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32A-138 (16) 25 MAIN ST-SUITE 333 BP-2017-0899 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 324- 138 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGIS I GRED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2017-0899 Project4 JS-2017-001530 Est.Cost: $7300.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: contractor: License: Use Group: KOHL CONSTRUCTION 073313 Lot Size(sq.R.): Owner: CHAMISA CORPORATION TO: HAMPSHIRE PROPERTY GROUP Zoning:Gil a Applicant: KOHL CONSTRUCTION AT: 25 MAIN ST- SUITE 333 Applicant Address: Phone: Insurance: 31 Campus Plaza Rd (413)256-0321 Workers Compensation HADLEYMA01035 ISSUED ON:1130/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE INTERIOR FINISHES, CONSTRUCT NON BEARING INT PARTITIONS, UPGRADE ELECTRICAL, INSULATE FOR SOUND, INSTALL NEW INTERIOR FINISHES 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 1/30/20170:00:00 $100.00 212 Main Sweet, Phone(413)587-1240.Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0899 APPLICANT/CONTACT PERSON KOHL CONSTRUCTION ADDRESS/PHONE 31 Campus Plaza Rd HADLEY (413)256-0321 PROPERTY LOCATION 25 MAIN ST-SUITE 333 MAP 32A PARCEL 138 000 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out *tr V Fee Paid Typeof Construction; REMOVE INTERIOR FINISHES,CONSTRUCT NON BEARING INT PARTITIONS UPGRADE ELECTRICAL. INSULATE FOR SOUND, INSTALL NEW INTERIOR FINISHES New Construction Non Strucntral interior renovations Addition to Existing Accessory Structure Buil 'n Plans Included: Owner/Statement or License 073313 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,DATATION PRESENTED: £/Approved_ Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project Site Plan AN D/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 • mg Of em 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. Version L7 Commercial Building Permit May 15,2000 ` Der(ent use only - City of Northampton usot Building Department itiffiftk 212 Main Street a " .,,,;,• RY ' Room 100 Water :,gtY 'N Northampton, MA 01060 Myna otStnwtura phone 413-587-1240 Fax 413-587-1272 rtg '1ans R � CIcc$pec :a 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 25 Main St Map Lot Unit Suite 333 Northampton Ma 01060 Zone Overlay District ._._... Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 3,1 Owner of Record: Chamisa Corporation 31 Campus Plaza Rd, Hadley, MA 01035 Name(Print) Current Mailing Address: (413)256-0321 Signature _ _ Telephone J Authorized Anent' Theodore Parker 31 Campus Plaza Rd. Hadley, MA 01035 Name(Print) Current Mailing Address: (413) 256-0321 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $5,800 00 (a)Building Permit Fee 2. Electrical $1,500.00 (b) Estimated Total Cost of Construction from(6) 3, Plumbing $0.00 Building Permit Fee 4. Mechanical(HVAC) --- -- 5. Fire Protection $0.00' -. 6. Total=(1 +2+3+4+5) 9 30 Check Number /00 %' '+' /Pr This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date 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 0 Demolition 0 Repairs 0 Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign 0 New Signs❑ Roofing 0 Change of Use❑ Other ❑ Brief Description Remove interior finishes, construct non bearing int partitions, upgrade electric, insulate for Of Proposed Work: sound, install new interior finishes SECTION 5-USE GROUP AND CONSTRUCTION TYPE A/0 CHAJCit TO use rrt 0CC'74S14 0.5) 77pE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 0 1A I El A-4 0 A-5 ❑ 1B ❑ B Business 0 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 0 F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 0 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 0 S Storage ❑ S-1 0 5-2 0 58 I 0 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: B _... _. _.. . . . Proposed Use Group: B _.. _... Existing Hazard Index 780 CMR 34) N/A ._._._ Proposed Hazard Index 780 CMR 34): N/A SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(st) 2^a _.... 2nd _.. aro __ _.. ... . 3rd ._.... 4u ._. _ . 4r' Total Area(sf) 33,400. Total Proposed New Construction(sf) 33,400 Total Height(ft) 60 Total Height ft _... . ... . .. 60 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑ 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 N/A N/A Frontage N/A N/A Setbacks Front Side L: R: L: R: ._. Rear Building Height 6Q , Bldg.Square Footage Open Space Footage (Lot arca minus bldg&paved Dark mg) #of Parking Spaces - --- - Fill: (volume&Location) ___ .. . _ . . .. ....._... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW © 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 O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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. 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 Kohl Construction Inc ,,. Not Applicable 0 Company Name: Theodore Parker/Fred Meyer Responsible In Charge of Construction 31 Campus Plaza Rd. Hadley,MA 01035 Addre s � _. _. il�1t zi 'j� ;Y,t�, c (413) 256-0321 Signature JJ/`` Telephone Version 57 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i as Parker as Owner of the subject property Kohl Construction Inc hereby authorize _..__.... to act on my behalf,in all matters relative to work authorized by this building permit application. 26.(par 01/24/2017 Signature of Owner Date I, Theodore Parker ,... . _..... _._. .._.. __.... _ ,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. _,,,,_ _.. .. .... Theodore Parker Print Name +� � � .. e a..G-ar 2ti' 17 1)1/2412017 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10,1 Licensed Construction Supervisor: Not Applicable 0 tame of License Holaet: Frederick R. Meyer CS-073313 License Number 16 Lover's [.ane Princeton,MA 01541 03/31/2018 Address Date 1,416",-4, (413)256-0321 Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 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: 25 M A' "J Sr The debris will be transported by: AnE,tNATiLt- ftcicun/c The debris will be received by: Lic.cNSZt soLtt wage t SPPAL_ C.4c c'r7 Building permit number: Name of Permit Applicant ,4et ekvcx E. l yt k- 0/ • zN• zo7 .77/7(/Glhi/ rzi/ Date Signature of Permit Applicant The Commonwealth of Massachusetts m= Department of Industrial Accidents 10 -`1- , =e�� l_�' Office of Investigations =�dt— � L Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le&ibly Name(Business/Organization/Individual): Kohl Construction Inc Address:31 Campus Plaza Rd, Suite 3 Cit /State/Zip:Hadley,MA 01035 Phone#:413 256 0321 Are you an employer? Check the appropriate box: Type of project(required): 1.111 I am a employer with 5 4. 0 I am a general contractor and I employees(furl antorr rrtnr), e have hired the sub-contractors 6New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. ®Remodeling ship and have no employees These sub-contractors have g, 0 Demolition workingfor me in anycapacity. employees and have workers' 9, 0 Building addition [No workers' comp.insurance comp.insurance.- required.] 5. 0 We are a corporation mid its 10.0 Electrical repairs or additions 3.0 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.]' c. 152,61(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant hat checks box a I 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. :Contractor,that check this Mix must attached an additional sheet showing the name of the sub-xontrnctors and state whether or not those entities have employees. lithesub—contractors haveemployees,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 andjob.site information. Insurance Company Name:AIM Mutual Insurance Company Policy#or Self-ins.Tic. #:WMZ 8008002872-2016A Expiration Date:02/1072017 Job Site Address: 25 Main St _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 certify under the pains and penalties of perjury that the information provided above is true and correct. Si:nawe: A S !ate:01/24/2017 mom#, 256 0321 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"_every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual, partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority" Applicants Please fill out the workers'compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LI..P)with no employees other than the members or partners,are not required to cany workers'compensation insurance. Wan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their set£insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the permit icense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write`all locations in _(city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit mast be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. etsti The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 'l Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617427-4900 ext 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 7-2013 www.mass.govtdia MAR-22-2016 09:17 AIM HOLY-SHE 1413 1335 5001 P.01.01 NOTICE 4 NOTICE TO TO EMPLOYEEStt44, 14/1 EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law,Chapter 152, Sections 21, 22, & 30,this will give you notice that I (we)have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY — — P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY WM2-800-8002872-2016A 02110/2016-02/10/2017 POLICY NUMBER EFFECTIVE DATES 88 King Street Suite B Alexander W Borowski Inc Northampton. MA 01060-3257 (413)5865011 NAME OF INSURANCE AGENT ADDRESS PRONE Kohl Construction Inc31 Campus Plaza Road Hadley, MA 01035 EMPLOYER ADDRESS 12123/2015 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In eases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL. ADDRESS TO BE POSTED BY EMPLOYER 751AL P_01 „ba,d,? g wg/ /J7/2 r �e4�/ /ye-U (,,,,,,,A_ Co4 City of Northampton NI �I hl �; I / Building Department Plan Review 212 Moi.Street Northampton. MA 01060 A 1B' - 7-1 ; _ ii ri-nn ; 9 fit, I -333 b 6 4 �. 0) � `, � o ICOHI_ CONSTRUCTION, INC. LZ I x 4 IJ 31 Campus Plaza Road -`1 Hadley, MA 01035 1 a -� N a C:T m (1 .3 -- I h \ j 1 \ , 4 \ 4 v_ c hod,_. r.,,_k- i 4 f---1 – i F I F ,-. i,, i ,_, ricArm IN c� Pr'n/�AJs AW4 r.1P/1 I JAN 3 0 2017 Kohl Construction N LINEN OM www.KohlConstruction.com 31 Campus Plaza Road,Hadley,MA 01035 ph (413)256-0321 fx(413)256-0130 Assistant Building Commissioner Miller January 26, 2017 Subject: Request for Waiver enclosed Commissioner Miller, The accompanying document is the request for waiver of controlled construction that was mistakenly left out of Kohl Construction's permit application for modification to suite 333 in the Masonic Building at 25 Main St. Northampton. Thank you for your attention to this, call with any questions. Sinnccee ely, J Frederick R. Meyer Kohl Construction P3 M E N S . . www.KohlConstruchon.com 31 Campus Plaza Road,Hadley, MA 01035JAN3 0 20!7 ph (413) 256-0321 LL _ fx(413)256-0130 Commissioner Hasbrouck January 26, 2017 Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the Masonic Building roof repair at 25 Main Street in Northampton because the work is of a minor nature, will not affect health,accessibility, life and fire safety,or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of 780 CMR.Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Respectfully, // 41/4 h (rL2�ei /< ////(1,9/2 Frederick R. Meyer / Kohl Construction Inc. 31 Campus Plaza Rd Hadley, MA 01035