Permit App - Concession Stand"6,
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The Commonwealth of Massachusetts
Office of Public Safety and Inspections
Massachusetts State Building Code (780 CMR)
lding Permit Application for any Building other than a one- or Two-Family Dwelling
is Section For Official Use Onlv)
Building Permit Number:Building Official:
SECTION 1: LOCATION
City /Town Name of Building (if applicable)
Block # and/or Lot #
SECTION 2: PROPOSED WORK
No. and Street
Assessors Map #
Edition of MA State Cocle
Existir-rg Building D
lf New Construction check here E or check all that apply in the two rows below
Alteration tr
ange ofOccupanry D
it Appendix 2)
I Specify:Char.rge of Use tr
Are building plans and/o
Is an Independent Stru
y{Description of P
construction docurnents being suppliecl as part of this pennit application? Yes }( No D
alEngineerirlgffr[u",u*rgguire{,f_ C l_ \ _ 1 Yes D No)(
THIS SECTION IF E)(ISTING BUILDING UNDERGOING RENOVATION ADDITION, OR
CHANGE IN USE OR OCCUPANCY
"n {'"gj1y:9ttglqgjlgj1 4 93!91 " .'f c losect_ (See 780 CMR 34) tr
Use Croup(s):
SECIION 4: BUILD AND AREA
SECTION 3; COMPL
Check here if an Existi
Existing Use Group(s):
) & Area Per Floor (sq. ft.)
sEcrloryLV.s_t_cf@Lcles-\jl p1!! _tr Nishtclub tr A-3 D A-4 D A-5 tr I B: Business E
No. of Floors/Stories (i
Total Area (sq. ft.) and T
A: Assemblv A-1 tr A
U.!reb.!43sd __ Jl-1 n H--2tr H-3 n __lt{_tr____U l8
Y:!!":g$:]. I __ _,_ _lR: Residential &E__!2D__l_9!__!t4 a;.--
-
;U: utilig tr_Llpg:gt tr'"!_l'Ilp$:1q9'.1'b" ujl"y, _
SECTION 5: CONSTRUCTION TYPE (Check as applica
tr I-3tr I-4tr
Factorv F-1 tr
I: Institutional I-1 fl I-
S: Storage S-1 tr S-
VAtr VBtrIAtr IBtr IIA tr IIB tr IIIA tr IIIB tr
ION 7: SITE INFO TION (refer to 780 CMR 10!.3 for details on each
A trenclr-rrfll not be
reou.il€cl E or trenclr
it is enclosed E
hirport approaclr area?
YesE orNoE
Debris Removal:
L,icensed Disposal Site tr
or speciiv:runicipal E
on site system D
Hazards to Air ljavir
Is Structurepplicable
nsent to Build e YesE No E
ATE OF OCCUPANCY
Edition of Code:
Does the building contai
Design Occupant loor and Assemblv s
SECTION 9: PROPERTy OWNER AUTHORIZAION
rcl Acldress
Name 0
oPe Owner
7ip
lt: IlA rytpSrcn _413l. ft_^l' I z fr
Telephorre No. (business) Teleplrone No. (cell)If applicable, the property ow hereby authorizes:
Strbet Adclress
owner's behali in all matters relative to work authorizecl
R
e-mail address
MA
ztp
this build nllt a lication
Date
TION 10: CONSTRUCTION CONTROL (please fill our epp"rrdi* 1han 35,000 cu. ft of enclosetl space antl/or not untler Corrstruction Cor.rtr.ol then ctreck he.ff
A-199,p!9vlle sqn$uelon-eqlrclfu (see s91!,o492$llt9 J9!tg)eClgtlr]lq{_*_:_\ :i:-'. :-:- -.-t:.:l_:::i:la.::l:.1:*____*_ __lU" f"LlqrytrClljS4 qo"qq-G!9lrofessional coordinating document submittals
No.e-mail adclress Regish'ation r
City/'fown State Expiration Date
thi9**otio nG -L-*bosS.,ec- -fr#{AufhH-;t cq!',H*'pJ - flu *)$;.."0'' ozP"'oo'" o6 z-7 -l
Citv/Town State Zip
%oL1sa. o+sz lsyrcoeu@Shneil, ewr-__ _ lgl_"$pr:e No. (e!L _ e-mail acld-ressi-wgstsgggENry
nsll rance Affidav it flornll"n t toN tNsUtANSt] (tvt.c.r. c. 152. g 25C(!)L___
florn the MA Deparhner-rt of lndustrial Accidents must be comrrletert-intt -
Failure to plovicle this affidavit will lesult irr the clenial of tlre-issuance of thc buitclirrg pemrrt.g4-{{r4gyrt-'-g9-'"r-S9g-ytqr-!l','glllse!'g{ _ ___ __!_"!X..N-"_..q,_..-.._SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
and Materials)I'otal Corrstructiorr Cost (fronr ltem 6) : $s-7ibOo --Building Pernrit Fee = Iotal Construction Cost x _ (lnsert here
appropriate nrurricipal factor) -, $
$
$-^
Note: Minimunr fee.- $_ --__ (contact municipalit_v)
ON 13: SIGNATURE OF BUILDING PERMIT APPLICANT
b)' "tt"tt "t ,t", tl*-t-"*;,,,G"";lt*; p;.Jr.y th"i"rr "f ir."l"f-.r*-ti. .-rt"i i"-a --t-nir"
t1
Professional
Name (Regish'ant)
Street Address
10.2 Genera-l Contractor
IJS-Un:ve
Conrpiyrv Namq^
Nanre of Person Resoonsible
Street Address
25.7:Pa&
.lclqrlrn', " llg_&seltess
SECTION 1
A Wolkers' Compensation
subnrittecl with this applicat
_.I rrlrgr-l*- _
2. Electrical
3. Plumbing
, N4..-h";l;;i-livn-i
5, Me_c-ha1!g! (Q!!eg
6. -fotal Cost
B" ;rlt"-lg ;r-ry r*"* b.l"-J
application is h'ue and accurate
and sign namc
Municipal Inspector to fill out is section upon application approval:
CITY OF'NORTHAMPTON
SE]'tsACK PLAN
MAP:___ _ LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONTSETBACK
FRONTAGIi
Name of Hauler:
Signature of Applicant Date: lZ'Ol-Urc
In accordance of the
Number
City of Northampton
Massachusett,s
DEPARTMENT OF BUILDING I,NSPECTIONS2I2 Majn Street . Municipaf BuildingNorthampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
OR ALL DEMOLITION AND RENOVATION PROJECTS)
ovisions of MGL c 4O, SS4, a condition of Building permit
is that all debris resulting from this work shall be disposed of in a
properly licensed was disposal facility, as defined by MGL c 1.j.L, S 1504.
The debris will be di sed orin: EV D is Posa-t
Location of Facilitv:o7r5 |
The debris will be tra ported by:
4ufl'
Initial Ccnstrnction CcntroX Document
T* t'e sutr::ritt*d r.';ilh tlte tru:.lding rr€r''dt ,rpplicatr.olr b"". a
Regisiered Sesign Fr,ofessio*al
f,i.rr ruork per fire nu:fll Erfifjo* *f ffte
.&f*ssrrcllu.setfs Sfnte Eriflding Cr:rde" iSS C.e.f& Sectioff IS7
EI
r beth as aprplicable: Ner+. cunEtruction Ccnstructioa
i IIA Regrs'tra liunrher:Expkati*rr date a rry.lsterer{ riesigil profes_rlrrrlrll. atrd I tra.r;e
r'., sed the Eleparaii*n af all drsigr s, c *nrpu ta ti,*rrs and sp're c ificatirt rs c once rrtirr g:
Architer
Project Title:
Froperty Adfuess:
Projectr Cnreck {r-} *rle
Project destription:
preparert r:r ri{l'ectl',. sqr
*.t tlw
Struciural
Ele.clrir:al
&{echanical
Other:Fire Frur{ect on
ior the a-be';e na*"led
r *mg-ru t& tri6i*s and sprec
olect *nr-1 fltat ts thefest L1f ill1' krrcrr'[66U*. in{srtxatisn, and belief ru.cts pians,
Clr,[Rl, and accepteri
,:i e :.:i gtee I slreall per$*nr
arrtl periodic lrasr:r to:
ications meet the ag able ;rrc.,'i*ions ef tl-re l,'{assachusetbl SieFe Euilding Code, ql$r-'r
ginee*i.trtg nracticU LTI cr the PTFFDEed pr$ect. I ,un"desstend erttl agree tirat I (or ler-..
t}'ee necessan'p sronal selr.jc*s aud b,e pr:ese*t ,:'n ti:Le construrtion gite on a regtrlar
Rer,.ier;t', fr,-r c,l to::nrartce thir cod.r arrd the design cr-rncept, shopr dralr.inga, samples and other
strbn*"ittaLs b-,,:
Perforur the d
Be prerent at
in accordanre rtith the requirenrents urf the ru-nstructrr-.* doct-nrents.
tererl riesign professionals in I,9* Cl,.{R Chapter 1i, aE applicakrle
propdate iu the :rtage of cnngtruction t'-r ber--onre generall',: familiar',';'ith tl-r*
Flt'Lrgfe:rs and qu ti'lt'l isrk and to determitrE if the '.tork ir being perforrned in a rna*ner csr,']sisteni
r.;'ith $re elrrFro onsbtection documents ar'ld. this cod.e
\*thing rn this d*cu t relie-;e-e the coniracturr cf itr res;'roruitrilitr. regardirrg tlr.e;rro.,'isior-r,s of J$* Cl'"lR i0l
l
1
l: Qlrtf
ginr,
i'Cing *fJicia1, I'-rhall subtnit fi*trd;Jprogres repcrts iree ite.*r -1. j tcgetl:e*r rr.ittrr pertinent
f:rtable ts the l.uilding afi'icial.
li,'trrk" n :r,3ea11 s,tibr*it t,-r thg 6u*ting officiai a 'Final Conste.uclien Coxrtrol Docuueni'
r:91:l a "rr.et" or
se$l:
t,'ihen required [::",
f L1l]'1"!ner1t!, ur a ln
Llpon cnrnp
Enter iii ihe
ele,:trol"t'i{ signature
P'nro*e numfrer:
Suilding Off icial l{arzrer Feruni't ]fs":D*tel
)totp 1, Indi**i: tiiJt an'rl'
c.I'.c'::r'.. pr,:r:d* r ce;cn1:tia
:u:er:i,3ri :J 1_{J 1_1,} ig
Suii'fi*g 0,fgrrr:l lfse Sulq.
I
*jeet de:l,$r x).r:r-', ronrp',-rLrtfun: ans. s:-e"rjirrah*i'u :]re: ',-cu r:r'*p*ei c,l ,j.xectli' suFenj-cad. t ctl.rel i.:
nltl
aut
Co
che
the
do<
lonstruction Docume
hecklist below is a co
re checklist and prov
ocuments. This appr
Appendix 1
ts are required for structures that must comply with 780 cMR 107. The
rpilation of the documents that may be required. The applicant shall fill out
le the contact information of the registered professionals responsible for the
rdix is to be submitted with the building permit application.
Checklist for Construction f)ocumentsx
Mark "x" where applicable
No,Item Submitted Incomplete Not
1 Architectural
2 Foundation \
3 Structural T
4 Fire Suppression C
tr Fire Alarm hlav lquire repeaters)
o HVAC
7 Electrical
8 Plun.rbins (includ local comections)(
9 Gas (Natural, Pro arre, Medical or other)x
10 Surveved Site PIa (Utilities, Wetland, etc.)(
1 Suecifications )
2 Structural Peer Rt lew
3 Structural fests &brspections Prograu'r
A Fire Protection Ni rative Report
5 Existiue Buildius iurvey/ Investigation x
o Energv Conserva on Reuort -'.-x-
7 Alchitectural Acc ss Review (521 CMR)
d Workers Compen ation Insurance
o Hazardous Mater I Mi-tiga tiqn Documentatiou )\
20 Other (Specify)ETC-x--__VOther (Specifv)rls I_
22 Otl-rer (Soecifv)-6nffi-?)
leas of Design or Corrstruction I
rst not bc conmreneeti urrtil tlris
lholity having jrrrisrlictior.r.
which plans are rlot conplete at the time of applicatiorr submittal must be iclentified herein. Work so iclentified
plication has been amenrlecl antl the proposecl construction riocument amentlment has been applove cl by thc
Itegistered Professional Contact Information
R"g"tr"tr.l Nmrb"t
Discipline ExpirationDateCity/Town
Nane (Registrant)
Street Address
e-mail address Registration Number
Discipline Expiration DateSt"t" Z:*Citv/Town
Name (Regishant)
Street Address
r"r"-pnon" Nr "-t*"u .,ic|**R"gtrtt^f.. N"-b"t
Discipline ExpirationDateCiW/Town State '' 7it
Name (Regishant)
/
Street Adclress /
lease follow this link for trol forms to be used bv Registered Desien Professionals.
PROCEI)
MUL
City of Northampton
Massachusetts
DEPARTMENT OE BUILDTNG INSPECTIONS
212 Main Street o Municipaf Building
Northampton, MA 01060
RE I.'OR OB'I'AINING A BUILDING PERMIT FOR COMMERCIAT, &
I-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
{- t.
Nft -2.MA- r.{ -a.{n5.
/ -6.Nft -7.
tvA - 8.
NA -9.pA - ro.
tt{ 'tt.
sJ k- tz.
Building
agent.
Application signed by legal owner and filled out by owner or authorized
One set plans and specification of proposed work (digital and hard copy).
Site Plan ith location ofproposed structure(s) and setbacks.
c Debris Affidavit filled out and signed by applicant.
Worker's ompensation Insurance Affidavit filled out and signed by applicant.
must supply a copy CSL and proof of Liability Insurance.
Energy C
Note any
nservation Compliance Certifi cate (if applicable).
onservation and/or Special Permit requirements (if applicable).
Driveway t (if applicable).
Proof of ater and Sewer entry fees paid (if applicable).
'I'rench it (if applicable).
Initid C ction Control Documents filled out and signed by the Registered Design
Profess I in rcsponsible charge.