18D-040 (17) SibigialigarNaP BP-2009-0332
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0332
Project# JS-2009-000453
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PRIDE CONVENIENCE INC 038811
Lot Size(sq.ft.): 42209.64 Owner: PRIDE CONVENIENCE INC
Zoning: HB Applicant: PRIDE CONVENIENCE INC.
AT: 375 KING ST - 17 DAMON RD
Applicant Address: Phone: Insurance:
246 COTTAGE STREET (413) 737-6992 O
Workers Compensation
SPRINGFIELDMA01104 ISSUED ON:9/25/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE & REPAIR CONCRETE FLOOR FROM
WATER LEAK
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 9/25/2008 0:00:00 $55.0010044726
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2009-0332
APPLICANT/CONTACT PERSON PRIDE CONVENIENCE INC.
ADDRESS/PHONE 246 COTTAGE STREET SPRINGFIELD (413)737-6992 Q
PROPERTY LOCATION 17 DAMON RD
MAP 18D PARCEL 040 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out lee q,S 7
Fee Paid y
Typeof Construction: REMOVE&REPAIR CONCRETE FLOOR FROM WATER LEAK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 038811
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
l 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
6y/7-0/68
Signature of Building 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.
Version1.7 Commercial Building Permit Ma. I .2000
Department use only
(` City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
•
2008 ! j Room 100 Water/Well Availability
sus2 5 Northampton, MA 01060 Two Sets of Structural Plans
phone-413-587-1240 Fax 413-587-1272 Plot/Site Plans
;5 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
1.1 Property Address: This section to be completed by office
S 15. V
oki Ma Lat'
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: �� G lie Y
N13 73 7 9�-
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailin Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ,} D (a) Building Permit Fee
D J ;
2. Electrical I (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) 4 �C 50 (9 Check Number f ,�yy7p76p ��
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Version1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs[ ] Additions LI Accessory Building El
Exterior Alteration ❑ Existing Ground Sign LI New Signs❑ Roofing 0 Change of Use CI Other ❑
Brief Description Enter a brief description here. (� f
Of Proposed Work: (�e(�o.re. Una Ce ail GM( r f C 4pct'l be�a�� o �Jr7f/ e� 'CCt�
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) _ CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ] 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A 0
I Institutional ❑ I-1 0 1-2 0 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A El
S Storage 0 S-1 ❑ S-2 ❑ 5B 71
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
___,
S Special Use ❑ Specify: i �� �
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: �,,,,._, , ,_ �_,_,,, . ._.__.___ Proposed Use Group: �..... _. _._ .. _e
•Existing 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 [
I 1
_
2nd 2nd .
qq
3rd 1 3rd t
4th 1 _— 4tn
Total Area (sf) Total Proposed New Construction(sfJ,,,,,,,,,7
1 i
Total Height(ft)
Total Height ft L
7. Water Supply(M.G.L. c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public r.' Private ❑ Zone .._ j Outside Flood Zone Municipal NE On site disposal systems
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
f
Frontage I
Setbacks Front
I i
Side L:— R: I L: R:
Rear 1
Building Height ""µ 7 '"-1
Bldg. Square Footage
Open Space Footage % pp
(Lot area minus bldg&paved t
parking)
I
#of Parking Spaces .
Fill: i
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW (,)) YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: i �j-i-(t°(', S 1\
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO ,/
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 0 NO 3)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 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 0
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
L_ a
Name Area of Responsibility
r_____. ..__ ,„.. .,........
...
__ 1 i i
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
Name Area of Responsibility
. _
Address Registration Number
I
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Qom__. dld� .
Responsible In Charge of Construction
aq fo Co±1 o _ st_ Noc A In 7!.E a 6 6
Address
fr/1- 21— - 1-'113-13 7 Ci'I)4—
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 0 No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ..__ ..__I, as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, Ro • d—• @0I PV C� , 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.
Roes — .Q�d
Print Name •
_ VW51Cr
Signature of Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
`
I
Name of License Holder: 6�f'�� a �c--
�` (�/I ` 1
License Number
AddressLt Cl. �l PI Ci QA d,� 1
Expiration Date
Signature Telephone
Z�
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 4 No 0
e The Commonwealth of Massachusetts
sz. Department of Industrial Accidents
L�M . IV
Office of Investigations
il
„�ry 600 Washington Street
Boston, MA 02111
.; z� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organisation Name: T)P C(yMie fl 1€V) IN. riPT-,,lq. \_,,,,,„,le.d e f S�i
Address: 1M b Cc)rkce +
Q ` � J
City/State/Zip: Jpc 1 a , ) ►`{P1 01 104 Phone#: ` 3 - 3-7 ` 6 q 9 2_
Are you an employer?Check the appropriate box: Business Type(required):
1.IZ I am a employer with a Od employees(full and/ 5. [ Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers'comp.insurance required]** 11.0Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing rjke s'co ensati.n ins ranee for my emplo ees. Below�j is the policy information.
Insurance Company Name: Vitas Y1 eta1 1 e fQ� C , 1b U 1 fir_
Insurer's Address: t p 1 }S� to l-?cap I.\ d �.
City/State/Zip: L C .1-}-,ail) j ,11 .1 0
Policy#or Self-ins.Lic.# 011 O(DJV 3 )g our Expiration Date: li 1 J b-1
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 certify, under the pains and penalties of perjury that the information provided above is true and correct
— Signature: (;(; Date: —0--Y-en
Phone#: 3 y r� '�l l
•
Official use only. Do not writeln: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 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
g/2e �, nw of f. a�
Board of Building Regulatiofis and Standards
Construction Supervisor License
License: CS 38811
Expiration: 10/31/2009 Tr# 10280
, Restriction: 00
ROBERT L BOLDUC r
49 WOODSLEY RD
LONGM€ADOW,MA 01106 Commissioner
S'
�,,- ea�T � � ^,. .K SETTS 9 =
4 F NUMBER p �...
74928105 ^7`' '®
Y.
EXP DOB17.15
•.Ati. >
10=31-2009 10-31 194 .. "
CLASS REST HGT SEX Air _ _
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BOLDUC Zi
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ROBERT L ; b
49 WOODSLEY RD
LONGMEADOW,MA yid „ r` `
01106 2516 -S ,, t/ ' 4ttti
IA 3119g3.< �l