18-013 (4) North American Roofing
41 Dogwood Road
Asheville,NC 28806
Miranda Byerly
Project Administrator �.E l V
mbyerly(dnaroofing.com RECEIVED
800-551-5602 ex. 179 _
Fax: 828-687-1230 JUL �2�i3 ji 5 2013
Letter of Transmittal
Date: July 3, 2013
City of Northampton
Building Department
212 Main Street Room 100
Northampton, MA 01060
RE: North American Roofing Services Inc
VIA:
Hand Delivered: Emailed: Mail: Overnight: X
Quantity: Date: Description:
1 Application for Building Permit
1 Workers Compensation Affidavit
1 Copy of Liability Insurance
1 2 Sets Engineered Plans
1 Building Permit Fee
REMARKS:
Louis
Please find the above included for pulling the permit to reroof the Wal-Mart in Northampton.
Please do not hesitate to let me know if there is anything else you need.
Thank you for your help!
Signature: Miranda Byerly
828-348-2268
Corporate Office:41 Dogwood Road•Asheville, NC 28806 IT 800-551-5602 • 828-687-7767 •Facsimile: 828-687-1230
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: 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 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO • DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
r
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: W.1" 1cd- Are 5 . ..i
D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 Q NO •
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
fr
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❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration El Existing Ground Sign❑ New Signs❑ Roofing El Change of Use El Other ❑
Brief Description Enter a brief description here.
Of Proposed Work: Replace existing roof membrane.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 El A-3 ❑ 1:1 1A �
A-4 El A-5 ❑ 1B SI
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 El 1-3 ❑ 3B ❑
M Mercantile El 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ 5-1 El 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)
tEttelsrei 1St
2nd
2nd
3d
3rd
4th
4th
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 ❑ On site disposal system El
The Commonwealth of Massachusetts Print Form
_` Department of Industrial Accidents
Office of Investigations
,I 1 1 Congress Street, Suite 100
Boston, MA 02114-2017
ice'- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
North American Roofing Services Inc
Address:41 Dogwood Rd
City/State/Zip:Asheville, NC 28806 Phone #:828-687-7767
Are you an employer?Check the appropriate box: Type of project(required):
1. A I am a employer with 20 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. [1] New construction
2.El 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.n Electrical repairs or additions
3.❑ 1 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' 13.0 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:American Casualty Co Of Reading,PA
Policy #or Self-ins. Lic. #:247978403 Expiration Date:6/23/14
Job Site Address: North King Street City/State/Zip:Northampton, MA 01060
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 certii y under the i'ins and •ena 'es of perjur that the information provided above is true and correct.
Signature: A �N II► �. Date:7/2/13
APP
Phone#:828-687-7767
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#:
Version).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, A b.4/14. k_c)4J2.4(__ ,as Owner of the subject property
1CeS
hereby authorize 1\30V4t) Anew tcu ) to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
A&efeil
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.
A 40/
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature 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
Version 1.7 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 ❑
G'HPctZ�G� A ' CA 114 rr"r FA
AR 31573
Name(Registrant): �, ` i , , / -{met/- (�/
&1 ( 0f" C/kV AY r"Cv4 Cp.o t.--Iv-I - 0 f (04917-Registration Number
Arias > f r 08/31/2013
(—Z
--14-4---4-1/4ftll---Pt.S-t-e- (212) 979-1857 Expiration Date
Signature
y 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
itddrrss Registration Number
4
Signature Telephone Expiration Date
9.3 General Contractor
NA Roofing Not Applicable ❑
Company Name:
irY)
ira_too
Responsible In Charge of Cons uction
40 Dogwood Road,Asheville,NC .,,
Addre Ai&.
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
Department use only
City of Northampton vvStaatteursmtofePneArm:ti:labiplitey
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100
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
This section to be completed by office
1.1 Property Address:
180 North King Street Map Lot Unit
Northampton, Ma. 01060
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A ii,4-0-1 /›.-04,-(-- )300 a s mi C.-. 1 EtAirb.ivig.4.1Ak...., .727/6
Name(Print) Current Mailing Address:
6/7432.7"--agi-13 I
Signature -<--------- Telephone
2.2 Authorized Anent:
Charles A. Schmitt 611 Broadway, Rm. 606, New York,NY 10012
Name(Print) Current Mailing Address:
Signature 111:-/4-1--6--/ /...iii.i....4 f/ Telephone
SECTION 3-ESTIMATED CO STpidiCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $21...:)k ncf:::,s,
/ (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) Check Number 49 900 3 (fly pa —4)--
1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature: j
0
Building Corn issionertinspector of uildings
Date 7/1/
File#BP-2014-0037
APPLICANT/CONTACT PERSON NA ROOFING
ADDRESS/PHONE 41 DOGWOOD RD ASHEVILLE (828)687-7767 0
PROPERTY LOCATION 180 NORTH KING ST-WALMART
MAP 18 PARCEL 013 001 ZONE (.
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE GAr
ZONING FORM FILLED OUT
Fee Paid py C
Building Permit Filled out
Fee Paid 02 yl603 #J,) � ' �,�_ D �e��-
f
Typeof Construction: REPLACE EXISTING ROOF MEMBRANE
New Construction 2
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
INFO TION PRESENTED:
pproved 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
�- on !-lay
Aer
j—/617--(3
Sig ature of Building Offi i• 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.
180 NORTH KING ST-WALMART BP-2014-0037
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-013 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-0037
Project# JS-2014-000107
Est.Cost: $201709.00
Fee: $1212.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NA ROOFING
Lot Size(sq.ft.): 452152.80 Owner: NORTHAMPTON HOLDINGS LP C/O GIBRALTAR MANAGEMENT CO
Zoning: Applicant: NA ROOFING
AT: 180 NORTH KING ST -WALMART
Applicant Address: Phone: Insurance:
41 DOGWOOD RD (828) 687-7767 0
ASHEVILLENC28806 ISSUED ON:7/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE EXISTING ROOF MEMBRANE
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 7/19/2013 0:00:00 $1212.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner