32A-101 (4) I I
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Final Detail of Work and Pricing
-26 Market Street - Communicate Health
Add door existing office 112 on map
Remove hallway door /demo walls to make new hallway /repair walls create new doorway /baseboard
throughout/ match ceiling/ sheetrock repair/ painting
Add door for telephone equipment
Conference Room
Demo 15' wall /remove bathroom foyer door /replace w frosted glass door and hardware /create, frame, tape
and mud brick exposure — 6' x 6'/ adjust or remove bathroom door closers (2 floor outlets previously included
in this room will be located in front office space)
Add wall and glass door and hardware to create entryway
New cork floor
New baseboard installed and painted throughout
Create and frame out interior ' 5' x 5' window on entry wall/ install tempered glass/ remove existing door and
frame out door opening
Repair sheetrock, tape and mud new opening
p ,
No scope of work included
No scope of work at this time
Painting 3 offices, ante room and entryway - chiropractor's office
Painting all new front office spaces: 2 offices, ante room and entryway
TBD - pricing on white board wall
Miscellaneous
Debris removal/ dumpster
Permits/ authorizations
The Commonwealth of Massachusetts Print Form
�.�...a.. Department of Industrial Accidents
=6..1.6........„ Office of Investigations
' r" tra 1 Congress Street, Suite 100
=; Boston, MA 02114 -2017
*
• - www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Pc L) TO C 0 0 I f e-_ C ( I k) 3-
Address: ' T Cc1X\ I `( 12-0 Pr fl
City /State /Zip: ,U Q 341 .,Q A. 0( l MA Phone #: k t ' . 5 - 7 G . - 1 c j
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. Ei I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling
ship and have no employees These sub - contractors have 8. g Demolition
workin an ca employees and have workers'
g for me in y p aci 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' 13.111 Other
comp. insurance required.]
*Any 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 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 $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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t, e pain' 1 , d penalties of s er'ury that the information provided above is true and correct
Sitnature: ,, � i. / .1;:e10-2:1441111 Date: i U 2-4 LO 12—
-,
Phone #: k)1 . 5 CI. 71 R
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one): .
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
CITY OF NORTHAMPTON
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A. /J
Address of Work: 2,40 N1 ' ` G NU`2 AA P T 6/3
The debris will be transported by: 1 AS - 11. ► AA MA 6 - a ik1■ /L.1 T
The debris will be received at: TiZIN N s t - D2 AT L Ui1/4)
Signature of Permit Applicant
Date 10/ ill/I--
Building Permit Number:
Versionl .7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
\ A G -Z-O 2--K , as Owner of the subject property e- R hereby authorize \. C t-i PaLio STA N TO kj to
act on my behalf 'n all matters relative to rk authorized by this building permit application.
Signature of ner Date
J ^ N T & , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
J$ N ET C E;Z 012K_
Print Name -
Signature of ner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: C4
Not Applicable ❑
Name of License Holder : `J I / L/
License Number
7 ?Z- 37 ry / c z- �17. .c76e7 5
Address Expiration Date
Est ., 1 I � 24
Signature . Telephone / _.2-c)
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 g No 0
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 ❑
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 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
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version1.7 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: 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 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES ® NO O
IF YES, describe size, type and location: E. ST% N Cr W 1'f X11).) W 1), IDo WS
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing] Change of Use El Other ❑
Enter a brief description here.
Brief Description
Of Proposed Work:
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 El A -3 ❑ 1A I ❑
A -4 ❑ A -5 ❑ 1 B ❑
B Business 2 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ El ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I -1 ❑ 1-2 ❑ I -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 El R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B
{ ❑
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:
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)
1 St
1 St
2nd 2 nd
3 d 3rd
4 th
4 th
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 2 Private ❑ Zone Outside Flood Zone' Municipal gi On site disposal system
i.. � k L t_ U
Version1.7 Commercial Building Permit May 15, 2000
6 2012 Department use only
City of Northampton S tatus of Permit:
-... Building Department Curb Cut/Driveway Permit
C c r OF ,ANG ,r =cnONS 212 Main Street
NcRTHAMPTON MA 01060 Sewer /Septic Availability
Room 100 Water/Well Availab lity
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/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
2,C¢ I n Aa. K &t � & � T Map 3 ? Lot p 1 Unit
N e)(2- 1-1 -tA AP r U u I Iv �A Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) 3 Rk) C O Y2 Current Mailing Address: 2 (p M R K tT ST
N O RTNAM PTO l V , J "t Jk O lue 0
Signature fr Telephone 4 3 . 5 Z5 co • C4 2 ?J'
2.2 Authorized Agent: r- R Name (Print) C,µ (a 12 )0 U k N P Current Mailing Address: t 4 Tcun nc I2_..e
/
\).) cl, M A- 0 1OF'&S
Signature L,�/A; L -40% - Telephone ('j . . 7 C1 . 4 ss
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 5 0 (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) , i ,c0 Check Number / 7'?
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building ommissioner /Inspector of Buildings Date
26 MARKET ST BP- 2013 -0502
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 101 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0502
Project # JS- 2013- 000803
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SETH WHEATON 057603
Lot Size(sq. ft.): 0.00 Owner: MARKETSQUARE CONDOMINIUM TRUST C/O JANET GEZORK
Zoning: CB(100)/ Applicant: SETH WHEATON
AT: 26 MARKET ST
Applicant Address: Phone: Insurance:
792 STONY HILL RD (413) 246 -2591 ()
WI LBRAHAM MAO 1095 ISSUED ON:10/29/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: NEW HALLWAY,RENO CONF RM & ADD & RENO
OFFICE SPACE
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 10/29/2012 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner