23B-046 (3) CITY OF NORTHAMPTON, MASSACHUSETTS
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT NUMBER: HAI -09 -82 DATE: January 8, 2010
PROJECT TITLE: Renovations for Gift Shop Relocation
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
=.� NESS OF THE PROJECT FOR OCCUPANCY.
0'c u- Ch/T
w K p.TS AR ,q" li �6 Subscribed and sworn to before po''`
c r C 7 c �► this day of k . , 2 +' S '
EASTHAMPTON �, • • t d, Notary Publi s , 2
F 4l ry 6• �� .'ri . 4 1S. os, AIA My Commission expires o : T +• _ 5``' - � ,+'
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DEPARTMENT OF BUILDING INSPECTIONS
. 212 Main Street • Municipal Building n � �
Northampton, Mass. 01060 M "
WORY,ER'S COMTENSA11ON INSURANCE AITIDAV1T
I, 77i// ot.2- 5 / /c» f/` /fratA/ 04 /C.14,)e ais -_7 .
(li censer/ppermi ttec)
with a principal place of business/residence at:
•
/ //° Sr LLd /di d /OS (phone#) .% /z -577. 2S0a
(stn t/ci ty /state /rip )
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following workers compensation coverage for my
employees working on this job:
7 (//vac .,Z" iti/J/ z 80055790 / 2ooy i 2 - 3) - 20/0
(Insurance Company) (Policy Nurlber) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Lasnance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Ex piratioa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(„t1,rh additircr shcri if noccauy to include information pertiniag to all actors)
( ) I a a sole proprietor and have no one w
m working for me. .
( ) I am a home owner performing all the work myself
NOTE: plwx Ix aware that tvtsilo bcmcowncrs who ample,' perwca to do roxlatcaaucc, coa�ructioa or repair work on a thyalling of
act mcco t h • n thrao waits in which the hou3oosvocr rc vdca oc oat o grouack appurtcnaat there-a) . arc not eaxr fly ccusidcrcd to be
cznploym utxicr the works s ,compccsation AC (GL152,_c1 1(5)), application by a homcoR'ocr fora tiaasc or permit may cvidaox t.^c
legal elahw of an employee under the Wockc,ea Comp.con rhea ALt_
I underov,nd that. a copy of this atatacoaat nv.y be forwarded to the Dcpartmcni of tochrs4i al AL -id t. Ono Offioo of 1-2-nLDC 1-2-n+ for tsn
covca.ga vcrif cation and chat failure to scenes covcraga undor radios 25A of MOL 152 can lord to the,' impoatioa of aimm1l pcualia
coxuistj of n fmc'of up to S1,50 end/or impresovmcoct of up to or year tiacl atij pcaaltia in tit form of a Stop Work Ord and a
fino of S1.00.00 i,diy igiinzt tax
- -� Fcc.'crI'l two only
�� / / pefrm�!i(t Number _
• J � 1� r '_ _4 J) or —r� 1�1a 74 _ T LUt # - t
Si :1,- Itirrz o��j PCmIRIat e LTh _ ._._- --, S`:
Ve.rsioni_I Conmmmrerc Bu i di :ao PC.Fili ut'
ECTION 10- STRUCTURAL REVIEW (780 CMR 110.11)
"1? ICc StrJCtu -21 ?eer Review Required
c 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN 1
OV AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
COOi LiC 1 S 01? h
/
aJ leorize fa �. ls
0( R, /7o uLe - Coi
n al' rn3tterS rel ;rr • + vorr: authorized by this building permit eppllcn-o-
/ 2-
I Signature of Owner Uai
�: - -- 1 . 3 t�'k.e ti . - � +�.''r '' ° .r' � 'v:�.;:+L'^ : i•:. '.,.�
i}`' ^'... .. - e..p?` _yes. %`.R••' r 5 ..,+;k.� s!;?Y'ry *, ... <. : e - � •:r =:?:w "•" :c:.c =s:''
_R 7 V/rl2//5 or>/ _ s luCTip c
• dec`are that the statements and information on the foregoing appilcation are ue. _ re: .,
_n;owledge and hel',ef.
-e,c under the pains and penalties of perjury_
J - r - Idame
/`
C nnatere of Ow, 4 > aen` Da:e
SECTION 12 - ;CONSTRUCTIOMSERVICES
20.1 Licensed Construction Supervisor_ a ;a�e
F �F of L e nse Holder :
Ti���� S . e� /e ti e D 6 227
5 _1__ / /e__ S- 7 — L (/ c/�o �//� O 10,5 O �`
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4/3-�S'7 50o
ar_re / Telephone
SECTION 13 - WORKERS' COMPENSATION:INSURANCEAEFIDAVIT (M.G.L. c.152,-.§ 25C(6))
C cmpensation Insurance affidavit must be completed and Submitted .:it - ca5 Fa' err
=su t In the crta of the issuance of tee bui!d!ng permit.
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5 O_,;OiDN l �O J O OOU ��. Iv-iVH1 ]dOD DNINIVI ^JOO) 9U ADD 02L 01 _ 0 J, ISiirIcii 10aiNOD- 001 10(1 J_SNC"J
-..iS0R U` LJ(l_ tS OH c ;, -1 iIf?g - S3'OIA NO1101 J_SNO9 °N`' N`OISl 1,j , aCl'S�_U l l r J
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1 .l. Supply (M.G.L. c. 40, § 54) i 7.1 Hood Zone Information: 1 7.3 Sewage Disposal System:
il r ics E a - Ir2tn [0 I Zone: _ -_ Outside Flood ?one X I Mu :ricipei p On site clsposn
H ORTHWTI P T ON ZONING
- - - - - -- -- --
Etisun Proposed . lb � r . _
LOTS7c ~ �G 9, 5'27. 96`7, y 7. 8 �'
Frontage �� 58 26 58 I
Setbacks Front 102 ' / o 2'
Site L: 98' Ft: i ll' L: 88 ` 0: y2
Ear I8' )9' 1
Builciingi ITeight — —
Bldg. Square Footage I — – -- , I – ----- -- - -- -i— - - --
VD2 8 6 /. j ;a ' V02,961 .
Open Space Footage % 1 T
(Lot area minus bldg & paved /0:. b / � 6 1
1 pal=:) _ I I 1 —
I o � 7
Parking Spaces / 6 I j / / 1 l
i
I 1 I
Flli: I ��;
(volume & 1 oca t, o ,),)
- -- — — — — —
A. Has a Special Permit/Variance/Finding ever been issued for /on the site?
NO DON'T KNOW YES X
IF YES, date issued: De 1.3 aOcI --
IF YES: Was the permit recorded at the Registry of Deeds:
NO DONT KNOW YES
I:F YES: enter Book 6_SOy Page 239 and/or Document ,
B, Does the site contain a brook, body of water or wetlands? NO DON'T KNOB'
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ___ Obtained _, Date Issued: _ _ __
C. On any signs exist on the property? YES � NO
IF YES, describe size, type and location' VA h i o vs —
B. ,Are Mere any proposed enlarges to or additions of signs intended for the prDpei ? – -
r... r 7
YEs, describe size, type and iocatiBo; - __ --
EC i ION 4 CONSTRUC.I ION SERVICES FOR PROJECTS LESS THAN 35,000
»O�13IC.FEET OF ENCLO.SE SPACE
raterior Alterations j Existing Wall Signs Existing Ground Signs Addit I Roofing CI
0 1 ❑
<i_erior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other H
]
❑ Accessory Building [ ] Repairs [ ]
,IR,E, DFsczl r�or�: l�eAoyc� o rce� <� 7v ��err� 6, SA o, 2 ~��/k
SECTION 5 USE GROUP AND CONSTRULI I.ON TYPE
_ USE GROUP (Check as applicable) 1 CONSTRULI ION TYPE
A. Assembly j❑ A -1 7 A -2 D A -3 ❑ 1A
A-�, ❑ AS 0 i 18 ❑ --
B Business E 27 ❑
E
Li L I LI
E Educational 25
Factory El rl a 3-2 ❑ II 2' O
H High Hazard_ I ❑ 3 A ❑
i
I Institutional I -1 ❑ 1 -2 .2 I -3 ❑ 38 ❑
r _
M Mercantile Ell I ❑
-1--
O Residential I P -1 ❑ R -2 Li R - 3 0 5A ❑
t r] S-1 S -2 32 1 ❑
S�oroe
U Utility ❑ Specify:
Li Mixed Use Di Specify:
S Spacial Use ❑ Specify:
CO MPLEI,__ THISSf- CI03IrFXISItf1G BOIL DifJ 1DDIITIONS "ANN DIORCH?SNGLiN 303
Existing Use Group: _ _I-12 - I Proposed Use Group: L -2
Existing Hazard Index 780 CM P. 34[: — — Proposed Hazard Index 780 CMR 34): 7 _ V
SECTION 6 BUILDING HEIGHTANDARFA .:_I
BUILDING- r — =" i _ r �? �� CO �:� r r' �i OF;
AREA EXISTI G OSEJ NEVI NSI RUI SON r , _ ,..
Floor Area per Hoof (sf) O Y / 2 i l it 7 Z p ! -�� .
- r'd h
l
y� s
-, I .; , 1
, -
i1
-
i''..r- `..rl 0 , s1
?r'
o g NSA [ F
ii
• Cm' o` Northampton ` o . � H � - v ,v
w )„: . `g .'� i `y, x ▪ ' t y -,
Building Department }e a DD Wag= e tam ▪ , ,
212 Main Street - u v r c aii :� �, t y
^ ROOfI 100 !ae E at e1 '' ,k�r . - s - � •
Northam - ptorl MA 01060 7v6 ets:s�s 5oer la S .
�� Nyphone 413 - 587 -1240 Fax 413 - 587 -1272 p i le aa f�� � a� ��
f
I /APPLICATION TO CONSTRUL i, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
,SECTION 1 SITE INFORMATION -
;s .1 Property Address:
F �� ThigiSi ion, o beroinpl byoffice ,
} 'mss - sit F _� 1 Vi > � c t . fie Phi F
Map r �D� t _= r aUI71t
l * Y ,. ' C7 4
30 Zone e Overi
4oCU,St S i0 Y
r, s ,`' �c l 0 p` ' ` -. -- ' r -
InrSt" DmUict Ct mT tECI: B.Disi ict L `51
S ECI10N2 PROPERTY; OWNERSHIPJA
2.1 Owner of Record:
Coo /e Dick /�so�No 30IoC st. Pa. _Lox b - ao/
Name (Pt) 4012, Current s
ent Mailing Address:
6'/3 55 = z3/
Signature Telephone
2.2 Authorized Agent:
_ yi�o th� _ 5, /'e //e t EM,.//et 5 y /�
7 . �u� /aID /O 56
Name (Pent) Cu rent Mailing Address:
y�J�7► 5 - g4'7- 500
Si Telephone
SEC. i iON 3:- ES t iMATED CONSTRUCT ION-COSTS
kern I Estimated Cost (Dollars) to be Official-Use Only
— _ completed by permit applicant _ _ .
1. Building ,$ O `'2 • ..,o ka3 Bu ilding Permit Fee
2. Elegy rical {b) estimated T otal Cost of
5
S 0 O . .Construction from.(6).- -
3. Plumbing -132 ilding Permit - Fee
, . ( �C ) / -�
Mechanical HV ^ _
C. Tire P-otection 2. Soo . c.,O
Total - (1 + 2 + 3 + 4 + 5) y� .5. O ,, oo •:Check Number ? c lC> --
i j This Section For Official Use Only
/i-/i `�-' -
O nn Permit t um - .?. Datelssued _ —_ -_ _
; ignature: — - -- — -
-
Building CommissionerJlnsp =Buildings Date —
File # BP- 2010 -0662
APPLICANT /CONTACT PERSON RAYMOND R HOULE CONST INC
ADDRESS /PHONE 5 MILLER ST LUDLOW (413) 547 -2500 0
PROPERTY LOCATION 30 LOCUST ST - 2ND FLR GIFTSHOP
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 t9/99 � y
Fee Paid ov
Typeof Construction: RENOVATE OFFICE ARE TO CREATE NEW GIFT SHOP - 2ND FLR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Include&
Owner/ Statement or License 066227
3 sets of Plans / Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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
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.
•
34 LOCUST ST - 2ND FLR GIFTSHO' BP- 2010 -0662
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 238 - 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 -0662
Project # JS- 2010 - 000961
Est. Cost: $44500.00
Fee: $267.00 PERMISSION IS HEREBY GRANTED TO:
Coast. 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 - 2ND FLR GIFTSHOP
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: RENOVATE OFFICE ARE TO CREATE NEW
GIFT SHOP -1ST FLR
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 $267.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo