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18D-040 (18)
375 KING ST BP-2009-0625 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-040 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Peinnut: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0625 Project# JS-2009-000908 Est. Cost: $1000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: David Sabourin Lot Size(sq. ft.): 42209.64 Owner: PRIDE CONVENIENCE INC Zoning: HB(100)IIWP Applicant: David Sabourin AT: 375 KING ST Applicant Address: Phone: Insurance: 246 Cottage Street SPRINGFIELDMA01004 ISSUED ON:1/5/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:Repair vehicle damage 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 1/5/2009 0:00:00 $55.0010044748 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2009-0625 'APPLICANT/CONTACT PERSON David Sabourin ADDRESS/PHONE 246 Cottage Street SPRINGFIELD PROPERTY LOCATION 375 KING ST MAP 18D PARCEL 040 001 ZONE HB(100)//WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: Repair vehicle damage 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 INFORMATION 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 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. - Vrsion1.7 Commercial BuiidinR Permit May 15,2000 City of Northampton tt , :".,> Building Department CuthCu rIvewi�y Peir ii Sevrer/ tie Ak :::... 212 Main Street - T" .._........ " Room 100 ullaterN!Ia lLp vailabn Northampton, MA 01060 Two Sets of Structural Plans -+ -"A phone 413-587-1240 Fax 413-587-1272 _::— =;'.'ter ''' Other Spec•ify 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� This section to be completed by office 1.1 Property Address: 39 5- l-<)ry C' ST Map Lot Unit Nor iVIAMPiO$J M4 b 1060 • Zone Overlay District —... ' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: . Signature Telephone 2.2 Authorized Agent: Ja _,CO- G 5 v►-. A. �F}+ivRiis) S..i'Ri/v)Fii✓t✓ ._..M.!"....._o_l.l_4•-/. Name(Print) Current Mailing Address: n 33-'29.c . Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only • completed by permit applicant 1. Building (a)Building Permit Fee - . 2. Electrical (h)Estimated Total Cost of Construction from($) —•-,--- . . . 3. Plumbing ; Building Permit Fee 4. Mechanical(HVAC) .__ .. . _._ ..... ...._... • 5. Fire Protection .---......., ,.,., • 6. Total (1 +2+3+4+5) Ai CZ 0 0 _ Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/inspector of Buildings Date T 0 0 ZLZTLBSCTV XVd 8Z:5T 800Z/ZZ/ZT Versionl.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:I Repairs Addit[ons ❑ Accessory Building❑ Exterior Alteration 0 Existing Ground Sign❑ New Signs 0 Rooting❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. Of Proposed Work:, . P?ftl.e,. 21aR....N0N ►N w( e, .. ftM.In.6l ...... a_.Q.W.Z,................. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 El ❑ A-3 ❑ 1A A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ W 2A 0 E Educational 0 2B 0 F Factory 0 F-1 ❑ F-2 ❑ 2C ❑ H High Hazard' ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ SB El M Mercantile ®�— 4 ❑ R Residential ❑ R-1 ❑ R-2 0 R-3 ❑ 5A ❑ S Storage ❑ S-1 0 S-2 0 5B ❑ U Utility ❑ Specify: . M Mixed Use ❑ Specify:' S Special Use © Specify:j • COMPLETE TI-HS..SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS;.ADDITIONS AND/OR CHANGE IN•USE Existing Use Group: . . ..... ...._..__._ ..... .. Proposed Use Group: :--•--- 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) _...__- • 4ih . . Total Area(sf) • Total Proposed New Construction_(sf) . ., 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 ❑ Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal sysloinD Z00Ij ZLZILBSCIt; Xl3 8Z:SI 900Z/ZZ/ZT 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 Sizc —_.._.... ..- Frontage Setbacks Front -' Side L:. ' R:.__...__,_...' L:'_—` R:;.____` Rear Building Height _......._.- --.._.. ., Bldg.Square Footage Open Space Footage (Lot area minus bldg&puved policing) _..___. _..-..._ • #of Parking Spaces ---- - -- Pill: (volume&Lotion) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES 0 IF YES; enter Book : Page' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO G DONT KNOW Q YES Q 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 eV' NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YE5 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excava n,or tilling)over 1 acre or is It part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. C000j ZLZIL85CTfi IVA 8Z:2T 800Z/ZZ/ZT • 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.OP ENCLOSED SPACE) 9.1 Registered Architect Not Applicable Name(Registrant): Registration Number Address _....._.. . .__....... Expiration bate — Signature Telephone 9.2 Registered Professional Engineer(s): i Name Area of Responsibility • Address Registration Number Signature • Telephone Expiration Date • i Name Area of Responsibility Address ... --- Re gistraGon,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 _ —_...—.......__—�_...---•-- Not Applicable Company Name: Responsible In Charge of Construction • Address Signature Telephone tOOZ ZLZTLSSCTT ZFd 8Z ST 800Z/ZZ/ZT Version1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yea 0 No _ SECTION 11 -OWNER AUTHORIZATION-TO BE.COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, -RA -a-r . L f, .l.c>.01-70C ........._._..... ... --- -.......„ .. `,as Owner of the subject property hereby authorize:..-. _�Pcv—>. ./- . SAiaovf.t.n.� . ---------..._._. .._....-•----.. ... ............... .. . .. :to act on my ehaif,in all matters relative to work authorized by this building permit application. -to-/tea Signature of Owner Date 1.11.1.111.1.11.111.111 •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 . .. . _ -:? -^-.,,_---_ Print Name _.........._ ....._.._.... ...._..-.... . tc-jc,1 . --; Signature of Owner/Agent Date • SECTION 12-CONSTRUCTION SERVICES 10.1 Llce_nsed Construction Supervisor. Not Applicable D Name of License Holder: BJ'r' ./... bC12. _.-_. ........_._ i .• ...... . ......._._.......... .... .. ..._.......-_.. License Number :./4/R..L.v..0222a.SCnr'1.._ ^614'b.M e,ca6-,w Alf ....—JC2A.1.O,b._.._...__.—......................'. ._o.3.F" f'/......... , Address Expiration Date Signature j _ Telephone /v(�ii-s A ---- Telephone 3-73?—Co 9 9c SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 Gri No 0 S00 E ZLZTL8SCT1 %F3 9Z:2T 800Z/ZZ/ZT The Commonwealth of Massachusetts Department of Industrial Accidents :' 11= l Office of Investigations _�I1ft� ; 600 Washington Street ``f— Boston,MA 02111 www.mass.gov/dia • Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ?F I Dc CON VA i 'NEE' t A/C' • Address: , q (,.t? � C F S 1' City/State/Zip: 5 !Q/iv�-rl,�D ;/1 j ' Phone#: 11/3- 73 /-6 n .'_ Are you an employer?Check the appropriate box: Business Type(required): 1)EiNI am a employer with 9 ) employees(full and/ 5. ']Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employers working for me in any capacity. [No workers'comp.insurance required] 8. ET Non-profit 3.❑ 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]* l i Health 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'cosutrscation 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 workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ili 4-SS• I1 C74 l L I4 l%R C 1 4 S Insurer's Address:7)c' PoR ir/SH.-.. kr,F-Al e ,%�Ai G V _.. _ City/State/Zip: L -�-1-t 4- Wj , p .V' / 1/U Policy##or Self-ins.Lic.# d/I 00 3 O/ t%1 0 7 Expiration Date: "/eZb/G Attach a copy of the workers'compensation policy declarafion 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, er the pain d penalties of perjury that the information provided above is true and correct Signature: � "� ` Date: i .-t7 Phone#: y/3- 737- 5 Official use only. Do not write in 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 'y 1 "zp°'a�" ""- ✓l�czoaac�izra iBoar o- uil mg egulatiofi s and Standards ) Construction Supervisor License i License: CS 38811 R ,1 • 1 ! -- Expiration: 40/31/2009 Tilt10280 • .i Restriction: 00 tt ROBERT L BOLDUC 1 49 WOODSLEY RD `-'__V � --- I LONGMEADOW,MA 011-06 Commissioner 1 is .ilklgP.& 'i:u.� �, P z - ': {n _� 0dNsw yyam�.„-,.--. '�'.1,3.1 k • F1• \ ' '3Cl-G.FYD.�y,m ' S�-CHUSET TS iP, a ®RI ICEt- .. 9t„ortg i*:4,. ,4,li0kz 5 ,,:;:",..'A':-.; tt. d i yiEam. 4.1 ... t�i 3 4 ' V (r3 9 3 i , _ l'CLASSY REST'�..HGT SEX � '� _ D: all M . -• 4`'7 l � � 7