22B-040 (13) 221 PINE ST BP-2019-0234
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:22B-040 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category, Building BUILDING PERMIT
Permit# BP-2019-0234
Project# JS-2018-002480
Es[ Cost $10650.00
Fee'$450.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group, JESSE BEREZIN 102213
Lot Sin(so.a.r 145926.00 Owner: BRUSH WORKS THE LLC
Zoning: SI(115)/WPH15)/WSP(I)/ Applicant. JESSE BEREZIN
AT: 221 PINE ST
Applicant Address: Phone: Insurance:
245 TANGLEWOOD DR (413) 374-2729 WC
LONGMEADOWMA01106 ISSUED ON.8121/2018 0:00.00
TO PERFORM THE FOLLOWING WORK:RENO BATH ON 1 ST FLOOR, RENO TENANT
SPACE ON 1ST FLOOR
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:
Drivexay Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 0y1; 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 Occuoancv Signature:
FeeTvoe: Date Paid: Amount:
Building 8/212018 0:00:00 $450.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Versionl.7 Commercial Building Permit May 15,2000
Dse uYy
W m a; City of Northampton stall of pemNL
z Building Department G1ab CUtlDrMSvsyPertaR
z o 212 Main Street $ipMs
°E Room 100 wat dwetlAre&461My'
Northampton, MA 01060 T)w$aborsough"PWA
w e 413-587-1240 Fax 413-587-1272 PIo V*P'bns .
o
PPLICATION TO CON RUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING . n �J
SECTION t -SITE INFORMATION r �Ja r
This sanction b be compbted q'office
t.i Property Adtlreea:
111 Q;na. 55 Florence .. Map � '�+rl Lot OLJO Unit
Zone Overlay Dbtrlet
Elm St Dlstdd CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
8rvA'v Tk> {\r#r a �.•�-vs�.vJ l-l-(, L/o �Apun�-)'�n�Jo�[e '�'�' � (0(07 rWaf•,Si
Name(Print) )_ {. �CYe 2+h Current Mailing Address: Ylnlyok� y ol0,10
Signature Telephone t)) 3 S 3 N 9qS S _I
2.2 Authorized Agent:
J2Xe gvc.vn 1'IS dr,.n..�lewo�•L�
Name(Print) Current Mailing Address:
6V�N sjoi,,' YON0110L `11379t11��4
Signature & Telephone
SECTION: -E MATE3 CCORUCTIONC T
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ('00c) (a)Building Permit Fee
2. Elemdwl 0 O (b)Estimated Total Cost of
! Construction from 6
3. Plumbing a b S O Building Permit Fee ('
4. Mechanical(HVAC) "1
5. Fire Protection
6. Total=(1 +2+3+4+5) ) o LSn Check Number Ig 7j
*]its Sectbn For Official Use Only
Building Permit Number Date
Issued
Signature /
6
Building Commissioneninspe lw of BullDate
P({dNE
OKJ, 7(3o1i8 - -TPOW Td WKG P2ev6pt AAAR6 INFO
ftAtf575Zc h" RP Rf Y tE w
11�542 444,z,- .0 ry�>
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Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 36,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition®' Repairs-0 Additions ❑ Aceensory,Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use Other❑
Brief Description Enter a brief description here.
Of Proposed Work: f)evovcde Bvhl.rrn>r oy.i,�s{ {I�or
rc wv4ele s r^� ��v vaw f-�,r•tnhl ow{"rr5� {)por
SECTION 6-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 ❑ 1 B ❑
B Business 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38
M Mercantile ❑ 4 ❑
R Residential ❑ 1R1 ❑ R-2 ❑ R3 ❑ SA ❑
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 Hezerd Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Fluor(so
2-
3" 4 o.,ooC' 3m _
0 f/97 O n 9 4e
Total Area(so (60/O o0 Total Proposed New Construction(so
Total Height(0) Nf1co YS
Total Height It
7.Water Supply(M.G.L.c.40,§64) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone[] Municipal ❑ On site disposal system[:]
Version L7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZON&
Existing Proposed Required by Zoning
This column w be filled in by
BuildingD pauftnent
Lot Size
Frontage
Setbacks Front
Side L:. R: L> R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Loi area minus bldg&paves
arkin
#ofPuking Spaces
Fill: _.
volume&Law'on
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW �' YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW ?Zir' YES O
IF YES: enter BookPage', and/or Document p
B. Does the site contain a brook, body of water or wetlands? NO 0 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 O NO
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
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 (Y
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versmnl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW 1760 CMR 110.11) /�
Independent Structural Engineering Structural Peer Review Required Yes O No Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, H e 6v4 A'c-71~ as Owner of the subject property
herebyauthodze 7fsse- 1i02Zlk to
act on my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner '� Date
1. JY S S4 PAJi z-.' r 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 underqW and allies of perjury.
Pri e
-7
ig elu of a ent Data
SECTION 12-CONSTRUCTION E ES
10.1 Licensetl Construction Suoemisor: Not Applicable ❑
Name of License Holder: `R'15e �evtZl h 10 a1I 3
License Number
1r 15 +enu�le��. eQr �phctrl-CL�Ctow � 0 1106 3�19
Address /� � �/ J Explosion Dale
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
Q
�\ The Commonwealth of Massachusetts
Wiledirkers'Compensation
Department of IndustrialAccidents
1 Congress Street, 100Boston,MA 011]4-104-20 177www.mass.gov/dia
Insurance Affidavit:Builders/Contractors/Eleetriciaos/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leaibly
Name(Business/Orgami ation/le ividuat: Mount Holyoke Management LLC
Address: 667 Main Street
City/State/Zip:
Holyoke, MA 01040 Phone#: (413)534-0955
Are you an employer?Clark the appropriate We:
Type of project(required):
1.®I an a employer with 88 employas(full act/«part-timr).• 7. ❑New construction
2.❑I..,.lepropriew,.,pactershipandhavowemployasworking Corrosion g. Wcemodeling
any capacity.[No workers'wmp.insurance required.]
3 I son homeowner doing all work myself(No workcrs'comp.iings.reinsug.lt 9. El Demolition
4❑1son ahomawneradwill hehingsministers to conduct all workonmyper,, twill 0❑Building addition
«e that an contomorecither have w«kro'compenseuon marriage««e sole I1.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5 I am a general connector and I have hired Ne subcontractors lined on the another]sheet.
these subc.naactors have employees nM have workers'comp.insurance: 13.[:]Roof repairs
6.0We me arm groutirm and its.Beers have exereixd their nght ofescingion per MGL c. 14.[:]Other
152,§I(4),and we haven.employees.INo workers'comp insumncare,mool l
•Any applicant that clacks box 91 must also fill out the seca.n w beloshowingtheb workers'compensation polity ioformuim
t Homwwners who submit this studied indicating they are doingall work and then hire outside contractors must submit a new affidavit indicating such.
Z..... check this box mustatrached an additional shat showing the name ofthe subcommcmrs act some whitheror tot those comities have
employees. If the sub-convsctors have employing,they mug provide their xarkere'wmp.policy number.
I am an employer that is providing workers'compensation insurance for any employees Below is the pocky and job site
information
Insurance Company Name: AmTr,st N th Aorrir•a To,
Policy#or Self-ins.Lic.#: WWC3305132 Expiration Date: 9/9/2018
Job Site Address: Brushworks LLC 221 Pine St City/State/Zip: Florence, MA 01062
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c rd er airts a penahies of perjury that the information provided above is true and correct
sign aNre: Date: 7/12/2018
Phone#: 1 534-0 5
Official use only. Do not write in this area,IVhe completed by city or town official
City or Town: Permit7Lieense#
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#:
»onssa;
Wesco Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION W C 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 5
INSURANCE POLICY INFORMATION PAGE
Ncci Code: 26135
I. Insumd: Policy Number: WWC3305132
Mount Holyoke Management LLC
667 Maio Street
Holyoke,MA 01040 Individual Partnership
Other workplaces not shown above Corporation X LLC
See Extension of Information Page
i
Produces: Federal Tax ID: 204912755
Rsk Id:
Am9'rust North America, Inc.
Ga Amity Insurance Agency, Inc. Renewal ol': W WC3224023
500 Victory Road. Marina Bay
North Quincy, MA 02171
2. The policy period is from 9/9/2017 to 9/9/2018 1201 a in. at the insured's mailing address.
+. A. Workers Compensation Insurance- Par!One of the policy applies to the Workers Compensation Law of
the slates listed here Massachu_mus,Vermont
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:
Slate Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$500.000 each accident $500,000 Policy limit $500,000 each employe:
C. Other States Insurance: Pan Three of the policy applies to the slates, if any, listed her,:
All stales except ND.OH,WA,WY and Slalefs)Designated in Item 3A.
D. This policy includes these endorsements and schedules:See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules.Classifications. Rates and Rating
Plans. All inlbnnation required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
STATE ASSESSMENT
TOTAL ESTIMATED COST
Minimum Premium
Deposit Premium
Issue Date: 9/12/2017 Countersigned by:
rc:-'-
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: dal hi ve S-
The debris will be transported by: N vv U ie- .Secyi c,s
The debris will be received by: Apiyb► C Sexy <-o
Building permit number:
Name of Permit Applicant jeSS<- Pzrut;.
Date Signature of Permit Applicant
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RECEIVED l
AUG 2 0 2018
I �
DEPT OF AURDING INSPECTIONS G
NORTHAMPTON,MA 01060 0
v�o(1 hcVlClHoti
To Whom it May Concern 8/13/18
1 am requesting a waiver to put up new walls at 221 Pine St Florence.The space will be used my Amherst
Archery Academy and we are only framing a couple new walls to break up the space.Therefor we do not
see a need to have the construction controlled.Attached please find a little sketch of our proposed new
walls
Thanks
Jesse Berezin
RECEIVED
AUG 2 0 2018
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON.MA01060