23A-115 (10) BP-2023-0394
10 MAIN ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-115-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2023-0394 PERMISSION IS HEREBY GRANTED TO:
Project# OFFICE RENO TRANSHEALTH Contractor: License:
Est. Cost: 70500 THAYER STREET ASSOCIATES, INC 117527
Const.Class: Exp.Date: 09/02/2026
Use Group: Owner: LLC TEN MAIN STREET FLORENCE
Lot Size (sq.ft.)
Zoning: GB Applicant: THAYER STREET ASSOCIATES, INC
Applicant Address Phone: Insurance:
8 COATES AVE (413)665-4018 WMZ8008008007
SOUTH DEERFIELD, MA 01373
ISSUED ON: 04/03/2023
TO PERFORM THE FOLLOWING WORK:
INTERIOR OFFICE RENO -TRANSHEALTH
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
CPPY:(
Fees Paid: $493.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
P
The Commonwealth of Massachusetts 3
t„, Office of Public Safety and Inspections
Massachusetts State Building Code(780 CMR) �r r,��I
Building Permit Application for any Building other than a One-or Two?.mil' Dwel ing
1 (This Section For Official Use Only)
Building Permit Number:�.5-3 9'7 Date Applied: Building Official:
SECTION 1:LOCATION
No.and Street City/Town Zip Code Name of Building(if applicable)
i0 (`Ram S CL.Q.uA- F O'C'eANC—e- nS\-\Q_0. -VVN
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building e Repair❑ Alteration Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 131-
Is an Independent Structural Engineering Peer Review required? 11 Yes 0 No
Brief Description of Proposed Work:Zt� e&'p•C c W CR. c er cvo.4 Oe\ - C hrlfk C]i1 C 9.
Cox t.iA,Ift) Le rthu C>K1 co 40,C n S U
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.It.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP Check
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 CB:Bu iness E: Educational ❑
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional 1-1 0 I-2 S I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3❑ R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Chec licable)
IA 0 IB ❑ IIA ❑ IIB 0 IIIA ❑ IIIB IV 0 VA 0 VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105. or details on each item)
Water SuppJ,y: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
• Public si Check if outside Flood Zone CIIndicate municipal CIA trench will not be Licensed Disposal Site 0
required 0 or trench or specify:
Private 0 or indentify Zone: or on site system 0 permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): _ Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner •
10 He-1 ) 57;c 7" f-/oQp,✓ci u /0 M&-N rov 0/ow
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
To IJ 413 _5 i7_ '32'fo - -
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes: I
� 0- 'K CC7C3 S Ruoz- 1-0A 0V3-13
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide constriction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor _—
\h� S\-c-1?�\ .\C.,Lc�
Company Name
! 61.132.1 fi GDal . In Sail
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
13_(a4 S Li 018 413 _` (03- a(o$ ►�ok r 1-@'14% sA-re_e}GSSbc o kog. row-,
Telephone No. (business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$1O
1.Building $ Ce, C)C)CJ. Building Permit Fee=Total Construction Cost x 1 (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $ U'tC\ Sb
4.Mechanical (HVAC) $ 1\)I` 1 Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ `�CSC(). (u (contact municipality)and write check number here I Oil7
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
r \ -)VO 1\7 Gos,OpJ- cuoner 9ts j4,e7
Please print a d sign 2S me Title Telephone No. Date
(OG Ak �`i `a 031_3 A \. t/ice c�c iili CzvvN
Street Address City/Town State Zip Ema Address
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
:".„..
Department of Industrial Accidents
1 Congress Street,Suite 100
s Boston. MA 02114-2017
7 www.mass.gor/dia
W otters'Compensation Insurance Afildas it: Ito ililers/C7ontractors/EkciriciansiPlu milers.
TO DE FILED WITH11IL FERMI EOM;AUTHORITE.
Applicant Information Please Print Legibls
Name(Business,Organizatiopindividual):_\\C"\' ,, • (-- etc'
Address: S C.co.:5 B 0,Q......
'373
City/State/Zip: SoQ--k-h iL51 Ct‘f\°1 hOtte#: Li I 3 . (Dcoc)-
,
Are yilii Illil employer?Cheek the apperpriste bat: Type of project(required):
Ina-ram a employer with IC-- employees(full astitilor part-time)..* 7. 0 New construction
2.0 I ant a sole iiruprietos or partnership and have nu cniployem working for rise in 8. aiemodeling
any capacity.[No workers'comp.illS4itallet required"
9. El Demolition
•ID I am a homeowner doing all wort myself.[No workas'cutup. imurance required"'
i 0 0 Building addition
am a homeowner and will be hiring contradors to conduct all work on my property. I will
ensum that all contraLiors either have*oilers cormiAmsation insurance or an:sole I 1 a Electrical repairs or addition.
proprietor with no erripluyees
i 2.0 Plumbing repairs or additions
4.0 1 am a general contractor and I has c hired the sub-contractors listed on the attached sheet
I 3,EIRoof repairs
These sub-contractors have employees and have workers'CLInp.insurance.1
14.1:10ther
,s0 We an a corporation arid its olliceis hove esti-cued their right of ciennition peT ktGl.e.
I.S2,§li 41.and we have no employees.[No workers'eoinp,insurance required.]
*Any applicant that clio..1%but al mint AllAii fill out the section lx^lcrv.show ici::their workers'compensation policy information.
+Honleowrion‘who submit this affidavit indicating they are doing all work arid then hut outside contractors must submit a new affulav it it:adi-inns such.
:Contractor:that cheek this box Rehr artarteA an additional sheet showing the name of the sub-scintractors and state whether or not those entatim have
employ ces I Idle sohei.,niractors has e einployees.Mc.,most rms.'ide their sk misers'eonm.Ni..., nuinhei
-
I am an employer that is providing worAers'compensation insurance,for my employees. Below is the policy one/job site
information.
Insurance Company Name: \c'cm _
Policy#or Self-ins.Lic.#: ki,..)Ct\-1-?CO- C:->CD'EC)Crl - aC)-DZ-A Expiration Date: 0 1 - aL\
Job Site Address: \0 “NOJX1 \-Nv....e...* CityiStateZip:ckox ct-\cs4.. OA i'A
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MO[_c 152.*25A is a criminal violation punishable by a tine up to S1,5001X)
and/or one-year imprisonment,as well as civil penalties in the limn of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of this stalotrent may be forwarded to the Office of Investigations of the DIA fur insurance
ctnerage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: cNR . -1/ Date: A N V6C)--\-----,
Phone#: AY' ) - l.0(.0
Official use only. Do not write in this itrell,to be completed by city or town official
City or Town: Permit/License ti
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 4:
City of Northampton
r•� Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building f ^b
.- Northampton, MA 01060 rat=,q �����
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: Cmb S BuS2 � 5� C� (-\(\'\ 0\313
The debris will be transported by:
Name of Hauler:
Date: Cnc1r » a
Signature of Applicant:( pa.3
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