23D-052 (5) 63 RIVERSIDE DR BP-2002-0291
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-052 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0291
Project# JS-2002-0440
Est.Cost: $350.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EARL F. ROLLAND 062404
Lot Size(sq.ft.): 10410.84 Owner: AMERICAN LEGION POST#28 HOME,
Zoning:URB Applicant: EARL F. ROLLAND
AT: 63 RIVERSIDE DR
Applicant Address: Phone: Insurance:
285 PROSPECT ST (413) 584-1361
NORTHAMPTONMA01060 ISSUED ON:9/14/01 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING IRON FIRE ESCAPE &
INSTALL WOOD DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/14/010:00:00 4337 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2002-0291
APPLICANT/CONTACT PERSON EARL F.ROLLAND
ADDRESS/PHONE 285 PROSPECT ST (413)584-1361
PROPERTY LOCATION 63 RIVERSIDE DR
MAP 23D PARCEL 052 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /5.6
Fee Paid
Typeof Construction: RE OVE EXISTING IRON FIRE ESCAPE&INSTALL WOOD DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 062404
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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
ermit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
Signature of Building ial 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 May 15,2000
Department use only
(� (� Q EC tik„ NorthamptonStatus of Permit:
r___
1Vilb u g Department Curb Cut/Driveway Permit
Main Street Sewer/Septic Availability._,.,___
SEP 1 2 2001 W om 100 Water/Well Availability_________Nor' am ton, MA 01060 Two Sets of Structural Pans.
c Bllto1.1 '., .". 87-1 40 Fax 413-587-1272 Plot/Site Plans
na�NRwIcrnN,Ua p106Q Other Specify
APP !CATION 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
'�' l Mapd31) Lot Unit
.� 3 �i /ex,/c4 , /,e/�z
/UCe y X__ 0/0 61? Zone It` " - Overlay District
/
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
x7,,,,,„/ „././,,,-0., 41z--).8 Q,,77 i 3 4,4 Lae, tz,,(a... z., 4 0/041.
Name(Print) gr/
Current Mailing Address:
� /~ �P y9 3 5$y . .- i y
Signature I., Telephone
2.2 Authorized Agent:
6/,,t,7,7 ,d 0,,,,,r Aclra 1Aizt 6/ ,/F/siI F P/bE g,I.Lict ilk
Name(Print) Current Mailing Address: ef/d6-•1
---� ,c e:1:- 7 z7 q,s -7 79 S'7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building . 5 0, i (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) ', J /a •— ` Check Number 4 33 7
Section For Official Use Only $5--a-
This
Building Permit Number: 'f-f--/-- 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 Existing Ground Signs Additions 0 Roofing 0
❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
.Igl DE Accessory Building[ ].. jiepairs / Q(
SC2 P ! 11vY e(ID &44 ifs (/G 11)
4.,...
SECTION 5'- USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly T A-1 0 A-2 0 A-3 0 1A I ❑
A-4 ❑ A-5 ❑ 1 B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - I ❑
F Factory 0 F-1 ❑ F-2 ❑ 2C ❑
H High Hazard 0 3A ❑
I Institutional ❑ 1.1 ❑ 1.2 El 1.3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential k- R-1 0 R-2 ❑ R-3 0 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use 0 Specify:
S Special Use ❑ Specify:
COMPLETE THIS 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) 1st
2nd
1st
3rd
2nd
4'
3rd
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft
Versionl.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone: Outside Flood Zone ❑ Municipal 0 On site disposal system 0
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
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 ,�C DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW X YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO A DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES X NO
IF YES, describe size, type and location: &:9761/1/ .2iy\/ A7d/e114/*...4,7-77—Z
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No X
IF YES, describe size, type and location:
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:
Not Applicable 0
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
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
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
.,(9.3 eneral Contr c r
) Not Applicable 0
Company ame.
Responsible I harge of Construct n
2Y1J— V . IV ,
Tevss.t4
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, , 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, , 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
Signature of Owner/Agent Date
ECTION 12 - CONSTRUCTION SERVICES
`S
/ 10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : 0Y ke, c76,r(-/ 0 ({ )`LI d LI
y� h .! ILicenseNumber
MKT J/�aJ Ndt J t. /110 nz m 1 V �{ G G 3
Ad ress Expiration Date
y ( -5 — Sr$--r 3 (A
Signatu e 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
fi. .
.
4-(l%AA1 p7,
.e Oy
e 'f�$ pfoit ; _*
9 g ki ifl. 6 ilassnclinsctta' '
..,r:�'== DEPARTMENT OF BUILDING INSPECTIONS ___�i
212 Main Street ' Municipal Building 'a -=_
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE A.FFt'LUAVTT
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(btltxt/city/state/ip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
I I.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet if nerr,rrry to include information pertaining to all contractors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
i NOTE:please be aware that while homeowners who employ persons to do Qtaiutc x a,r constructionor repair wort;on a dwelling of
a not moos than throe units in which the homeowner reifies or on the grounds appurtenant thereto arc not generally considered to be
employers under the woeiccs`s c sxtion Ad(GL152,sa 1(5)),application by a homeowner for a license oc permit may evidence the
legal status of an employer under the Worker's Campemation Ad_
I understand that a copy of this rt.tr.n.nt may be forwarded to the Depertmcat of Industrial Accidents'Off oc of Iusursaoa for the
coverage verification and that failure to secure coverage under section 25A of MOIL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S 1,500.00 andfor imp of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against mt.
For dqurtnal uac only
Permit Number
gyp# Lot#
_, Signature of LiccnseeJPerm.ittee Date
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