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31B-252 (4)
' COMMONWEALTH OF MASSACIILJSIIi1TS Construction Control Affidavit Architect Project Number: 1 Project 'Title: Slith_Cv|leAc Auditorium Project Location: 60 Elm Street NlrU.omp Name o[Building: John M. Greene Auditorium Nature "[Project: Accessibility Upgrades In accoi dance with Section I 16.0 Registered Architectural and Professional Engineering Scnices'[nnxxuuim`Cnnov\ o[ the k8oaochumuo Stine Building Code, i Du|,hE Kugisnuinu No, 4\)o being a Registered Architect, HEREBY CERTIFY that | have prepared o,directly supervised the preparatioil of design, plans, computations, and specifications concerning: Entire Project Architectural X Structural Mechanical Fire Protection Electrical [*hcrt,prcify1 _ ______ FOR 'HIE ABOVE NAMED PROJECT AND TU PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PKOV|3|0N'SUyTKC78OCMRM/\SB&CH UNFITS STATE BUILDING CODE. ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR TIIE PROPOSED USE AND OCCUPANCY. | FURTHER CERTIFY TUAT| SHALL PERFORM THE NECESSARY PROFESSIONAL SER\TICES AND BE FRESENT ON THE CONSTRUCTION SITE ON A REGIJLj\R ANE) PERIODIC I3ASIS TO DETERMINE THAT THE WORK |SPKOCC�U|NG1N ACCORDANCE VY|TH THE DOCUMENTS APPROVED FOR T88BUILDING yEKk4}T AND SHALL U2 RESPONSIBLE FOR THE FOLLOWING SPECIFIED |N SECTION |\622. |. Review, for conformance to the design concept, shop drawings, samples, and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Be present at intervals appropriate to the state of construction to become generally familiar with the pro ress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with Oic construction documents. UNDER SECTION 116.4. I SHALL PERIODICALLY SUBMIT A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS, TO TTIE COMMONWEALTH OF MASSACIIUSETTS BUILDING INSPECTOR, UPON COMPLETION OF THE WORK, 1 SHALL SUBMIT A FINAL REPORT AS TO SATISFACTORY • COMPLEXION AND READINESS 0['[ PROJECT �, >z, .w MA 7..natu Stamp (no FacsimiR) 41T s- k . 1)). It' ND SWORN TO 13EFORE / __DAY OT 201/ — __ MY COMMISSION EXPIRES 70a_ NOTARY PUNJ[ zxu Tpnopn�mxrri tio* The Commonwealth of Massachusetts Department of Industrial Accidents v . + " Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): A.R. Green & Son, Inc. Address: 19 St James Avenue City /State /Zip: Holyoke, MA 01040 Phone #: 413 - 538 -7947 Are you an employer? Check the appropriate box: Type of project (required): 1. © I am a employer with 15 4. ❑ I am a general contractor and I employees (full and /or part-time).* have hired the sub contractors 6. n New construction 2. ❑ I am a sole proprietor or partner- These sub - contractors have listed on the attached sheet. 7. WI Remodeling ship and have no employees 8. ❑ Demolition working for me in any capacity. employees and have workers' coin insurance. 9. El Building addition [No workers' comp. insurance p required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 1 1 . n Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: The Travelers Insurance Companies Policy # or Self -ins. Lic. #: DTAUB 299K620 - - Expiration Date: 01/01/12 Job Site Address: John M. Greene Hall, 60 Elm Street City /State /Zip: Northampton, MA 01063 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert y under the pains and penalties of perjury that the information provided above is true and correct. Signature: S President Date: May 26, 2011 Phone #: 413 - 538 -7947 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 1 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 Q No Q SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date { k�, > . , ° c.rr ,..x; , 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. Print Name Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Karen Tobia - Sprague 104581 License Number 10 Lyman Barnes Rd, Brimfield, MA 01010 11/26/2013 Addres Expiration Date �-- 413- 538 -7947 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 building permit. Signed Affidavit Attached Yes a No 0 Version1.7 Commercial Building Permit May 15, 2000 1 SECTION_ t 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: Ralph Edward Dinneen Not Applicable 0 Name (Registrant): R E Dinneen Architects & Planners, Inc. 4119 123 North Washington St, Boston, MA 02114 Registration Number Add 31 August 2011 617-227-7727 Expiration Date Signs 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 ResponsibWty Aaaress Registration Number Signature Telephone - Expiration Date 9.3 General Contractor A.R. Green & Son, Inc. Not Applicable ❑ Company Name: Russell A. Sprague Responsible In Charge of Construction 19 St James Ave, Holyoke, MA 01040 dress 413 - 538 -7947 Signature Telephone Version1.7 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: L: Rear Building Height .{f = Bldg. Square Footage / Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) f A. Has a Special Permit /Variance /Finding - er been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO or DON'T KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO a IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations !2 Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. i /,,' ` :, 11 P3;; `; r I A pp. _ r' s Of Proposed Work: e s ° ,, `. ,) t SECTION 5 - USE GROUP AND CONSTRUCTION TYPE /� USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly I / A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ L � A -4 ❑ A -5 ❑ 1B El B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 0 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 0 S -2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: : de-e a Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 2 ( (a 61 " f 1 st � `- 1" 2nd 2nd 3rd 3 rd 4 th 4 th Total Area (sf) ' j' ,,,,-7- Total Proposed New Construction (sf) 2 I `.1=> kf-`) r; 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 ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system , .04 __r. _ Versionl.7 Commercial Building Permit May 15, 2000 �vcD Department use only Gity of Northampton Status of Permit: JUN E uilding Department Curb Cut/Driveway Permit - 2011 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability DePr of ButoiNG = Northampton, MA 01060 Two Sets of Structural Plans .Q„13,587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office John M. Greene Hall Map 2 \ Lot ;? ", "2 unit 60 Elm Street Northampton, MA 01063 Zone ' Overlay District -e Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Smith College Current Mailing Address: 126 West Street Northampton, MA 01063 Signature Telephone 413 -585 -2441 2.2 Authorized Agent: Name (Print) j -;' 4 . ?A 5-14.. Current Mailing Address: ) 2 Signature k j Telephone 1:-) SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 17, 985.00 (a) Building Permit Fee 2. Electrical 3,500.00 (b) Estimated Total Cost of Construction from (6) 3. Plumbing 3,880.00 Building Permit Fee 4. Mechanical (HVAC) 0.00 5. Fire Protection 1,750.00 6. Total = (1 + 2 + 3 + 4 + 5) 27,115.00 Check Number 51:49$ 0/Z9d/6 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -1034 1\1/ 0 t APPLICANT /CONTACT PERSON A R GREEN & SON INC ADDRESS/PHONE 19 ST JAMES AVE HOLYOKE (413) 538 -7947 PROPERTY LOCATION 60 ELM ST -JOHN M GREENE HALL Now Cop MAP 31B PARCEL 252 001 ZONE URC(100) / /EU - 1 E , G sere - THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out leg/ P )/ !) Fee Paid /1/ Typeof Construction: INSTALL STAIR LIFT & REMODEL UNISEX ACCESSIBLE BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 104581 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9MATION 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 6 5 r1 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. 60 ELM ST -JOHN M GREENE HALL BP- 2011 -1034 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 252 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-2011-1034 Project # JS- 2011- 001578 Est. Cost: $27115.00 Fee: $162.69 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: A R GREEN & SON INC 104581 Lot Size(sq. ft.): 62726.40 Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: URC(100) / /EU Applicant: A R GREEN & SON INC AT: 60 ELM ST -JOHN M GREENE HALL Applicant Address: Phone: Insurance: 19 ST JAMES AVE (413) 538 -7947 Workers Compensation HOLYOKEMA01040 ISSUED ON:6/30/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL STAIR LIFT & REMODEL UNISEX ACCESSIBLE BATHROOM 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: FeeTvpe: Date Paid: Amount: Building 6/30/2011 0:00:00 $162.69 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner