31A-076 Cochrane Dental Associates
264 Elm Street, Suite 11
Northampton, MA 01060 August 10, 2010
CR &C will provide remodeling services to
prepare for the installation (by others) of dental chairs in the
rear corner room in suite 11.
Plaster /drywall finishes will be demoed only
if to extent necessary to facilitate rough plumbing and wiring
C O () changes for the new chairs.
After electrical, plumbing and building
RESTORATION& inspections, plaster /drywall surfaces will be restored and the
CONSTRUCTION entire room finish painted.
908 BERNARDSTON ROAD The above to be done on a cost plus, time
and material basis for an estimated cost of $3,800.00.
CrREENFiELD, MA. 01301 It is understood that the chairs are to be
413- 475 -3833 delivered 9/3/2010, and that CR &C will try to have room
ready for that date.
Benton ook Dr. Rebecca Cochrane,
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rkmiies.com
PAGE NO 1
SINCE N C E I O All approved material returns are subject to a restocking fee.
618 depot street • po box x125 88 exchange street • po box 746 9 4 Merchandise returned must have been purchased from
manchester center, vermont 05255 middlebur}; vermont 05753 r.k. MILES within 30 days and must be in resalable condition.
802 362 1.952 toll free 888 447 5645 Box 388 2722 toll free 800 564 2721 Proof of purchase is required on all returns. Special order
rk mILEs
items artrnon- returnable.
185 cole avenue 24 west sneer Accounts not paid when due are subject to a SERVICE charge of
williamsrown, massachusetts 01267 west har6eld, lnassachusetts 02088
413 458 8i TS toll Gee Roo 670 7433 413 247 8300 toll free 866 446 582o BUILDING MATERIALS SUPPLIER .134% pee month until paid which is an ANNUAL RATE of 18 %.
Customer No. Job No. Purchase Order No. Reference Terms Clerk Date Time
500505 BRENTON APP# BRENTON 5% 10TH NET EOM VA 8/12/10 12:23
Sold To Ship To
Cook Restoration & Const. DOC# K55009/4
. 908 Bernardston Rd TERM #461 * * * * * * * * * * * **
. *CREDIT MEMO*
Greenfield MA 01301 -1159 SLSPR: 53• VALERIE ARCHAMBAULT * * * * * * * * * * * **
(413) 475 -3833 TAX 040 MASS TAX
SHIPPED ORDERED UM SKU DESCRIPTION UNITS PRICE /PER EXTENSION
—1 EA 6392310 LARGE HOOK BLADE 1 5.16 /EA —5.16R
CREDIT RETURN
—4 EA 268SP 2X6X8 SPRUCE 4 3.591/EA — 14.36R
CREDIT RETURN
—24 LF 14P 1X4 PREMIUM PINE 24 .51 /LF — 12.24R
CREDIT RETURN
3/ 8.00
tIr'
951 ** AMOUNT CREDITED TO ACCOUNT ** 33.75 TAXABLE — 31.76
NON— TAXABLE 0.00
(BENTON COOK ) SUBTOTAL —31.76
TAX AMOUNT —1.99
TOTAL AMOUNT —33.75
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
= ` www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
• 1
Name ( Business /Organization/Individual): 1s� �lL - 0' 1 •i
Address: �Q�r1 `fi 5u��cvaCX
City /State /Zip: pt ck-r \ , of 30 l Phone #: //3 4 95 3 ? 3 3
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State /Zip:
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 S1,500.00 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 and : pains nd naltie of perj ry that the information provided above is true and correct.
Signature: Date: �r /l3 /
Phone #:/ 3j ^ �
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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Version1.7 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
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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 perlur
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder . \ ) Ce ( ! C"
License Number 63,4 + '
A ddress Expiration Date
Signature Telephone
SECTION 13 -W RKERS' COMP NSATION 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 bu jding permit.
Signed Affidavit Attached Yes No 0
•
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 ❑
Name (Registrant):
Registration Number
Address ...
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Ristration 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 it
g p p' ation Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
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
Frontage
Setbacks Front
Side L. _ __...__ R ..._.... n._ 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 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ' Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 (3 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0
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
Interior Alterations Ed Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief descriptign here. S i' 1 . c r A-A-4- �6.1"..4 WaLS
Of Proposed Work: ;, h qq 1 CAA t f� 1 40 t 11 \ a (,e.9 CI,. v / fi e � r 1n e-v'
,r, _ .....;. p,. i t.. f .. x4 .._lte�l.�-,_.cs.4c�. , .:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE !
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business fzi 2A ❑
E Educational ❑ 2B f ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
_ _
S Special Use ❑ Specify: fy. a_____._.._,..n ___4 ____
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) ael find -A77 "C a
1 st
1 5�
72
2 nd
2 nd
..�. ..._., ._ . 3 rd
3rd _,_,_ ,., ,
4 u,
4`"
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 ❑ Zone Outside Flood Zone❑ Municipal 0 On site disposal system
Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton status of #u
Building Department CurbCu B t 1 ya r
212 Main Street sewerte c Uatlabtlity
Room 100 Wateri3Nel ilabi(if � ` 10
Northampton, MA 01060 TWO Sets f Structural Prans
phone 413 - 587 -1240 Fax 413 - 587 -1272
Plot/Site., sans
lei I� , $)
Other Specify, . �, 'l '
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
a 6z/ M ap Lot Unit
in • 1 ',✓1 )i/7 i j J dloU Zone Overlay District
CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address
YZ.T, ler
Signature Telephone J a 3
2.2 Authorized Agent:
► n-r fir,
Name (Print) / Current Marling Address /
/
61 a a f ,3 °_l_.
Signature i� Telephone if /3 '? S _ ,7 o 3
SECTION 3 - ESTIMATE • CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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) 3 etre Check Number S 74'
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0122
APPLICANT /CONTACT PERSON BENTON D COOK
ADDRESS/PHONE 908 BERNARDSTON RD GREENFIELD (413) 475 -3833 0
PROPERTY LOCATION 264 ELM ST - SUITE 11
MAP 31A PARCEL 076 000 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out a we L/Va . ,
Fee Paid
Tvpeof Construction: RENOVATE 2 ROOMS IN DENTIST OFFICE
New Construction
_ Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 049209
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INI+ RMATION 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
Demolif n Delay
r-/?_10
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.
264 ELM ST -SUITE 11 '. BP- 2011 -0122
GIS #: COMMONWEALTH OF MASSACHUSETTS
. ck: 31A -076 '" CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit # BP- 2011 -0122
Project # JS- 2011- 000212
Est. Cost: $3800.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BENTON D COOK 049209
Lot Size(sq. ft): Owner: WELCH EDWARD JOSEPH JR
Zoning: Applicant: BENTON D COOK
AT: 264 ELM ST - SUITE 11
Applicant Address: Phone: Insurance:
908 BERNARDSTON RD (413) 475 -3833 0
GREENFIELDMA01301 ISSUED ON :8/20/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: RENOVATE 2 ROOMS IN DENTIST OFFICE
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 8/20/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner