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23B-046 (3) CITY OF NORTHAMPTON, MASSACHUSETTS CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: HAI -10 -73 DATE: August 22, 2011 PROJECT TITLE: Renovations for Chapel PROJECT LOCATION: 30 Locust Street, 1st Floor NAME OF BUILDING: Cooley Dickinson Hospital SCOPE OF PROJECT: Interior Renovations In accordance with the Massachusetts State Building Code, 780 CMR 8 Edition, Chapter 1, Section 107.6 Construction Control, I, Richard E. Katsanos, Massachusetts Registration No. 8355, 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 scope for the above named project and that, to the best of my knowledge, such plans, computations and specifications meet applicable provisions of the Massachusetts State Building Code, 8` Edition, all acceptable engineering practices and all applicable laws for the proposed project. I ENTIRE PROJECT I ARCHITECTURAL STRUCTURAL FIRE PROTECTION ELECTRICAL MECHANICAL OTHER (specify) I further certify that I shall perform the necessary professional services and be present on the construction site on a regular 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 Construction: 1. 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. 2. Perform the duties for registered design professionals in Chapter 17. 3. 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. Pursuant to Section 107.6, I shall submit periodically, a progress report together with pertinent comments to the Building Inspector. Upon completion of the work, I shall submit a final report and an affidavit of completion as to the satisfactory completion and readiness of the project for occupancy. ��RFD AR�y / � Subscribed and sworn to before me P 44, KATS 1 4. F this 4 day of ilaesi 2011 No. s 355 �� 1�� . • 1 TJL 4TH OF tAs Edward D. Etheredge Notary Public My Commission Expires 3/30/12 ( .,� 1' � Alxssxcllnaclls =5_ � Ni. n ■ DEPARTMENT OF BUILDING INSPECTIONS '1 . 212 Main Street • Municipal Building Northampton, Mass. 01060 NO' WORIaR'S COMP ENSATION INSURANCE A_UEEDAVT1 1, /77// ot"h2- 5, P / /c7) f/` /frc d1 e_eo4 s7` -74 c , (licensedpermltiee) with a principal place of busin.ess/residence at: _C/ )://e d' S LLhd e4/ //44 . d /OS‘ (Phoneh) . / / / -5 7- ?So° (str /city/statn/z do hereby certify, under the pains and penalties of perjury, that: ( I am an employer providing the following worker's compensation coverage for my employees working on this job: 4_-7/g /4/7va I _Z s 1 8oD53 790 / 2e i6 / 2 - 3) - 2o)/ - (La Company) (Policy Number) (Expiration Date) i ( ) I am a sole proprietorr_enera.l contTactoror homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Policy Numlxr) - (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Lnatrano Corn Numbed (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additio¢zl shed ifn000royto include infocmi.7oa pertaining to all condors) ( ) I a a sole proprietor and have no one w m org for me. - ( ) I am a home owner performing all the work myself • NOTE: please be nwarc th. vifrilo banoowncn wino anp lay pia to do caliatocursoc, coc ruction or repair work on a dwelling of not meta thou thou, units in which thx boa» ,wncr rrzidcs or cc tho pounds app,IrtrnAot thoocto arc not gcamlly «usidcrcd to b cn2ployers under the wodcoes. ,cccnpcasatice Ad (GL152.�1 1(5)), Apprirapou by a hommn acs fort liccmc a pormit may cvickox the legal ctoau of nn emp loyes undertho Woricces Cone mo..tioa Act._ I uada-si.n d thzt a c of this ctalc:mcat may be forwnrdod to tiro Dcpartmca2 o f 1 ■ -or; nl AccOho& ors eo of Io omni for than coverage vcrificstioo Ann that failure to secure coverago under archon 25A of MOL 152 can lad to tba impositioo of criminll penalties cocsisting of a fa 'o cf up to S 1,560.00 and/ot impri000z cat of up to orx year and civil pccaNtia in trx. focm of a Stop W oa Order and a _ firm of S 160.60 a . thy anoint coo. Fon dcpazY Cr3sl rvo OC gi n , 2 7::7-.* � Ptr�t Nttmtr Lot 4 �,- ( n l.(;IL3fLtI'C 0� 1/I�CiIILL1tt.CC�- • —;- Vtrs i,n'.., G, rur 0 [ N 0- STRJCTU ,AL PEER RE'NIEW (7.80 CLOS LQ 171 ui Required _ . r 0 , i1 - A,r��R .�UTNCRIL.TIO � TO BE COMPLETED WHEN lAcENT OP C0NTOACTOR APPLIES FOP BUILDING PERMIT / _ rt7e R . i01 R /1 0U e_ C /2 rfU _c t 10- _Ty)C - al, iiia:Ito a do`I: authorized by this bidding pies r'lli Signature of Owner Date — - - 'F '� -e 1 .7? .. "!w .).CR .. .'. r 4.rs._.;&1 ^ i =: '.:�i, ; p.. ,.: dec.,,:re that t:r atatr:ments and information on the 'orego•op appltc.,_io n hue F•no',•. c - -•e acid belief Ir ` ed under the, Dams arc oe elHes of perjury. rid dame , - ore of Owr4:, -ae_ D `e SECTION i7 - CONSTRUCT!OtNSERVICES 13 LIcensed Construction Supervisor: ff,i- _ ^y 06� -or telephone SECTION 13 WORKERS' COMPENSAPION INSURANCE AFFIDAVIT (d CIL c. 152, § 25C(6)) Lnsurance affidavHt must completed and submiLter wan - ap i:_,11._)r - sl , r, i i t t sente ; t`re Issiance of the permit_ fir n - Peas, ,Littecceert es o - i,i , ii 7 1_=)/// - GJ l i.l llJ _ C,' /0/ • O 3 7 72 J LrC�( �uCl z�s - 3S = Cfi n © �o J C ] S C ) - 1 0 ? 0 10 COO S2 ' > ; 1 ? O l . ` J l d l l v d i d l _ !OJ) - » 7 7 lCd LNO ") NOII:DAdJ_Sf 2 "J CI��� :L`_il5'�1 17i'CI�c:?r0?H ,;SiG :_ 1 l _1wO1Cr1 1b !1;L, 'Le' ,_._ supply (Nl G L. c. 40, p 54) 7.1 Flood Zone Information: 17.3 Sewage Disposal . rs,e r P � , ate Di Zone: Outside Blood 7 1 :r ; I � r.icionl W 7r ,ate e o s . .. S. , ;i_ RIII. -ViMP DO ZONING — 77..' -,.;• —_ -� PTDp . 1 . c -I by _ L _ i _ s T'7 i ..- T - 76 y2 E, 96 9,, v278 i Frontai2e 2 58 26 j r— � Setbacks Front I /02 / 0,2' Side A: f38 R: L/2 L: 88 R: 1 72 Rear /,e l8 Building Height I ' 6�r 6y5 Bldg. Square Foctage 1 - - - -- - -� -- I - -- I LA92 86 I I 1 1 11 On Space Footage ie I (Lc am :minus rw, s Tdg F paved 1 7 o 6 4 i # of Pari_in � S aces 76 ,l. N �� /� i (' �: L .ocada') I A. Han a Special Permit,/Variance /Finding ever been issued for /on the site? NO DON'T KNOW YES X IF YES, date issued: De_I.3,_aoQ1 :IF YES: Was the permit recorded at the Registry of Deeds? l': DON'T KNOW YES �� IF YES: enter hook 6 50y Page 2 3 c i— and /or Document B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained -_ _ Obtained - , Date Issued:_ Do any Sig EIS exist on the property? YES i/ n NO Tk '_S, J_.criFbe _ize, type end I ,__:tI rn. V4 YS L . ,,Lrepthere D rTn/ J1 eSed ch a rig -s to or additions c' _ g I Itery_ _ci 'I T±) ST pI rn. S - _ ' .. e '.. � �, �� -_ - fir :::,:t, r '— cirri �a�l � .. .;E�i ION• -- CONSTRUCTION SERVICES FORJ'ROJECTS'LESS THAN 35 0OQ ,:C3EIC FEET:. OFENCLOSED_-SPACE; rr }ieriorA!terations i Existing Wall Signs j Existing Ground Signs Additions rii 1 Roofing ❑i "--r: i -, ❑ .sterior Alterations I Demolition❑ New Signs [ ] Change of Use [ 1 Other ] ❑ Accessory Building [ 1 Repairs [ ] 17 I.EE' DE[CRIPTI [N : _ ` r + '9 / J � 1c .� `e?rY 1 � � ice , c' L rie. Li,' C I.,‘. 1) c I SECTION 5 - -USE GROUP AND CONSTRUCTION TYPE . USE GROUP (Check as applicable) CONSTRUCT ION TYPE ssernbiv ❑ A-1 F, Eli P, 3 ❑ I IA B Business ICU )A ❑ Educational C - -_.aI 2, - r U _ - I Factory ❑ 1 ' — 2L 0 L ,3 r r f _— ------ _.- _-- ... —_ —_ — _-- .— '—'_ -. —_ T J H High Hazar� I — �_ 3A El ii I — — — L nst[tutional E ? '� u I -P 3 — U l'errantii I ❑ -- I' 1 T —Cl R R esidentia! ❑ R -1_ .7_1 R -2 Cl P. -3 [1 I 5p, 0 S Sto�aoe S-1 S-2 E] -1 55 D U U M /Ed Use El Specify: COMPLE' t THIS'SECTIDN -Ir CIS I _t` G DUitDING UNDERGOING RENOVATTONS,ADDITIONS 'ANDJOR CH [UIGL IN .US-.,L . Istinc Use Group: _....T., �_ — -._ Proposed Use Group: Z" -2 :Ising H lard index L`0 CUR 34): �� —___ — __ I E� 1 Proposed 'U,azard Index IJO CUP. 4). - -� __ _ — SECTION 6_BUILDING HEIGHT ' `' `S 1 OFf�CEUS n � �i 1C 7 NE° CON.�r`,LI rte; � O _ ;��LD_NG , �. c u�T_ . - � o � s : s pi,-,—, _ , nnr - I y `;Ij r� 1 y�g �cr ? 5 , r r -- _.._- - - - - -- — ti , u 1 r , r ___.---- r , ,_. .. ... ., ,f — -- — — -- — „"ABM y epe:C only . v of Northampton .r o P b • �� � � '`i 0 B '!ding Departmen rveyaccg _ -r� � � � a=� 12 Maim Street .,- w T> ▪ ei=` .vaialoiil w-4 W � , `� , Room n - ,y .� y - ,-- : x P El N• t � i tJn, MA 01060 S ,e#s s e rat la — ° � � ,_ , 57 -1272 p� e a as phone .,,� 87 0 Fax 41., -5� �' .. � %,,, eyF� F� F P ! SIB s- ...,,,,.a. � ` kle ' i APPLI II I . ?.w'■ SI RUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION F r - - �-,, `��Thi o e - pl a _t,1 Property Address. 7r i �.; + '+' ▪ - r, t i l i Dis Map ▪ ' y r a. 'Lot . ,, �t riunrt .._._ 0 [= h-� O O S I I G • kg � TFa' f \ i .: - T Y �,� F M1 1 L i i / /� , I {- [ 'Z - ° t i t w , 30 h o C V S ! y 1' 7 'S..ik „ k tit? P j. .sn','% +r ^'!'. -.. c ' .� L A,,,, iva lt- `tig-O, ci e ka' ,,2 •,i�F y 4 -P ,F4 i ' 1 1 cc ,i i �'�fTT:$t'"b]tTJCt'4 ° ::,. t...:._ '^i ,tS,DI a'` - SECTION 2 = _ PROPERTY OWNERSHIPJAUTBORIZED AGENT 2.1 Owner of Record: Cop ley D,cz( b a 30 .aC'USf St. /?O. ,GoX 500/ Jame (P' •p Current Mailing Address: OF _ y/3 - 5a - 23/3 Signature / Telephone 2.2 Authorized Agent_ • ;ri Q_ tAy 5 . _ /e l/e t"/ e r — EM,' / /et S f. � u cal o u/� /�1d_ 0/0 5 6 "dame (Print) Current Mailing Address. /-.0�._: IPIP . •• �i1 f -- 5%2 - 54/7- 2 60 - -- Slgnalure Telephone SECTION 3 - ES I IMATED`rCONSTRULI ION -COSTS Item Estimated Cost (Dollars) to be Ofhcial•Use Only completed by permit applicant Building f� . c-; o) ! Building Permit Fee — 7 . J I I ` - ( ° - -- - b g stimated Total C ost -of 7. Elect - rival - C;C' {.) _ - - / . - . :Constructon from (5)' 9 umding — � � Buildm P fee __ _ 1 , 3 ' Mechanical (.H VAC) I - — P �t _coon �� �� - -- ot ( !- 2 + 3 - 4 5 ' "�t Check'Nur ber r 7 Th Sect .For Offic Use Only ildi m PeritNu,mba __ _ Datelssuetl: Euii ng Cn� nissio� ]Ins �taroF uilaings Dale r ■ I File # BP- 2012 -0265 APPLICANT /CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS/PHONE 5 MILLER ST LUDLOW (413) 547 -2500 0 PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/URB(1) //WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /P9,3 6 i3,3 J� LfU Fee Paid Typeof Construction: RENOVATE MEETING RM FOR NEW CHAPEL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 066227 4 ' 6 71 t .o 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IATION 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 Signa re of Building O icial Date 914 I 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. ■ 1 30 LOCUST ST BP- 2012 -0265 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 046 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- 2012 -0265 Project # JS- 2012- 000430 Est. Cost: $55955.00 Fee: $335.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYMOND R HOULE CONST INC 066227 Lot Size(sq. ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC Zoning: M(99) /URB(1) //WP Applicant: RAYMOND R HOULE CONST INC AT: 30 LOCUST ST Applicant Address: Phone: Insurance: 5 MILLER ST (413) 547 -2500 0 Workers Compensation LUDLOWMA01056 ISSUED ON:9/28/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE MEETING RM FOR NEW CHAPEL 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 9/28/2011 0:00:00 $335.40 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner