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23B-008 The following list describes newly designed 780 CMR documents for use by Massachusetts Registered Design Professionals (Architects and Engineers), MGL 112 §81R Contractors, and Building Officials to assure and/or confirm compliance with 780 CMR, the Massachusetts Building Code, and associated specialty codes and reference standards. • Design Professional in Responsible Charge (for new construction) - This document is to be filled out by ONE Massachusetts Registered Design Professional when required for new construction. (for compliance with the requirements of 780 CMR § 1 07.3.4) • Design Professional in Responsible Charge (for existing building renovations and/or additions to existing buildings /structures) - This document is to be filled out by ONE Massachusetts Registered Design Professional when required for renovation and/or addition to existing buildings. (for compliance with the requirements of 780 CMR § 107.3.4) • Construction Control Document This document is to be filled out and submitted by any and all Massachusetts Registered Design Professionals with design responsibilities. (For compliance with the requirements of 780 CMR § 107.6) • Required Inspections Document This document is to be issued by the Building Official upon issuance of the 780 CMR Permit. This document conveys the Building Officials minimum requirements for his/her inspections as well as the Building Officials requirements for inspections and documentation by Massachusetts Registered Design Professionals and/or/MGL 112 §81R Contractors. (780 CMR § 110) • Phased Approval Document This document is to be filled out by the responsible Massachusetts Registered Design Professional, or MGL 112 §81R Contractor, to document compliance of portions or phases of "controlled" and/or designed portions of the work. (For compliance with the requirements of 780 CMR § 107.6) • Final Construction Control Document This document is to be filled out by each Massachusetts Registered Design Professional at the completion and acceptance of the portion of work performed per their design, stating they have inspected the work and find it in substantial compliance with their design. (For compliance with the requirements of 780 CMR § 107.6) • Design Professional in Responsible Charge - Final Construction Document (Final approval of designed projects) - This document is to be filled out at the completion of a project, by the ONE Massachusetts Registered Design Professional so designated, as /when required by 780 CMR § 107.3.4. • Certificate of Occupancy — 8 Base This Certificate of Occupancy document may be issued by the Building Official when applicable per 780 CMR § 111, when the Building Official determines the work complies with 780 CMR, and the building (or portion thereof) is safe to occupy. • DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE (continued) ( #2 continued) 780 CMR 8 edition, Section 110.6, Approval Required, states work shall not be done beyond the point indicated in each successive inspection without first obtaining approval of the Building Official. Required inspections will be noted on the "Required Inspections Form" and may include, but are not limited to the following: Soil Condition Roofing Footing and Foundation Special Inspections (Sec. 1701.1.1) Specify Concrete Floor and Under Floor Mechanical Systems Lowest Floor Flood Elevation Energy Code Compliance Structural Frame Fire Alarm Installation Lath and Plaster /Gypsum Fire Suppression Installation Fire Resistant Wall Seismic Reinforcement Above Ceiling Inspection AAB 521 CMR Compliance This list may be altered by the Building Official, depending on the scope of the project. Other required construction documents (geo- technical reports, structural tests and inspections, etc) may be required prior to accepting an inspection request. Acceptance testing for fire alarm and fire protection systems will be coordinated through the Building Official. # 2. - Understood and Agree [ 3. Variance from Strict Compliance with 780 CMR or 521 CMR: Documents Attached [ 1 - N/A [ 1 Indicate if any Variances were received that would alter strict compliance with 780 CMR or 521 CMR. Attach a copy of the written decision and docket number. 4. Variance or Special Permit from Strict Compliance with Local Land Use /Zoning requirements: Documents Attached [ 1 - N/A [ 1 Indicate if any Variances or Special Permits were received that would alter strict compliance with Local Land Use /Zoning requirements. Attach a copy of the written decision and docket number. Complete this section if applicable: I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning the following: [ ] Entire Project [ ] Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other Specify) for the above named project and that such plans, computations and specifications meet the applicable provisions of 780 CMR (8 edition) the Massachusetts State Building Code, all acceptable engineering practices, and all applicable laws for the proposed project. I shall submit a Construction Control Document for the discipline designated. Page 2of2 Version — March 12, 2012 1 DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE ri 1 4, ez submit with permit application for Existing Building • Renovation, Alteration, Addition, or Change of Use V Per 780 CMR Section 10'7.3.4 — Massachusetts State Building Code Project Title: k W (' Date: 67/ (y Project Location: 2 _6(1 c t k St • Ak ' A.....' i 111 Scope of Project: _ ,, ' . 1_,,i 1_,,i 1 f I C.�t�c�,---- 3 (bk. T 1�-- (Permit # ) (to be determined by Building Official) In accordance with 780 CMR, Section 107.0, most specifically 107.3.4 "Design Professional in Responsible Charge" of the 8th edition of the Massachu etts State Building Code: I, t) 3( 1.) ` M ass. Registration Number L7 / Expiration 5 Is being a Massachusetts Registered Professional Engineer /Architect hereby certify that: I am the Design Professional in Responsible Charge and that I shall be responsible for reviewing and coordinating submittal documents prepared by others, including phased submittal items, for compatibility with the design of the building and for compliance with the requirements of 780 CMR ( ;. 1 s State Building Code). 5.f Aqe Signature and Seal of registered professional: Q �0 GE E. ). G FC � , � o. 7141 / i 112 g MONSON, G y MASS. •• , �� �TNOF1Aa5 5 k The following checklist is based on the requirements of 780 CMR 8 edition (Massachusetts State Building Code), is not all inclusive, may be modified by the Building Official depending on the scope of the project, and reflects an acknowledgement by you, as the DPRC, that 780 CMR, 8 edition, chapter 34, (IEBC 2009 with Massachusetts Amendments) has been reviewed for code compliance. Said review includes a review of the required investigation and evaluation report, as well as the "Compliance Method" used for design. 1.) Existing Structure: The design complies with the following 780 CMR , 8 edition Chapter 34, (IEBC 2009 with Massachusetts Amendments) Design Methodology - Prescriptive Method [ ] - Work Area Method [ ] - Performance Method 1 ] 2.) Inspection Requirements and Notification Responsibility: It is a requirement of 780 CMR that the Building Official be notified, through written documentation, indicating that the work complies with the plans and specifications at the completion of each phase of construction (see 780 CMR S edition, sections 107.6.2.2, 104.4, 110.4 and 110.5). As the Design Professional in Responsible Charge, you will gather, review, and submit to the Building Official any required "Phased Approval Documents" and /or supporting documentation from testing agencies or Registered Professionals responsible for their designed portions of the work. ( #2 is continued) Page 1 of 2 Version — March 12, 2012 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` r 1 Congress Street, Suite 100 • " - =-�' d Boston, MA 02114 -2017 -, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Craig Sweitzer & Co, LLC Address:231 Butter Road City /State /Zip:Monson, MA 01057 Phone #:413- 626 -1498 Are you an employer? Check the appropriate box: Type of project (required): 1. FA 1 am a employer with 2 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6, ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. E/ Remodeling ship and have no employees These sub - contractors have 8. [J Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance. $ 9. 0 Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: General Casualty Co. of WI Policy # or Self -ins. Lic. #:CWC 0397276 Expiration Date: / Job Site Address: ao Lo c -i % 5 / City / : Northampton, MA 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 tine 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 certify under the pains and penalties of perjury that the information provided above is true and correct Si. nature _mss—• Date IIIIIIIWAITIIM. Phone #: 413-62.-14. 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. CityfTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark "x" where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm (may require repeaters) 6 HVAC 7 Electrical 8 Plumbing (include local connections) 9 Gas (Natural, Propane, Medical or other) 10 Surveyed Site Plan (Utilities, Wetland, etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests & Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey /Investigation 16 Energy Conservation Report 17 Architectural Access Review (521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other (Specify) 21 Other (Specify) 22 Other (Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information of TA `rs'roS_ 7 / / Name (Registrant) _Telephone No. e -mail address Registration Nu �er Street Address City /Town State Zip Discipline Expir lion Date - - Name (Registrant) Telephone No. e -mail address Registration Number Street Address City /Town State Zip Discipline Expiration Date - Name (Registrant) Telephone No. e -mail address Registration Number Discipline Expiration Date Street Address City /Town State Zip SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name (Print) No. and Street /011 /Town / Zip Property Owner Contact Information: X Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes 'A 5wW TL X3 c { ,iTI- 1p.o ;M01u1bJ IMfi d (W Name Street Address City /Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 2) (If building is less than 35,000 cu. ft. of enclosed space and /or not under Construction Control then check here ❑ and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control LAN,A , TO 4- ' 7S 1 ql Nape (Registrant) Telephone No. e -mail address ,� Re istra 'on Number vU t- s' • a�,v�. j." -, � o l 66� i [ Street Address City /Town State Zip Discipline Expi ation Date 10.2 General Contractor A'( cs CJc - P - . Co l_-L. C Company Name C _� -(4, J - 2 -) c- ("C 2 cr. C ca t s - 7 / Name of Person Responsible for Construction License No. and Type if Applicable .L.3 i Z.:.>1 L 20 lM,otwon.3 tn,li 0 i or/ Street Address City/Town State Zip 4 -4G ! 5 33 / 4(3 _J2Co_ 1 ` tq t ,S..)e-,T2.Cc' w (dr?raL. p . CO-/ Telephone No. (business) Telephone No. (cell) c e -mail address SECTION 11: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) A Workers' Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the i ance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost (from Item 6) = $ 1. Building $ Ie°, ✓ Building Permit Fee = Total Construction Cost x (Insert here 2. Electrical $ 9 u U appropriate municipal factor) = $ . 3. Plumbing $ S, 0 C 0 4. Mechanical (HVAC) $ p G v Note: Minimum fee = $ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ 4i 000 (contact municipality) and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. , ,4 )3i7 Amok X 4 2 la _61& - 119 8 /,/ L Please print and sign n e � Title Telephone No. Date 23 ( aiTtCR J ' 4- c2 (c217 Street Address City /Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date r , . vOtIP The Commonwealth of Massachuse \ LM, ., � . ! 3 2012 Department of Public Safety I r Massachusetts State Building Code (780 CMR) DEPT. OF BB$ ml v�`i_ 'it A pplication for any Building other than a One- or Two - Family Dwelling NORTHAMP (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1: LOCATION (Please indicate Block # and Lot # for locations for which a street address is not available) 24,q , G .' c ' -4‘ 14 610 62- t, \C— �,t✓ No. and Street 2 9 wn Zip Code Name of Building (if applicable) }�- SECTION 2: PROPOSED WORK Edition of MA State Code used If New Construction check here ❑ or check all that apply in the two rows below Existing Building [31( Repair ❑ Alteration ( Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and /or construction documents being supplied as part of this permit application? Yes No ❑ Ls an Independent Structural Engineering, peer Review required? Yes ❑ No e Brief Description of Proposed Work: 11 . g-(b. r 601J t( t t..)C + 1. toll 'A-t - 1 1 rEAMMULIZINIMMUNTIM I EWIta Let SECTION 3: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION, OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No. of Floors /Stories (include basement levels) & Area Per Floor (sq. ft) Total Area (sq. ft.) and Total Height (ft.) SECTION 5: USE GROUP (Check as applicable) A: Assembly A -1 ❑ A -2 ❑ Nightclub ❑ A -3 ❑ A -4 ❑ A -5 ❑ B: Business [ E: Educational ❑ F: Factory F -1 ❑ F2 ❑ H: High Hazard H -1 ❑ H -2 ❑ H -3 ❑ H -4 ❑ H -5 ❑ I: Institutional I -1 ❑ 1 -2 ❑ I -3 ❑ 1 -4 ❑ M: Mercantile ❑ R: Residential R -10 R -2 ❑ R -3 ❑ R -4 ❑ S: Storage S -1 ❑ S -2 ❑ U: Utility ❑ Special Use ❑ and please describe below: Special Use: SECTION 6: CONSTRUCTION TYPE (Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public ❑ Check if outside Flood Zone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑ Private ❑ or indentify Zone: or on site system ❑ required ❑ or trench or specify: permit is enclosed ❑ Railroad right -of -way: Hazards to Air Navigation: MA Historic Commission Rev iew Process: Not Applicable ❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes ❑ or No ❑ Yes ❑ No ❑ SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): _ Type of Construction: _ Occupant Load per Floor: Does the building contain an Sprinkler System ?: Special Stipulations: File # BP- 2012 -1111 APPLICANT /CONTACT PERSON CRAIG SWEITZER & CO LLC ADDRESS /PHONE 231 BUTLER RD MONSON (413) 626 -1498 PROPERTY LOCATION 269 LOCUST ST - UNIT F3 3RD FLR MAP 23B PARCEL 008 000 ZONE SI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Na jO N � Fee Paid 7 lJ Typeof Construction: RENOVATE DENTAL OFFICE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 15713 ld) 4A/ [" 3 sets of Plans / Plot Plan ate THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQ1tMATION PRESENTED: if 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 9 l,0 / Signature of Building Official Date g g 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. 269 LOCUST ST - UNIT F3 3RD FLR BP- 2012 -1111 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 008 CITY OF NORTHAMPTON Lot: -000 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 -1111 Project # JS- 2012- 001897 Est. Cost: $41000.00 Fee: $246.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CRAIG SWEITZER & CO LLC 15713 Lot Size(sq. ft.): Owner: WOHL MARTIN A Zoning: SI(100)/ Applicant: CRAIG SWEITZER & CO LLC AT: 269 LOCUST ST - UNIT F3 3RD FLR Applicant Address: Phone: Insurance: 231 BUTLER RD (413) 626 -1498 WC MONSONMA01057 ISSUED ON:6/20/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE DENTAL OFFICE 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 6/20/2012 0:00:00 $246.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner