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13-073 (8) CONSTRUCTION CONTROL AFFIDAVIT PROJECT LOCATION: 25 Coles Meadow Road,Northampton, MA PROJECT NAME: Rockridge Retirement Community NATURE OF PROJECT: Addition to existing commercial kitchen for new walk-in cooler and freezer ARCHITECT: DMS design, lic ADDRESS: 100 Cummings Center, Suite 215C, Beverly, MA 01915 TELEPHONE: 978-965-3470 In accordance with Section 107.6 and 107.6.2 of the Massachusetts State Building Code, 1, Daniel M. Skolski, MA Registration No. 20038, being a registered professional Architect,hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning,ARCHITECTURAL Plans, 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 accepted engineering practices and applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 107.6.2.2. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. Perform the duties for registered design professionals in Chapter 17. 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 if the work is being performed in a manner consistent with the construction documents and this code. I shall submit periodically,_daily,_weekly,or_X_other periods(specify)Bi-weekly or as construction dictates progress reports together with pertinent comments to the Building Department. Upon com etion of the work, Architect, shall submit final affidavits as to the satisfactory completion and readiness the project for occupancy. Signatu �,�EpEO gcy�j !i 03u 4kyF • .•' y rs•f City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 95' (7o/,,S 1W-ee.,ZrLy The debris will be transported by: 171cJe Co tiS7-�c'T'i cti The debris will be received by: R Y{,1L c r� ti S �.-� S 7>0 Building permit number: Name of Permit Applicant Y -n e -'�( ✓7 f�`U-�� �^C'` �' Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 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): Raymond R. Houle Construction, Inc Address:5 Miller Street City/State/Zip:Ludlow,MA 01056 Phone #:413-547-2500 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 30 4. ❑ I am a general contractor and 1 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. 7. ■❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working or me in an capacity. employees and have workers' g Y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.'- required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 11F Other comp. insurance required.] *Any applicant that checks box#1 must also till 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:A.I.M Mutual Insurance Company Policy#or Self-ins. Lic. #:WMZ-800-800579-2013A Expiration Date: 12/31/2014 Job Site Address: 25 Coles Meadow Rd. City/State/Zip: Northampton, MA 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.ce ' under the pains and penalties of perjury that the information provided above is true and correct. ( 10/30/2014 Si naturd:' Date: Phone#: 413-5 500 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#: 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Rachel Kania as Owner of the subject property hereby authorize Robert Langevin to act on my beh , in all maoerq relative to work authorized by this building permit application. Signature of caner 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. r >r7- Print Name /013/ /'- Signatur f er/Agent Date SEC ON 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Robert Langevin CS066195 License Number 69 Moreau Drive. Chicopee, MA 01020 12/08/2015 Address Expiration Date (413) 547-2500 S at 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 (D 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: M 5 Sf�� // L - - -- - Not Applicable ❑ Name(Registrant): ID 00 3 g 100 Cummings Center, Suite 215C. Beverly, MA 01915 Registration Number Address q f7-G 4 f U(D may.,�C /'� 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 Raymond R. Houle Construction, Inc Not Applicable ❑ Company Name: Robert Langevin Responsible In Charge of Construction 5 Miller Street. Ludlow, MA 01056 Address (413) 547-2500 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: 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 Q DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO () DON'T KNOW Q YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO Q 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 Q 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 ❑ Demolition❑ Repairs I Additions Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Addition to existing commercial kitchen for new walk-in cooler and freezer Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B B Business 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H Hi h Hazard ❑ 3A ❑ I 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 ❑ 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: 13'j,,A,cc S 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(so r S � 1 St 1St �j 2nd 2nd 3rd 3rd 4tn 4tn Total Area(so Total Proposed New Construction (so ass sz, 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 Zonea Municipal4& On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 f1 City of Northampton Building Department tw NWWV ••3 20k 212 Main Streetn Room 100 WOW � Electric,Plumbing Northampton, MA 01060 i ��� North amp t , bone.413-587-1240 Fax 413-587-1272 Pftit "�' 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 d R119 � 1.1 Property Address: This section to be completed by office 25 Coles Meadow Rd. Northampton, MA Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ... .. .. . ......................... Rockridge Retirement Community 25 Coles Meadow Rd. Northampton, MA Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Anent: Po�rrt �e•�y�[von TI-1 Name(Print) Current Mailing Address: / l-- m/kw , Jr,Ci Signature Telephone SECT -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building L/O 3( 0-G (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=0 +2+3+4+5) 36 "' Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0519 APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 Q PROPERTY LOCATION 25 COLES MEADOW RD MAP 13 PARCEL 073 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out --a Fee Paid Typeof Construction:_ADD WALK-IN COOLER,FREEZER TO COMMERCIAL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: ��Q \��,, ,� Owner/Statement or License 066195 i' ITT`�` aF'�`�^ �- 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition, Delay 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. 25 COLES MEADOW RD BP-2015-0519 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -073 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catep,ory:renovation BUILDING PERMIT Permit# BP-2015-0519 Project# JS-2015-000984 Est.Cost: $40369.00 Fee: $240.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYMOND R HOULE CONST INC 066195 Lot Size(sq. ft.): 501462.72 Owner: NEW ENGLAND DEACONESS ASSOC Zoning: Applicant: RAYMOND R HOULE CONST INC AT: 25 COLES MEADOW RD Applicant Address: Phone: Insurance: 5 MILLER ST (413) 547-2500 () WC LUDLOWMA01056 ISSUED ON:1111712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD WALK-IN COOLER, FREEZER TO COMMERCIAL KITCHEN 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 11/17/2014 0:00:00 $240.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner