31B-004 (3) Bell Hall
Third Floor
CLARKE! ,
Bell Hall Family Center
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EADOWBROOKg
TPA ASSOCIATES
A rnember of Meadowbrook Insurance Group
DATE: 7/1/10
TO: Clarke School for the Deaf
POLICY NUMBER: WC 000998 -10
Enclosed you will find an endorsement /change to your Workers' Compensation Policy along with an
invoice, if applicable. The following item(s) is (are) changed by this endorsement:
❑ Member's Name
❑ FEIN
❑ Policy Number
❑ Member's Mailing Address
X Experience Modification
From: 1.02 To: .95 Effective: 7/1/10
❑ ARAP Factor
From: To: Effective:
❑ Item 3 B. Limit
From: To: Effective:
X Item 4 Class, Rate, Other
❑ Audit — Year
❑ Other:
X Premium Change:
Increase: $ Decrease: $ 1,232
X DIA Surcharge Change:
Increase: $ Decrease: $ 34
❑ Other $ Change:
Increase: $ Decrease: $
If you have any questions or concerns, after reviewing this endorsement /change, please don't hesitate to
contact either Marisa Saviano at extension 162 or Bill Griebel at extension 136.
Thank you.
10 New England Business Center, Suite 303 — Andover, MA 01810 — 978 - 691 -2470 — Fax: 978 - 691 -2477
www.meadowbrooktpa.com
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 O No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Stephen Balicki
1, , as Owner of the subject property
hereby authorize John Scott -
to
act on my behalf, in all m -lative to work authorized by this building permit application.
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8 o ., 08/03/2010
Signature of Owner Date
Stephen Balicki , 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.
Stephen Balicki A
Print Name
'' lie Grt , 08/03/2010
Signature of Owner /Agent �' Date
SECTION 12 - CONSTRUCTION - VICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : John Scott CS78899
License Number
11 Hunt Rd., Hawley Ma. 01339 03/18/2011
Address Expiration Date
(413) 339 -5508
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 budding permit.
Signed Affidavit Attached Yes 0 No
Aillitk
Version1.7 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 ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
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
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor _
Not Applicable o
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: 1,: R:
Rear
Building Height
Bldg. Square Footage "'o
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 0 DON'T KNOW 0 TES 0
Al
:-
;, [Ls, tSflic 'iJ34.+CV.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW V ES
Page ._ e,6 vi. a_�x, x .de i. er
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Page
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t. + � � __ � y..t` .�.?�•Ca••• � �a 4.vr.. a,;..:� �i ,.c,''s` :) v1('t.tcitdCi�: i i `, 0
W YES, has a permit been or need to be obtained from the the Conservation Commission?
Needs b o bF d 4 4 Obtained Date. !s sued:
to �i.,c..4�i1tiE< [ >e�E3si:t_u � x Date r.'sSlteEZ.
C. Do ai iy ,i i is t„;Xii. 011 die 01 UP i Y= %, (3 NO ' ._.f
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x �vJ i. 4it.{ size, - �'ti {/''�'t
D. . _ _ __ :: _. _..F 7 ' L - 0 NO
u Arc thcre x _ a.a . i�r i .3 63 i J xt:s =_w txxi.l'iee�e,.� for i:1 L.i twwL+f i. x•.Je �.e vi ,,r e i,� xx e�t.xeU?.: ii �+is„ i ...f i� Cy
r:i;t"= , acie f,3f ill curt of < common plan
CONSTRUCTION e� �VIC - �^; RO £ z- ?P,
SECTION 4- ��.:fMJ l f[+.J4 t E�l�! SERVICES � (� Vi': PROJECTS 7 S 4..G... � .] THAN #`�F N .}. els.$0 1
CUBIC FEET OF ENCLOSED SPACE
01 Proposed Work: ., ith panic hair and •i; sti,
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'SECTION __i- GROUP _ I
5 • USE GRO .?4- AND CONSTRUCTION TYPE
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L COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS ANC /OR CHANGE IN USE I
1 P roposeed Use Group I
Existing Ha d trade 780 CMR n'i)- I Pr Hazard Index . 8 r MR 31): I
j SECTION 6 BUILDING HEIGHT AND AREA
( I _ •_ "• _ . OFFICE USE ONLY
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Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: `'`
Public p Private ❑ Zone Outside Flood Zone is Municipal 12 On site disposal system❑
• ,
Version1.7 Commercial RuildinPermit May 15, 2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
2 12 Main Street Sewer/Septic Availability .401.1004,.
Rociiii 100 Waterilke .. - i i ' ,
:,!orthcrripton, MA 0106C Two se Ataitturi:Pia;hsV!,1/ 7\
A 1 cp,7 1:-)7? Plot*Plans
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I SECTION 3 - 't STIMATED CONS:RUCTION COSTS
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This Section For Official Use Only I
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I Building Pk Ntirribc.ir i Dail: „ , ....,. 1
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: t PUG 23 2010
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Buildin Commissionerlinspector of Buildings i Date ; 1 ; 011110 4),
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File # BP- 2011 -0154
APPLICANT /CONTACT PERSON JOHN SCOTT
ADDRESS /PHONE 11 HUNT RD HAWLEY (413) 339 -5508 ()
PROPERTY LOCATION 45 ROUND HILL RD - BELL HALL 3RD FLR
MAP 31B PARCEL 004 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / �� 4.55
Fee Paid loo
Typeof Construction: INSTALL ELECTRONIC DECURITY DOOR IN EGREE HALLWAY W /PANIC BAR &
CLOSER
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 078899
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,FAIATION 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
y23)
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.
45 ROUND HILL RD - BELL HALL 3RD FLR BP- 2011 -0154
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 004 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- 2011 -0154
Project # JS- 2011- 000251
Est. Cost: $3800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN SCOTT 078899
Lot Size(sq. ft.): 311018.40 Owner: Clarke School for the Deaf
Zoning: URC(100)/ Applicant: JOHN SCOTT
AT: 45 ROUND HILL RD - BELL HALL 3RD FLR
Applicant Address: Phone: Insurance:
11 HUNT RD (413) 339 -5508 () WC
HAWLEYMA01339 ISSUED ON:8/24/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ELECTRONIC DECURITY DOOR IN
EGREE HALLWAY W /PANIC BAR & CLOSER
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 8/24/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner