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18-013 (19) 180 NORTH KING ST BP-2020-0299 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: renovation BUILDING PERMIT Permit# BP-2020-0299 Proiect# JS-2020-000497 Est.Cost: $24000.00 Fee:$168.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: R L SPENCER INC 080775 Lot Size(sq. ft.): 452152.80 Owner: Walmart Zoning: Applicant: R L SPENCER INC AT. 180 NORTH KING ST Applicant Address: Phone: Insurance: 4500 PEwter LANE BLDG #7 (315) 682-7734 WC MANLIUSNY13104 ISSUED ON.10/8/2019 0.00:00 TO•PERFORM THE FOLLOWING WORK.-REMOVE AND REPLACE DIGITAL PHOTO LAB, REVISE POWER LOCATIONS AT RELOCATED FIXTURES AND DIGITAL LAB 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 10/8/2019 0:00:00 $168.00 212 Main Street,Phone 413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0299 ��� APPLICANT/CONTACT PERSON JOHN H HEIMAN ADDRESS/PHONE 1437 S BOULDER SUITE 550 TULSA (918)587-8600 PROPERTY LOCATION 180 NORTH KING ST MAP 18 PARCEL 013 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLI ECKLIST E LO D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 1k x Building Permit Filled out Fee Paid Typeof Construction: REMOVE AND REPLAC AL PHOTO LAB,REVISE POWER LOCATIONS AT RELOCATED FIXTURES AND DIGITAL LAB New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 32283 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION PRESENTED: _iZApproved 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 /Ohll 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. DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 Versionl.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit: RftEiVED Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability SEP 3 q lNorthampton, MA 01060 Two Sets of Structural Plans �tSne 13-$'87-1240 Fax 413-587-1272 Plot/Site Plans DEPTpj, Other Specify 1. h(�d'�A ?it$�UCT,�EPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING "'0 OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 180 N. King Street Map l g Lot O/ 3 unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Walmarl Real )✓state Business Trust 2001 SC 10th St, Bentonville. AR 72716_ Name(Print) Current Mailing Address: DocuSigned by: (479) 277-2918 Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $16,000.00 (a)Building Permit Fee 2. Electrical $8,000.00` (b)Estimated Total Cost of Construction from 6) 3. Plumbing Building Permit Fee /1 4. Mechanical(HVAC) 5. Fire Protection 6. Total =0 +2+3+4+5) 24, 000 . 00 Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/inspector of Buildings Date WR 4� ff-L G f 4, r i-�?r DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 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 ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑ Brief Description Entera brief descrip ion here. Remove and replace digital photo lab, Of Proposed Work: Revise power �ocations at relocated fixtures and digital photo lab. Remove, Relocate and add new fixtures in the Electronics Dept. 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 I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 1 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ ..._____. __.__ . ______ ............. U Utility ❑ Specify: M Mixed Use ❑ Specify:r 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 96,352 1St 2nd M.._. 2nd 3rd 3"d 4th 4th Total Area(sf) [ 96352 Total Proposed New Construction (sq Total Height(ft) 30' Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood,Zo,ne Information: 7.3 Sewage Disposal System: Public E] Private C] Zone Outside Flood Zone[-] Municipal E] On site disposal system E] DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 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 y # Lot Size Frontage Setbacks Front Side U R L:i 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 O DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW @ YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ® , Date Issued C. Do any signs exist on the property? YES O NO 0 ... ......... IF YES, describe size, type and location: Not sure, existing to remain D. Are there any proposed changes to or additions of signs intended for the property? YES © 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 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 El H. Heiman __. _... 32283 Name(Registrant): John H. Heiman Registration Number 08/31/2019 Address 1437 S . Scuicter, Suite bbU, Tuisa, 918-58 7—8 60 0 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): ---__.. -------- ---- Gregory L. Nadvornik Electrical Name Area of Responsibility ............ _ _w _.._ 8345 Lenexa Drive, Suite 300, Lenexa, KS 66214 54375 Address Registration Number 013) 742-5000 Signature Telephone Expiration Date Ralph G. Rice Structural Name Area of Responsibility 200 East Brady Street, Tulsa, OK 74103 49978 Address Registration Number (918) 584-5858 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 TBD Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 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 0 SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property i hereby authorize' to act on my behalf, in all matters relative to work authorized by this building permit application."