23B-046 (2) CITY OF NORTHAMPTON, MASSACHUSETTS
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT NUMBER: HAI -09 -91 DATE: January 8, 2010
PROJECT TITLE: Renovations to Radiology Waiting and Registration
PROJECT LOCATION: 30 Locust Street
NAME OF BUILDING: Cooley Dickinson Hospital
SCOPE OF PROJECT: Limited Interior Renovations
IN ACCORDANCE WITH THE MASSACHUSETTS STATE BUILDING CODE, 780 CMR,
CHAPTER, SECTION 116, I, RICHARD E. KATSANOS , MASS. REG.
NO. 8355 , BEING A REGISTERED PROFESSIONAL ARCHITECT /ENGINEER,
HERBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE
PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS
CONCERNING:
'ENTIRE PROJECT I ARCHITECTURAL STRUCTURAL
FIRE PROTECTION ELECTRICAL MECHANICAL
OTHER (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE,
SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE
ENGINEERING PRACTICE AND ALL APPLICABLE LAWS FOR THE PROPOSED
PROJECT.
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 116.2.2:
1. Review of shop drawings, samples, and other submittals of the Contractor as required by the construction contract
documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required controlled materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in appendix B.
PURSUANT TO SECTIONS 116.2.3, 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.
EA R
A
��R 6' Subscribed and sworn to befor� e ��'' SLY A ��_
TS „ � this 1 3 'N day of 1 \(VY
o O I . ` e , �BER
Cr / J ; / • Q. cep N
o No. 8355 2 `_ �U, `
EASTHAMP •', / Notary Public .0
Witic • Y K; Banos, AIA My Commission expires on = L r,
� q �TH OfNiP . ' S4r R Y
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�° �.�� Ckt Net tIaii ptnn ' * 4 =___‘____514...
.* = DEPARTMENT OF BUILDING INSPECTIONS al R=
, 212 Main Street ' Municipal Building �9r
Northampton, Mass. 01060
WORKER'S COMPENSA'liON INSURANCE Ak'1+'LDAVIT
I, //ii o7' S, / /cTl£/` /frayA;oAcil RA o437 ,
(Iicerisecipermsttee)
with a principal place of business/residence at:
S,)7, //e ea ST itre Ides i4 d/OS C (phone/0 %/3 'S y7-? 0°
(street city /staleI p)
do hereby certify, under the pains and penalties of penury, that:
6 <I I am an employer providing the following worker's compensation coverage for my
employees woridng on this job:
4-7/0 / 7Va / _i s • 4./r;7 z 8a 9 S 790 / 2 R9? 1 2 - 3) - 20 /O
(Insurances Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have lured
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) - (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsttrance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(ntLach additicaal cheek if naaracry to inchu}e informati on pa to all ocatrndors)
( ) I am a sole proprietor and have no one w ork rig for me. .
( ) I am a home owner performing all the work myself.
•
NOTE: please be aware that while homeowners wino employ persona to do raximicaliacr, ccn tructioo or repast work. on a dwelling of
not tnocc than tbrbo units in which the honxowocr resides oc on the grounds ap-pu tenwi thccto arc not gera311y ccaridcrcd to be
employers under the wock.c .compensation Act (GL152,sa l (5)), application by a homcowocr for a ticnix a permit may evidence the
legal Wt. h,a of an amp loyor under the Woriccla Coca; viiou Ark
I understand tfui a copy of thin rtatcmcat may bo focwardod to t e Dopartmcni of I ,, tri al Acadk:oil' Of5oo of Incur oco for the
coverage vcrificstion and that failure to sea= coverage under section 25A of MOL 152 can lord to tbs" imposition of crimin l penaliica
can/sting of a fine of up to S1,500.00 androt iaprisoocncc t of tip to one year and civil, penalti a in the form of a Stop W ark. Ordc and a .
fine of 5100.00 a day against mc.
Fa' dcpxrtnroLs.l use only
,
m_i Number
�.f., ''' / /3 -Z ° Per j Lot ;I ii«
Signature o''',iccnscelPcrmitter. I to • - trf _
•
Versionl.7 Con Building Permit May 15, ?O0r)
_*DECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
_ Structural Engineering Structural Peer Review Required es
SECTION 11 -OWNER AUTHORIZATION.:- TO BE COMPLETED WHEN
OWNERS AGENT 0R CONTRACTOR APPLIES FOR .BUILDING PERMIT
rooley Dec son j/c,sp %TaZ tnn , 1E -ct
o authorize G/ 2 l G_ l / � - C
hereby �� ta iro R, l�ou /e Cot s ?" u t O �
my be ?, in all matters rel ; t ork authorized by this building permit application.
i'J _ J — /Y Zoel -
I Signature of Owner Date
I , RcA /n /7, c _s ) cric)h - 17 . as o:,i e Auth.o -ize 7
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
l .nov: ledge and belief.
Signed under the pains and penalties of perjury.
l S. P& //e. 7
Print Name
Signature of OwAts'��g Date
SECTION 12 - CONSTRUCTIOMSERVICES
10_1 Licensed Construction Supervisor: Not Appl :cable
Name of License Holder: �1��� S . Re//e. 1 ' 06 22 7
-sense r
�v / / e f^ S r L v c 7 / 4 4/ M / 9 d /O u r 6 o 7- O 7 - 4 1 .1-
Address
Expiration Date
'--
4//3 - 55/7 50o
Si Telephone
SECTION 13 - WORKERS' COMPENSATION! INSURANCE AFFIDAVIT (M.G L. c.-152, § 25C(6))
oorr.ers Compensation Insurance affidavit must be completed and submitted with this apo on Fm use top o t aftid .
will result in the denial of the issuance of the building permit.
f
'Affidavit Attached Yes N o J
V'ersior„1 .7 Commercial Bu Pennit 1 ]5, 2000
SECTION.9- PRCFE55IONAL DESIGN AND CONSTRUCTION..SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION 'CONTROL PURSUANT TO 780 CG1R 11 3
6 (CONTAINING MORE THAN 5 ,000 C.F. OF ENCLOSED S - - - - - - - -
PACE)
I 9.1 Registered Arc`��itec`. - - - - -- — - - -- - -- - -- - -- -
/ t re L
rJa^ e nti: -
1
1 ‘X "ii,) c 3 T il T 4_ A-frje /e/y- I Hearstratren Nur
- - -- � � 4/ V 1 7 1
� F x o i ra `ion Date - - - - - - -- �
- -- ��
S!gneture Telephone
92 Registered Professional Engineer(s): —
N done Area of ,°erponsioi. tr
Address ReEristraIior Number
Signature Telephone 1 expiration Date
- - -- 1 'I Area o ResponsIbikty
Address I, Registration Number
I I
°nature - eiephone Expiration Date
I
NalT,e Area o, Responsibility
Address - ! Registration Number
I
Signature Telephone 1 Expiration Date
i
I Nacre 4rea of Responsibility
-- - - - -- Regis`ratioc. Number
Address .
Ca,ature. - T elephone Expiration Date
- —
9.3 General Contractor —_
/ a " i d _ _ _ _ fi . 1 � o v � Co 7 C 7`/0/7.,_7/7a . Not Appl o
1
Company Name:
7` z` S . 11 tip —
Re.soonsible In Charge of Construction
A101 -
- ,_.5 2 5o
------- - - - - --
' Versionl.7 Commercial Building Permit May 15, 2000
P. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
1 PLlbllc ❑ Private ❑ Zone: Outside Flood Zone X Municipal 154 On site dispos sycem E
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning �j
This column to be filled in by
Building Department
Lot Size I g 969,y27.8
Fronta•e 2658' 2655
Setbacks Front /02 r / 02 '
Side L: 88 R: 4'2' L: SS' R: 5/2
I
Rear 18' 191
Building Height 6g.5/
6.5 Bldg. Square Footage %
V02,961. 5/02,86 / I .
Open Space Footage % 1
(Lot area minus bldg & paved 9'o o. /
parking) �7 ! v
# of Parking Spaces / 6 / 76/ 1
I
Fill: AO N/A
i (volume & Location)
A. Has a Special Permit/Variance /Finding ever been issued for /on the site?
NO DON'T KNOW YES X
IF YES, date issued: Der, 13, 2O0J
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES (/--
IF YES: enter Book 650Y Page 239 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:_
C. Do any signs exist on the property? YES lr NO
IF YES, describe size, type and location: VA h) o vs _
D. Are there any proposed changes to or additions of signs intended for the property ?YES ___
No _V
IF YES, describe size, type and location:
• Version1.7 Commercial Building Permit May 15, 2000
SECSI ION 4 CONSTRUCTION SERVICES'FORPRO]ECTS LESS'. THAN 35,000 .
CUp3I C.FEET OFtNCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ I Roofing
C ❑ / —
Exterior Alterations D oli ' n❑ N- .• ,. ,o , - - - ge of Use [ ] Other i_ ]
❑ : ; ilding ] Repairs [ ]
BRIEF DESCRIPTION: eeM1,Iy /e YgtF t7A 'I✓e--a T� ff d) 3 /I eel-/ a 77'/ c&C
SEC:I ION S -USE G ROUP: AND CONSTRUCTION TYPE
USE GROUP (Check as �
_ �
applicable) CONSTRUC,I lON TYPE
A Assembly i❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A
A-4 ❑ A -5 ❑ 1B l ❑
B Business ❑ 2A ❑
E Educational ❑ I Z3 ❑
F Factory ❑ F -1 ❑ F -2 ❑ , 2C I ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I -1 ❑ I -2 ?l. I -3 ❑ 3B { ❑
M Mercantile ❑ 4 0
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify:
NI Mixed Use ❑ Specify:
S Special Use ❑ Specify:
CO I THISSECTION TFEKSTING BUILDING_ UNDERGOING;RENOVA3IONS,`AD I IONS ANDJO,R _CHAIJGE IN U SE
Existing Use Group: I -2 Proposed Use Group: Z -2
Existing Hazard Index 780 CMP, 34): y Proposed Hazard Index 780 CMR 34): y
SEC TION 6 BUILDING HEIGHTANDAREA
BUIT LDING AREA EIS I ING I PROPOSED NEW CONS I RUC I ION fi d OFFICEijSEflNLY -
`'.' nJ hr' I . 1_
3Ta.1 e E -
Floor Area per Floor (sf) Aeo l n _ X600 4 g
r
u '
2nd = h 3 -.
n , r
aF . f ' a
.- a
2 n d i �V h ` `
3� z
,
3 rd . f�
u
4 v
_ U
4t' `:a
iii -
Total Area (SO_ Total Proposed New Construction (sf)
r} O IY 1 {
Total Height (ft) A .,,r F
Total Height ft N/
V1 JLV111. I ■01111 i11.1V141 L u.u.,,,u 11.111111. 1VJGy 13, GVVV
y i,
City of Northampton T r of Q � 'x ,i ,¢; 4 ,�� , �-
Building Department }ees �
212 Main Street = �v rrse Y
Room 100 " '"
, N � Northampton, MA 01060 gb. s ets s ' 'a ' : .,
\ � pbne 413 58� X240 Fax 413 587 1272 I? s f Sit?aQS , —
0¢ i'gt6iu -1 1 tri
APPLICATI TO CONS I RUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SEC I ION 1 SITE INFORMATION
x - `i$Mliissec itiii to iie�ompleted b office ,
1.1 Property Address: "� :,„ Y ;� ,F k NV.,
} atz- 0 est` Syr+«+ T:. r r 3 S h r :. 4 . ^c c 0, s. f Y.-
1 S • / Map r i G k1a � u r .Ummrt r
. e D;
a 0 o a s si ,rifx
3O - " .
/ /� / , - /^ - - `Zones � +.� `�ver�ay D�SL�1 iCt 4 t - � - ` s F
�^ C V �� ! / c �-c2 `F.a,'c, s1-' �� y u ti tt XS.# ? pt= t i -
k i . : IsLO� - ` '1"' , Gee- L i A r'S r ' r s .>-. r Lt. ti t' s 1
pYSt.�ri1Si icf ,�> > n Wart t a �-eiii5I 1 4 _ft
• SEC(ION.Z PROPERTY ,OWNERSHIP /AUTHORIZED
2.1 Owner of Record:
Cooley Dick/1).50h Nos l 30I ocUs f s t. Po. t20x 50a/
Name (Piet) Current Mailing Address:
: , 1 - //3 — 5E3 - Z 3/3
Signature Telephone
2.2 Authorized Agent:
Tr S. / e // 77' e r 5M,' / /et St. Luck /o u/, '111 (3/0,56
Name (Print) Current Mailing Address:
- , 2 � 5/3 - 5 2 500
Signature Telephone
SEC tiON 3— EStIMATED CON °CO
Item Estimated Cost (Dollars) to be _ Officia(Use Only
comaleted by permit applicant
1. Building _(a) Building Permit Fee
2. Electrical 6 SS,. m ` (b) Estimated Total Cost of : -
..Construction from,(6)_'
3. Plumbing 'iBuildiny Permit Fee.
4. Mechanical (HVAC) 3 .540. oe;
5. Fire Protection � I 3 7 S ,..., .
A d � �i
5. Total ,/ 1 i 2 + 3 + 4 -+ 5) 7S,5* Check'Number
A M U - ,, - A1 This Secti For Official Use Onl i ___
ui ding Perrnit N, nber: Date issued:
To nature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0663
APPLICANT /CONTACT PERSON RAYMOND R HOULE CONST INC
ADDRESS /PHONE 5 MILLER ST LUDLOW (413) 547 -2500 O
PROPERTY LOCATION 30 LOCUST ST - RADIOLOGY
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 703 4:3/7" Fee Paid / / ..7
Typeof Construction: RECONFIGURE RADIOLOGY RECEPTION AREA TO ADD 3 NEW OFFICES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Plans / Pt or lot Plan 066227
3 sets of r / �� �//J p-el/
Plans /Plan (,�L
T F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
A pproved 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
'"---- ...,,-;-- /
lo v
Signature of Building Official Da e
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.
•
30 LOCUST - .I "LOGr * BP- 2010 -0663
GIS #: COMMONWEALTH OF MASSACHUSETTS
- 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: BUILDING PERMIT
Permit # BP- 2010 -0663
Project # JS- 2010 - 000964
Est. Cost: $57550.00
Fee: $345.00 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 - RADIOLOGY
Applicant Address: Phone: Insurance:
5 MILLER ST (413) 547 -2500 () Workers
Compensation
LUDLOWMA01056 ISSUED ON:1/19/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: RECONFIGURE RADIOLOGY RECEPTION
AREA TO ADD 3 NEW OFFICES
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 1/19/2010 0:00:00 $345.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo