42-089 (9) City of Northampton
# O a H M TO 5■5
a} y Massachusetts ,
"a DEPARTMENT OF BUILDING INSPECTIONS y ''
' s y 212 Main Street • Municipal Building
� Northampton, MA 01060 Js �'D,11
INSPECTOR
Louis Hasbrouck Fax: 413 - 587 -1272 Chuck Miller
Building Commissioner Phone: 413 - 587 -1240 Assistant Commissioner
CONSTRUCTION CONTROL DOCUMENT
(For professional Engineers /Architects responsible for Entire Project)
„ �,:�
Project Title: - 1--- 16? -1-t : { 1 I ,,.. s,�. � ?t, t Date: fr i (7 v t'L
Project Location: /{ j j I.. la I N:) ,Y - n Map: a 2_ Parcel: () %` I Zone:00 1
Scope of Project: 1.� .r: ✓� U f L 16 I 4 v" 74-
In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107.6: ` '�`"
1, c a c 1. (.,L7 Mass. Registration # (C ( G
Being a registered professional Engineer /Architect hereby CERTIFIES that I have prepared or directly supervised
the preparation of all design plans, computations and specifications concerning:
'ENTIRE PROJECT
For the above named project and that to the best of my knowledge, such plans, computations and specifications
meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices
and all applicable Laws for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that
the above mentioned portions of the work proceed in accordance with the documents approved for the building
permit and shall be responsible for the following as specified in Section 10.7.6.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction documents as submitted for the building permit, and approval for the conformance
to the design concept.
2. Review and approval of the quality control procedures for all code - required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed
In a matter consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent
comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory
completion and readiness of the project for occupancy.
Signature and Seal of Registered Professional
cr NO. 31010
27 Day of it w t 20 1Z SHAM
J (seal)
•
fOF _ ,.
The Commonwealth of
Massachusetts
k, \tat'
Department of Public
Safety
One Ashburton Place, Room 1301
Boston, Massachusetts 02108 -1618
Phone (617) 727 -3200
Fax (617) 727 -5732
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
K) iVha-nq 1- en
(name of facility)
o 6A- it e, , V•∎ mA t o( a
(address of facility)
signatur of permit applicant
date
debrisaff doc
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803
(800) 876-2765 NCCI NO 26158
POLICY NO. I WMZ 8005651012012
PRIOR NO. WMZ 8005651012011
ITEM
1. The Insured Burke Construction Co., Inc.
Mail Addiess:
6 Renfrew Street Adams MA 01220
Street No. Town or City County State Zip Code
FEIN iooca5389
❑Individual ❑Partnership Corporation ❑Joint Venture DAssociation DOther
Other workplaces not shown above:
2. The policy period is from 04/20/2012 to 04/20/2013 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 500.000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 500.000 each employee
C. Other States Insurance: Coverage Replaced By Endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated - Per $100 Estimated
Na Total Amual Of Amen
Remsnetafiom Remuneration Premiss
•
INTRA 279154
SEE EXTENSION OF INFORMATION PAGE
Minimum premium $ 483.00 Total Estimated Annual Premitmt $ 20,928.00
As indicated interim adjustments of premium shall be made: Deposit Premium $ 5,579.00
❑ Annually ❑ Semi Annually ❑ Quarterly 0 Monthly
MA Assessment Chg.
$23,543.94 x 5.9000% $1,389.00
nn nn
This policy, including all endorsements, is hereby countersigned by 02/15,2012
Autiormad &prunes Date
• GOV GOV KIND PLACING CLAIM NAME SAFETY Coakley Pierpan Dolan &
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Collins Insurance Agency Inc
MA 5437 8 802 26 Union Street •
North Adams, MA 01247 •
WC000001 A(7 -11)
Includes copyrighted =tend of the National Canal on Compensation Muaamos
used with its pemtissian.
The Commonwealth of Massachusetts
1 ,
Department of Industrial Accidents
► E Office of Investigations
=1I 600 Washington Street
Boston, MA 02111
IND , ; . www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information s Please Print Legibly
Name ( Business /Organization/Individual): , V t Lif Cone ` ?k "fit u c c ° Co
Address: to \ Lv rte' -
City /State /Zip: A n.5 , t'\A 0 1a) Phone #: tt i `� " RU(( )'•
Are you an employer? Check the appropriate box: Type of project (required):
1.1I am a employer with C\ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I 7 • Igttemodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 1011 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.0 Other
*My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: k (VY1 li1"1 t .� 1 C6 !
Policy # or Self -ins. Lic. #: m2 F> S�(o �j 1 L) 1 tL� 1 D. Expiration Date: yI Zi-) I 1
Job Site Address: 1 ' L ' I \ e r l a t t . f 2 ) \ ()('ch(.i , kt n , 01 k City /State/Zip: v Q (
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: ' ' . 3 1 )C 1 `^". J f Date: e I1-1 Z..
Phone #: A 15 `14 3 jCto5
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 ® No 0-
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, E-) I,A/ A izz 1 - 7 T .G) fet c , as Owner of the subject property
hereby authorize R K / 13 1AP' F CUiJ3Ti C-i1 0 ,3 to
act on my beh.If, in all matters relati e 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 perjury.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : J c ' n J -
License Number
(' Q€y rem . , A Ac s , ► �,A ac: C5 5 I `
Address Expiration Date
1� 1y 3 -. ► /0)0
Signature Telephone
SECTION 13 ORKER ' 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 0. No
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):
"z7I0lCJ
Registration Number
11`i ►,'l -S1 (e-,ti r W1 � 22�
Address " �3 l 1 - 2 v
- Expiration Date
b 3 ZG _ 7.77 72(
Signs Telephone
9.2 Registered Professional Engineer(s):
f'1 evi it . 160, eS s
Name Area of Responsibility
40 YA 4 it/4 G I p 44o -,1i/i1 7 04$ Z
Address z 4,7
1. C� f Registration N mbar
Sign re 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 General Contractor
1?? v k- CDY\S'K )C 17 6'41 CC). -. Not Applicable ❑
Company Name:
Responsible In Charge of Construction
(� "i2e n w 3 . Pacurts , NI A ) iao
Address
Signature Telephone
Vcrsionl.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 52 acres ....___.... - 52 acres _........_ .._ .......
t 5 feet feet 25 f � ;
Setbacks Front F- 2 ..
..- ........_ :2400.; '2400;',
Side L : R: 660....E L.300_. X660 i
Rear '160 1 160 1
Building Height
0 -� 20 _.,
Bldg. Square Footage =684a <1 1 68401 i<1 I
Open Space Footage %
(Lot area minus bldg & paved ;. 2 14 9 4 ,. , ., ' 1,2,14 94-. -. __.1 1 1
parking)
# of Parking Spaces NA NA
Fill:
(volume & Location) 2,600 CY - Backfll go
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 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 ' i Page ? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: £ 06/28/2012
C. Do any signs exist on the property? YES ! J NO
IF YES, describe size, type and location: 'Landfill b Emergency A and Re
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
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 ❑ Existing Wall Signs in" Demolition Eit Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use'®" Other ❑
Brief Description Enter a brief description here.
p C , /rte �-� �:�-�` „ -e---
Of Proposed Work: /
I /Gc� wVr-� � ✓�`�(1.^��A T� l l�`U�'C� � � Cj "RJir; (G`'
f
✓'��
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 ❑ 2A
E Educational ❑ 2B 1
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 1 ❑
U Utility ❑ Specify:
M Mixed Use ❑ 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: _ l
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)
Cv.�"d 1st
1 st
2nd 2nd
3rd 3rd
4 th
4 th
Total Area (sf) 68 4o r r Total Proposed New Construction (sf)
Total Height (ft) Z C
Total Height ft 20 �' Z
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewa a Disposal System:
�]
Public Private ❑ Zone Outside Flood Zone' Municipa On site disposal system El
Version1.7 Commercial Building Permit May 15, 2000
Department use only
ity of Northampton Status of Permit
uilding Department Curb Cut/Driveway Permit
}� 3 1 2012 �' 212 Main Street Sewer/SepticAvailabilty
l t Room 100 Water/Well Availability
c-FA N. hampton, MA 01060 Two Sets of Structural Plans
NO TRAM. : :! - 587 -1240 Fax 413 -587 -1272 Piot/Site Plans
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
r1 0 Ithcix3e. t` t ock.K. Map Lot Unit
Zone Overlay District
K\Or ftlarn (Yl v C` c,c)
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: _
Name (Print) Current Mailing Address:
Signature Aaj Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building `I 1 ( �? l a'5 (a) Building Permit Fee
2. Electrical (b Estimated Total Cost of
1a I 000 Construction from (6)
3. Plumbing 0 Building Permit Fee
4. Mechanical (HVAC) , ()C)U
5. Fire Protection
6. Total = (1 + 2 + 3+4 + 5) c l a 1'37) Check Number r-
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0244
APPLICANT /CONTACT PERSON BURKE CONSTRUCTION CO INC
ADDRESS/PHONE 6 RENFREW ST ADAMS
PROPERTY LOCATION 170 GLENDALE RD- LANDFILL
MAP 42 PARCEL 089 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out n
Fee Paid
Typeof Construction: CONVERSION TO STORAGE BUILDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 51347
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
V 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
VC/i <7.
Signa re 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.
170 GLENDALE RD- LANDFILL BP- 2013 -0244
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42 - 089 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0244
Project # JS- 2013- 000380
Est. Cost: $723723.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BURKE CONSTRUCTION CO INC 51347
Lot Size(s4. ft.): 2265120.00 Owner: NORTHAMPTON CITY OF LEACHATE TREATMENT FACILITY
Zoning: Applicant: BURKE CONSTRUCTION CO INC
AT: 170 GLENDALE RD- LANDFILL
Applicant Address: Phone: Insurance:
6 RENFREW ST WC
ADAMSMA01220 ISSUED ON:9/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:CONVERSION TO STORAGE BUILDING
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 9/4/2012 0:00:00 $0.00 1
Sar/1(46!*- EcEcTle G
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck - Building Commissioner