F-2 ❑
H Hi h Hazard ❑
3A
3B
❑
❑
Institutional ❑
I-1 ❑ 1-2 ❑ 1-3 ❑
M Mercantile ❑
4
❑
R Residential ❑
R-1 R-2 R-3 ❑
5A
5B
❑✓
❑
S Storage ❑
S-1 ❑ S-2 ❑
U Utility ❑
Specify:
Specify:
M Mixed Use ❑
S Special Use ❑
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: R'2
Proposed Use Group:
Existing Hazard Index 780 CMR 34):
Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE ONLY
BUILDING AREA EXISTING
PROPOSED NEW CONSTRUCTION
Floor Area per Floor (so
15f
1 5t
2nd
2nd
3rd .. �.
3rd
4th
Total Area (so
Total Proposed New Construction (so
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 ❑r Private E]Zone
Outside Flood Zone❑
Municipal ❑� On site disposal system❑
Version] _7 Commercial Buildine Permit Mav 15. 2000
4 90-t�
0& -rd esst46 D6AAo PE2vvAT SSrao Fci
City of Northamptontatuof
Permit
Building Department
G4� Cu#llrtvay Permiti �"
212 Main Street
so plSeptir,
Room 100
1Nalepyveil R aitab�li jr
Northampton, MA 01060
two Sets o S Cu ural Plan
phone 413-587-1240 Fax 413-587-1272
pip i
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE O OL H ANY BUILDING
OTHER THAN A ONE OR TWO FAMI DV fELLING
MAY 1 ? 2013
SECTION 1 - SITE INFORMATION
ted by office
T t OG,r seri
1.1 Property Address:
s
NOR7HAMRTON, MA 07060
74 Bridge St.
Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Unique Lodging, LLC.
74 Bridge St., Northampton, MA. 01-060
Name (Print)
Current Mailing Address:
(413)237-5555
Signature
Telephone
2.2 Authorize A e
`Pioneer Con ract rs
P.O. Box 1145 NOrthampton, MA. 01061
Name (Print)
Current Mailing Address:
(413) 586-5491
Signature A
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
com feted by permit applicant
1. Building
$5,000.00,(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 Number
This Section For Official Use Only
Building Permit Number
Date
Issued
Signature
`✓4 //of�
! V
1—/1
Date
n
Building Commissioner/Inspector of Buildings
4 90-t�
0& -rd esst46 D6AAo PE2vvAT SSrao Fci
74 BRIDGE ST BP -2013-1114
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 177 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit # BP -2013-1114
Project # JS -2013-001834
Est. Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 22999.68 Owner: UNIQUE LODGING LLC
Zoning_URC(100)/ Applicant: PIONEER CONTRACTORS
AT: 74 BRIDGE ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413)586-5491 Workers Compensation
NORTHAMPTONMA01061 ISSUED ON. 5/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK. -SELECTIVE INTERIOR REMOVAL OF WALL &
FLOOR COVERINGS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground: Service:
Rough: Rough:
Final: Final:
Gas: Fire Department
Rough: Oil:
Final: Smoke:
Meter:
House #
Driveway Final:
Building Inspector
Footings:
Foundation:
Rough Frame:
Fireplace/Chimney:
Insulation:
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 5/20/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck — Building Commissioner