_ Signature of Owner Date Mark Richardson 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 pelrjM,ppr r Print e Nag ocuSigned by: Al � ��� 8/22/2019 Sig r nt Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ 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 0 No 0 DocuSign Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 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: 180 N. King Street The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Walmart Real Estate Business Trust DocuSigned by: 08/22/19 Fl Ayrc K'Lv ,sb"' Date Signature of Permit Applicant Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT - - -- as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner 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. I Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ i Name of License Holder: Mark Ingraham CS-080775 License Number 4500 Pewter Lane Bldg#7 Manlius, NY 13104 :07/18/2021 Address Expiration Date !,(315)682-7734 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 (F) No The Commonwealth of Massachusetts W- Department of Industrial Accidents I Congress Street,Smile 100 Boston, MA 02114-2017 www.mass.gov/dia %Yorkers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(I3asiness/Organization,'Individual):R.L. Spencer Inc. Address:4500 Pewter Lane Bldg#7 City/State/Zip:Manlius, NY 13104 Phone#:315-682-7734 Are you an employer?Check the appropriate box: Type of project(required): I.O 1 am a employer w h employees(full and/or part-time).* 7. [:]New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.INo workers'comp insurance required.] 3.[:]l am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.R1 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S Q 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13•�Roof repairs These sub-contractors have employees and have workers'comp insurance.: 6.O We are a corporation and its officers have exercised their right of exemption per MGI.c 14.[—]Other 152,41(4),and we have no employees.iNo workers'comp insurance required] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. }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:Reagan Companies Policy#or Self-ins.Lic.#:6046226273 4/1/2020 Expiration Date: Job Site Address:1415 Curran Memorial Hwy City/State/Zip:North Adams, MA 0124 Attach a copy of the workers'compensation policy decla ration 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 eerdj,under he pains ird penalties of perjury that the information provided a ove is rue and correct Phone#: 315-682-7734 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#• DocuSign Envelope ID: DE97443B-58DF-4F66-9904-52BE58D2D5C1 The Commonwealth of Massachusetts ( Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia 11 orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type Of project(required): ].[j I am a employer with employees(full and/or part-time).* 7. F-1 New construction 2.M 1 am a sole proprietor or partnership and have no employees working for me in R. ❑Remodeling any capacity.[No workers'comp.insurance required.] 1. ❑Demolition 3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.EJElectrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 6.[—]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'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 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 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#: Docu&gn Envelope ID:DE97443B-58DF-4F66-9904-52BE58D2D5C1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to ibis 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(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an 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 self-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/license 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 must 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia John H. Heiman TRANSMITTAL Architect 1437 South Boulder,Suite 550 Tulsa,Oklahoma 74119.3609 p:918.587.8600 f:918.587.8601 www.sgadesigngroup.com Date 8/29/19 Attention Meghan Cahill From LaWayna Dalessandro Company City of Northampton - Building Department SGA Proj. # 19596120 Puchalski Municipal Building-212 Main Proj. Name Northampton, MA Street Suite/Bldg 2901 City/ST/zip Northampton MA 01060 Routing UPS - 2nd Day Country United States Copy Phone (413) 587-1240 Fax E-mail Quantity Descripton 1 Plan review fee check in the amount of $168.00 Remarks Meghan, Please find the plan review fee check for Walmart located at 180 N. King Street. Thank you, LaWayna Dalessandro SGA Design Group 1437 South Boulder Ave., Suite 550 Tulsa, OK 74119.3609 918.587.8602, ext. 289 (direct) Signed