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31B-004 (6) 08/08/2012 15:31 14135821118 CLARKE SCHOOL PHYSI: PAGE 02 r.';l1,a -0th• 16 F�: U:? k'� Ear!f rib �� City of Northampton S.J. DLasiachuest Cs 4 • ; M Or swsr rsrilG iws *crx 212 1[w.th IErwc • »Sic4pa1 sbaL2d4►a wurosabiorim, ka 01.010 - 4,7 :4 L Z . !VECTOR Louts Hasbrouck t=ax' 413 ber•1272 Chuck Mlle Building Commissioner Phone: 413-687-1240 Assistant CornmlUPiorier CONSTRUCTION CONTROL DOCUMENT (Fcw IMAgra a*t L+o...a4A,d lie s respomdblo kr Emirs Promo § Project T te; . _r ' Sis1' ' 1 Dstar_a_i„a. I2. Project Location: Cl Atrl�ae map: Peroat :___ Zone: Scope of Prq .t:.. Wittififir In accordance with the sixth edition Massachusetts State Building Code, 7130 CMR Section 1100: Mess. Rsgistretion rk 411 being a registered prvrsssiQral Engineer/Architect hereby CERTIFY that I have prepared or directly supervle the preparation of all dee.lgr pions, Lamputslions and spacific ation& concerning: ENTIRE PROJECT ►ol the miaow named pro}sct and Chit to ttte bast of my knowledge, such plans, computations and speclf9caeons meet the applicable priwisssions of the Massachusetts Static 3uill7ing Coda, all acceptable enairostrin9 preclloss and all applicable Laws for the proposed project Furthermore, i understand and AGREE that I shalt perform the necessary professional services to determine that trio Nava mentioned Pistons of the work pros td In accvrdancxr +Mfrs trio documents approved for the bolding permit and shoill be responsible'ry the following as specfttad In Section 110,22 1, Reafelw of shop drawings, samples and attser submittals of the cotltrector as required by the oonsztruc on documents at submitted for that building permit mid approiraf fat the Conformance to the desiGn t nc>rspt 2. Review and approval of the quality control procedures for all code-required controlled instertaM. 3, Be present at intervals appropriate to Pie stage of construction to beeeenc generally familiar with The proems and qua!tty of he work and to detertnirle, in general, if the work b being performed In matter consistent with the construction documents, shat sut t periodically, in a font acceptable to the building official, a progress report together wt pertinent o ern. r+ents. Upon aomoietlor~ of the work, I shall submit to the building off *ol a fnal rapOlt as to the satisfactory ;,u+rp,etion and readiness of the project for occupancy otED AAs"j Sigr - tor - ! of - . ad Professional fessional +'l . I�oasi .�.. Day of U&Y_....20 cr TM FL PJ 2 Client #: 126371 CLARKESCHO ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 4/26/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Sandy Torino HUB International New England PHONE 781 792 -3297 FAX 866- 252 -8812 (A/C, No, Ext): (A/C, No): 600 Longwater Drive ADDRESS: sandra .torino @hubinternational.com Norwell, MA 02061 781 792 -3200 INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: Independent Schools Compensatio INSURED INSURER B : Clarke School for the Deaf, The dba Clarke Schools for Hearing & Speech INSURER C: 47 Round Hill Rd INSURERD: Northampton, MA 01060 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER jMM /DD/YYYYLjMM /DD/YYYYL LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED (Per accident) HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE _ $ DED RETENTION$ $_ A WORKERS COMPENSATION WC00099812 01/01/2012 01/01/2013 X TORY1J U- S OTH- AND EMPLOYERS' LIABILITY TORY LIMIT ER Y/ N ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? N N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Massachusetts only WC CERTIFICATE HOLDER CANCELLATION City of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE y p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 AUTHORIZED REPRESENTATIVE I .e Ch— © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S718229/M686802 ST001 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 O SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Steve Balicki 1 , as Owner of the subject property hereby authorize John Scott to act on my behalf, in all matters relative to work authorized by this building permit application. 04/09/2012 Signature of Owner Date 1 Steve 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. • ek'r- ` 3w1rc.k Print Name Ix) /fl r-/— a 04/09/2012 Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES • 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : John Scott CS78899 License Number 11 Hunt RD> Hawley, MA. 01339 03/18/2013 Address Expiration Date (413) 582 -1174 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 0 No 0 Versionl.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: R.E. DINNEEN Not Applicable El • Name R.E. DINNEEN Registration Number Address (617) 227 -7727 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 Clarke School Not Applicable ❑ Company Name: John Scott Responsible In Charge of Construction 1 1 Hunt Rd. Hawley Ma. 01339 Address ) i" (413) 582 -1174 Signature Telephone Versionl.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 SAME SAME Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage 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 O DON'T KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT 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 O DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: 3' x 3' front of building D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO Oi 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 O NO O 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 IS Existing Wall Signs ❑ Demolition ID Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New. Signs ❑ Roofing Change of Use ❑ Other ❑ Brief Description Moving staff and student body into Bell Hall, Minor alterations throughout building with no change Of Proposed Work: in use. upgrades to Tech / Electric and HVAC and a few partition walls add and removed. SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 p A - ❑ 1A I 12 A - ❑ A -5 ❑ 1 B ❑ B Business Fl 2A 0 E Educational 12 2B I ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A 0 I Institutional 0 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use specify: audiology service/ school S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: 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) 1 st 1 st 2nd 2" 3 3rd d 4 th 4 th 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 p Municipal IS On site disposal system ❑ Versionl.7 Commercial Building Permit May 15, 2000 Department use only City of Northampton Status of Permit: uildin Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability 26 2012 100 Water/Well Availability C N rthampton, MA 01 Two Sets of Structural Plans phon 41 - 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 45 Roundhill Rd. Map Lot Unit Northampton Ma. 01060 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Clarke Schools 46 Roundhill Northampton Ma. 01060 Name (Print) Current Mailing Address: (413) 582-1111 Signature Telephone 2.2 Authorized Agent: Steve Balicki 46 Roundhill Rd. Northampton Ma. 01060 Name (Print) Current Mailing Address: (413) 582 -1156 Signature t - Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical — - .- (b) Estimated Total Cost of "7" '''� Construction from (6) 3. Plumbing Building Permit Fee / C ) 4. Mechanical (HVAC) ��ti 5. Fire Protection e) g /-� � 6. To •`= + 2 + + 4 + 5) /0? 000 Check Number I 1 D I v / This Section For Official Use Only :ui . g Permit Nu ser Date Issued Signature: Building Commissioner /Inspe' c\f Buildings Date 45 ROUND HILL RD BP- 2012 -0935 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: renovation BUILDING PERMIT Permit # BP- 2012 -0935 Project # JS- 2012- 001629 Est. Cost: $109000.00 Fee: $654.00 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 Applicant Address: Phone: Insurance: 11 HUNT RD (413) 339 -5508 O WC HAWLEYMA01339 ISSUED ON:8/8/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: MINOR ALTERATIONS,UPGRADES TO TECH /E;EC & HVAC,ADD & REMOVE PARTITION WALLS 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 8/8/2012 0:00:00 $654.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 41 (Lula cr 1\3 File # BP- 2012 -0935 Ca 1 , - K - 1 1 1 QC FL tC � APPLICANT /CONTACT PERSON JOHN SCOTT a . ADDRESS /PHONE 11 HUNT RD HAWLEY (413) 339 -5508 Q 4‘1171111 � PROPERTY LOCATION 45 ROUND HILL RD 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 Fee Paid 2 / f / e 06,5 Typeof Construction: MINOR ALTERATIONS,UPGRADES TO TECH /E :EC & HVAC,ADD & REMOVE PARTITION WALLS 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 INFORMATION 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 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.