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38A-050 (4) Associated • Building Wreckers, Inc. 352 Albany Street, Springfield, Massachusetts 01 105 Tel: (413) 732- 3179/(800) 448 -2822 Fax: (413) 734 -6224 4 t October 24, 2012 ` 2012 a Louis Ilasbrouck, Building Commissioner City Of NOlthampt0l] � �� Z P7 OF BUILDING INSPECTIONS NORTHAMPTON MA 01060 Puchalski Municipal Building 212 Main Street Northampton, Massachusetts 01060 RE: Demolition Permit Application for Building No. 12 of the former Northampton State Ilospital located on Village Hill Road in Northampton, Massachusetts Dcar Mr. Hasbrouck: Please find the enclosed Demolition Permit Application for the above referenced location along with the required back up documentation and a check for $ 200.00 to cover the application fee. Please let me know if there is anything else you require. "Thank you, Talia Enclosures Certification o Visual inspeclion- Asbestos i I Grc. Environmental Consul lIng, l.I.0 ■ .-_-----..-- ._- , ----- Projec I am: V.1.14.‘1(in 0..! Projor. 0: 4),0_6_7( — _-. Projc ddr: A; o I A e Vs. • ("? V41.1tit_ttL_m04...._____ • 1....okk.- 1 -^' 1 . W ork Areao(s) In ec t (3 d: Mai odd( s) Removed and OlJar itTiy: 1 1 In occordanco with opplicoblf.4 rAgulations and ASTM F1 368 "Standard Proc.' ico for Yu at Ilmpection of Asnslos Abatement Projocts", Illo Ovint.)r's Roo' esentolive and Contractor heroby c6rtify that illoy hori e,. visually inspect od surfacfis in the Work Armco anctbave found no vi5lble debris. ...-- 1 _Zig10- 0 Y.1.1-- -- . 6, 1.‘.!Li t us ( r r1 Owne Ropmsent a tiv 63 LIconself/EXp., Date i _11)19/1/7 tq fr Confroc for Supervisor I 1 itlExp, Do - " .I1A- '.14:11-1.5e1-442:2A1,11\--V,44:k---i410.1.,,,!,3rkftl.....-44411,-)1..Ldt4 _I-1g__ . 4 5 • „I' it :.; • , .r. ..._ ' , A ; •-• f• • z "--• - ,-"---, — ,1 -.\ Asbes S amp l e o, Custody f 0 “ k. '') Green E4 .- 0 ons.ulif.? ILO , i Proiect Infoirriatien: f- - ...) ,. t I pFojeot Nome kLk„..1.•_..- %--...i...4.,_........ .a,3,....‘„. 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Laboratoty infown. crticittv: , 1.. i Analysis T-Tee i ia.,1, -- )kl . O.b of Ancti-14 -" ------,---, ' „—r ,,,, AnriJySTgnatiore Releosc. ,Fic-or es : i - ';- I _ L _ ,,,/ _ K.e.lInquislled oyi: i....4aibilinile Re-ceyed by: Date/Tirrie Green 7 Conc,-2.. L - 2:7" S:_ teir Poo:: F!Dr P... A 01'062 • PIF ;4'13 ) 341-3418 . i ....,..._ - - . . 4 10 4 014, O k4 Page 1 l 11 4 Green Environmental Co:wilting, LLC , - ---- Phase Contrast Microscopy (PCM) Air Sample Report Cilont: EnviroGreen I_LC GEC Project k 00631 Client Address: 81 Chestnut Ave. Sampled by: Brian fioneud Jamaica Plain, MA 02130 Analysis Date: 10/16/2012 Project Nerno: Northampton State 1-Inroiral Project Address: Building 12 Village I Illi Ave, Nortiumpton MA ampia. ita 0.1.2 V (.._ 11,4 Mgr ir 0 Pk" ifitelZ $P.171010 141.1111b1./. Warzlalc40112.0 Tv rn pate. (jiterS) ,ElOars Floft14 : r ma .......m....... , soor.nor ".o, ............*....... ,........4.....4 00631.01 B6SOment Northeost Final Air ClearanCe 10/16/2012 1200 3 100 .002 <.002 —.— 00631-02 Basement Northwest nom Air Clearance 10/16/2012 1215 3 100 ,002 4 ,002 00631-03 Basement Middle Hall Pinal Air Cloarnnore 10/16/2012 1200 1 160 .002 <,002 00631-04 Bascrnent Sout1least rtnol Afr Clearance 10/16/2012 1200 5 100 .002 <.002 00631-05 easement Southwest Final Air Clearance 10/16/2012 1215 3 100 ,002<.002 00631-06 Reid Blank 10/16/2012 0 '100 00031-07 PIL:IO Blank 10/16/2012 0 100 Analyst Name: Brian Renaud . / r Analyst Signature: Fiber count by Pharr) ariiialer&roopciZVZ3 'Method, rarZlori,%17TCZ.4 tIATI94. results have been blank corrected ea 40plleeblei. "Ms report relates only to ttie snippet reported above., This report may not be reproduced, except In MI, without written approval by Green trivIroornentol CeMulting, LLC (060), Massachusetts dastz."C"AsbikstOS.NulyticlitIconsor at AA000206 744 „1,, . \s 'Nflog Green Environmental Consulting, L.LC 296 Sylvester Road • Florence, MA, 01062 • Tel /Fax (413) 341 -3418 October 17, 2012 Louis Jabier EnviroGreen LLC 81 Chestnut Hill Avenue Jamaica Plain, MA 02130 Re: Asbestos Project Documentation Building 12 Village Hill Ave. Northampton State Hospital Northampton, MA Dear Louis Jabier: Attached please find project documentation for asbestos final air clearance services performed by Green Environmental Consulting, LLC (GEC) at the above - referenced address. Mr, Brian Renaud (MA Project Monitor # AM900441) performed Phase Contrast Microscopy (PCM) final air clearance sampling on October 16, 2012. Air samples were below the clearance level of 0.010 fibers per cubic centimeter (f /cc). Green Environmental Consulting, LLC appreciates the opportunity to work with you on this important project. If you have any questions please contact us at (413) 341 -3418. Sincerely, Green Environmental Consulting, L.LC Adam Lesko President GreenEnvironmonta1Consulting .com Massachusetts Department of Environmental Protection 1100157196 Bureau of Waste Prevention — Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF -001 and AQ 06 G. Certification The undersigned hereby states, under the penalties of perjury, that he /she has read the Commonwealth of Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his /her knowledge and belief. ILO UIS JAVIER ? ;LOUIS JAVIER 1 Name Authorized Signature `PRESIDENT 1 19/19/2012 2. Position /Title 3. Date (mm /dd /yyyy [ENVIROGREEN LLC __.._.._....._. .... _...,._ __ .__._.._.__, a.. i [ 8578913842 i 4. Representing 5 Telephone 181 CHESTNUT AVENUE Address AMAICA PLAIN ' :02130 7. City /Town 8. Zip Code anf06pdrn.doc • rev. 2/5/04 Massachusetts Department of Environmental Protection 1100157196 Bureau of Waste Prevention — Air Quality Decal Number Project Revision Notification For Asbestos Notification ANF -001 and AQ 06 Important: A. Facility Location When filling out Y formson the _�..._m.___.�.�... �......... �..__....�,.n.....��____._.._� .. .__._. ._..��.__�.�__..__._........._. _......_._v__...__..... �_......_.....______._. r._..._._._.__._......... r.__.....__.....__.__.... � ...... ............._._._..._......... computer, use NORTHAMPTON STATE HOSPITAL only the tab key 1. Name of Facility to move your VILLAGE HILL ROAD cursor do not ............. �...... _w. _._._._..._.._...__._....... _.__....__. _.__..... _............._ _.___.............__ .._....._.._ use the return 2. Street Address ... ... t key. (NORTHAMPTON 'MA 3. City 47 State 5. Zip Code 6. Telephone Number INSTRUCTIONS B. Project Cancelled 1. This form is only available for l Check here if this project is /was cancelled. online filing of project date revisions. 2. Enter project decal number. C. Project Dates 3. validate that [11/2012 t '9/25/2012 theproject „ �.. ..._.__........._...____....__� _..___.__.___._._�__� - w._..._..___... ...._��_�._._.._.___..__.�....� �d�...__.__..____..._. .__......___...._.__..__......� location is correct 1. Original Start Date (mm /dd (yyyy)__ 2. Original End Date(mm /dd /,yyyy) for the entered 9/25/2012 1 110/9/2012 decal 3. Latest Revised Start Date (mm /dd /yyyy) 4. Latest Revised End Date (mm /dd /yyyy) 4. Enter your new project dates. 5. Certify your notification. D. Revised Project Dates Submit date changes. 110/9/2012 1 110/16/2012 1. Revised Start Date (mm /dd /yyyy) 2. Revised End Date Date (mm /dd /yyyy) E. Other Project Revisions I l F. Revision History __._.. ......._......__.___.._....._._ _. IEDEP: 09/06/2012 04:01:39 PM EDEP: 09/17/2012 09:46:29 AM anf06pdrn.doc • rev. 2/5/04 Massachusetts Department of Environmental Protection • Bureau of Waste Prevention • Air Quality 100157188 BWP A Q 06 Decal Number Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project, were the structure(s) surveyed for the presence of asbestos containing material (ACM)? Yes [1] No If yes, who conducted the survey? b. Surveyor Name c. Division of Occupational Safety Certification Number x.9/11 /2012 12/30/2012 7. Construction or Demolition: _._.__. _._........__ ...........__._W._._.____...... a. Start Date (mm /dd /yyyy) b. End Date (mm /dd /yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: seeding i paving ✓' wetting shrouding b. If other, please specify: covering other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? a. Name „ of DEP Official b. Title c Date (mm /dd /yyyy) of Authorization d. DEP Waiver Number D. Certification CO I certify that I have examined the ANDREW MIRKIN o above and that to the best of my a. Print Name o knowledge it is true and complete. Andrew Mirkin The signature below subjects the b Authorized Signature signer to the general statutes PRESIDENT o regarding a false and misleading c. Position /Title o statement(s). ASSOCIATED BUILDING WRECKERS, INC. d Representing 18/28/2012 c0 e. Date (mm /dd /yyyy) 0 0 1 aq06.doc • 10/02 BWP AQ 06 • Page 3 of 3 1 � v Massachusetts Department of Environmental Protection Bureau of Waste Prevention • Air Quality Decal Number � �� AQ U�� ~ ~ .�� ~~ ~~ Notification Prior to Construction or Demolition General U� General Project Description (cont.) Statement: x B. ~~ ^ ^ ~� ~ ~~ ^. ^^ � ^ asbestos is found during 4 General Contractor: Construction or � Demolition 'ASSOCIATED BUILDING WRECKERS, INC. operation, all a Name responsible parties • must comply with [352 ALBANY STREET 310 CMR 7.00, b. Address r.oe.r.1o.and Chapter z1Emthe iSPRINGFIELD ,MA 01105 General Laws of c. City/Town d State e.,Zip Code the Commonwealth. This would include, f. Telephone Number,(area code and extensionl Address (optionalt, but would not be limited m, filing an asbestos removal h. On-site Manager Name notification with the Department and/or a notice of release/threat »' C. General Construction or Demolition Description release `~^ ~~ ' - - - - - '^ - hazardous substance to the 1. Construction or demolition contractor: Department, if applicable. |NGVVRECKERS INC. a. Name 1352 ALBANY STREET b. Address :MA 01105 c. City/Town d. State e. Zip Code 4137323179 f. Telephone Number (area code and extension) g. E-mail Address (optional) h. On-site Manager Name 2. On-Site Supervisor: ;WILLIAM BABCOCK On-Site Supervisor Name 3. Is the entire facility to be demolished? '11 You l No 4. Describe the area(s) tobe demolished: --' | o Em//RE FACILITY m | o �------------------ -- --� ° 5. If this is a construction project, describe the building(s) or addition(s) to be constructed: r ------------------------- --------�---- -- �--- - o L___- ----- NN ovos.uor^ 1002 mwPm3wo^ Page zoxs 111 -------" Massachusetts Department of Environmental Protection N Bureau of Waste Prevention • Air Quality 100157188 BWP A A 06 Decal Number Notification Prior to Construction or Demolition Important: A. Applicability When filling out pp Y forms on the computer, use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building, or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor - do not use the return (DEP), Bureau of Waste Prevention - Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09 (2) ten (10) days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. d3, I B. General Project Description 1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner- occupied Instructions residence of four units or less? 1 Yes LS1 No 1. All sections of b. Provide blanket decal number if applicable: Blanket Decal Number this form must be completed in order to comply with the 2. Facility Information: Department of BUILDING 12 Environmental Protection a. Name notification [ FORMER STATE HOSPITAL VILLAGE HILL ROAD requirements of � ..��_-- .- ..w..w,aa__�. --,.�m 310 CMR 7.09 b. Address Northampton MA 01060 c. City /Town d. State e Zip Code . -, [ f. Telephone Number fared code and extension) Email Address o p tional 12400 ...__..m._ J 1 h. Size of Facility In Square Feet i. Number of Floors j. Was the facility built prior to 1980? ✓j Yes 1 No k. Describe the current or prior use of the facility: FORMER NORTH EMPLOYEES HOME I. Is the facility a residential facility? 1 Yes ✓ No o m. If yes, how many units? Number of Units o 3. Facility Owner: N , HOSPITAL HILL DEVELOPMENT CIO MASSDEVELOPMENT o a. Name o 33 A PARKWAY ., ss b. Address e .. __.. DEVENS MA 01434 c. City /Town d. State e. Zio Code o 19787726340 i f. Telephone Number (area code and extension) q. E -mail Address (optionali,__ , 0 ! ADAM DELANEY Q h. Onsite Manager Name ■ ag06.doc • 10/02 BWP AQ 06 • Page 1 of 3 1 DIG SAFE SYSTEM, INC. - Print A Copy Of Your Ticket Page 1 of 1 Request Number: 20123409049 Date 08/23/2012 Time 12:05 Latitude: Longitude: State: MASSACHUSETTS Municipality: NORTHAMPTON Address / Intersection: VILLAGE HILL RD Nearest Cross Street 1: PRINCE ST Nearest Cross Street 2: Additional Information: AT BLDG 12 AT FORMER STATE HOSPITAL NEXT TO MILL RIVER Nature Of Work: DEMO BLDG Area Of Work: ALL AROUND THE BLDG Area Is Premarked: YES Start Date: 08/28/2012 Start Time: 12:00 Caller: TALIA Title: Return Call: BEF 430PM Phone #: 413 - 732 -3179 Fax #: 413 - 734 -6224 Alt. Phone #: Email Address: ABW_INC @COMCAST.NET Contractor: ASSOCIATED BUILDING WRECKERS Address: 352 ALBANY ST City: SPRINGFIELD State: MA Zip: 01105 Excavator Doing Work: SAME Member Utility List Code Abbreviation Name X AJ COMCAS COMCAST - SOUTH BURLINGTON X MC NGRDEL NATIONAL GRID ELECTRIC -MASS ELEC * ON ONTARG ON TARGET LOCATING * RJ IDM INNOVATIVE DATA MANAGEMENT X SP VERIZN VERIZON * WB BRKGAS BERKSHIRE GAS * WG CMAGAS COLUMBIA GAS OF MASSACHUSETTS 1 Previous Screen J New Query Print Ticket Display Dig Location Map 1 Return To Menu 1 L Return To Home : I http:// digsafeform .digsafe.com /cgi- bin/rtcgi.exe 08/23/12 DIG SAFE SYSTEM, INC. - Renew Existing Ticket Page 1 of 2 Request Number: 20123911580 Date 09/28/2012 Time 10:39 Latitude: Longitude: State: MASSACHUSETTS Municipality: NORTHAMPTON Address / Intersection: VILLAGE HILL RD Nearest Cross Street 1: PRINCE ST Nearest Cross Street 2: Additional Information: AT BLDG 12 AT FORMER STATE HOSPITAL NEXT TO MILL RIVER Nature Of Work: DEMO BLDG Area Of Work: ALL AROUND THE BLDG Area Is Premarked: Y Start Date: 10/03/2012 Start Time: 11:00 Caller: TALIA Title: Return Call: BEF 430PM Phone #: 413- 732 -3179 Fax #: 413 - 734 -6224 Alt. Phone #: Email Address: ABW_INC @COMCAST.NET Contractor: ASSOCIATED BUILDING WRECKERS Address: 352 ALBANY ST City: SPRINGFIELD State: MA Zip: 01105 Excavator Doing Work: SAME Member Utility List Code Abbreviation Name Al27 G4STEC G4S TECHNOLOGY LLC AJ COMCAS COMCAST - SOUTH BURLINGTON F103 FVCOLL FIVE COLLEGE NET LLC J8 FBRTEC FIBERTECH NETWORKS - MA MC NGRDEL NATIONAL GRID ELECTRIC -MASS ELEC ML MCI MCI ON ONTARG ON TARGET LOCATING RJ IDM INNOVATIVE DATA MANAGEMENT SP VERIZN VERIZON WB BRKGAS BERKSHIRE GAS WG CMAGAS COLUMBIA GAS OF MASSACHUSETTS WH WMAELE WESTERN MASS ELECTRIC CO n http: / /digsafefonn.digsafe.com /cgi -bile /dwcgi.exe 09/28/12 Associated I3uilding Wrecker, Inc Pagc 1 of 1 Talia Totten From: Romito, Jeff [Jeff_ Romito @cable.comcast.com] Sent: Monday, August 27, 2012 8:50 AM To: Talia Totten Subject: RE: Building 12 of the Former Northampton State Hospital All set From: Talia Totten [ mailto :Talia ©buildingwreckers.com] Sent: Thursday, August 23, 2012 12:46 PM To: Romito, Jeff Subject: Building 12 of the Former Northampton State Hospital Please see the disconnection request below. "Thanks, "Falia Associated Building Wreckers, Inc. 352 Albany S1., Springfield. MA 01105 Tel: (413) 732 -3179/ (8011) 448 -2822 Fax: (413) 734 734 -6224 August 23, 2012 "10: Jell Romito Email: jeft romito(acable.comcast.com of: Comcast Please cut all services of all buildings at the following location as it is being scheduled for demolition: Building 12 of the Former Northampton State hospital (top of property, located between Village 11i11 Road and the Afi11 River. Abandoned building. Formerly known as North Employees 11ome.) Once disconnection has been completed, please either sign below and fax it to 413- 734 -6224 or send a notification on your company letterhead. thank you very much for your assistance in thi matter. Sincerely, Associated Building Wreckers, Inc. SERVICE AT: HAVE 13EEN DISCONNECTED AS 00 PRINT NAME /: SIGNATURE: REMARKS, IF ANY: 08/28/12 Associated Building Wreckers, Inca 352 Albany St., Springfield. MA 01105 Tel: (413) 732 -3179/ (800) 448 -2822 Fax: (413) 734 734 -6224 August 21, 2012 To: John Hall Fax: 413 587 -1576 Of: Northampton DPW Sewer Dept. Phone: 413 587 -1574 Please be advised that the Former North Employees IIonie located at: Former Northampton State hospital (also known as Building 12) (top of property, located between Village hill Road and the Mill River. Abandoned building.) it is being scheduled for demolition. When demolition is complete, the sewer will be properly capped and we will call to request an inspection. 'Thank you, Associated Building Wreckers, Inc. Sep 04 2012 6:37 City of Northampton DPW (413) 587 -1389 p.1 AUG -29 -2012 13:53 From: To:DPW Central F.1/1 Associated Building Wreckers, Inc. 352 Albany St., Springfield. MA 01 Tel: (413) 732- 31 (800) 448-2822 Fax: (413) 734 734 -6224 August 23, 2012 To: .Dave Sparks Fax: 413 587-1576 Of: Northampton DPW Water Dept. Phone: 413 587 -1095 Please cut all services to any buildings at the location of: Building 12 of the Former Northampton State Hospital (top of property, located between Village 11111 Road and the Mill River. Abandoned building, Formerly known as North Employees Dome.) as it Is being scheduled for demolition. Once disconnection has been completed, you may tither sign below and fax it to me at 41 - 734 -6224 or you may fax me notification on your company letterhead. Thank you very much for your assistance. Sincerely, Associated Building Wreckers, Inc. Service at: have been disco I ted as of Print Name: Z Signature_ 44fiL - Remarks, if any: Page 1 of 1 Talia Totten From: Quinlan, Kevin [kevin.c.quinlan©verizon.com] Sent: Tuesday, September 04, 2012 1:40 PM To: talia @buildingwreckers.com Subject: Building 12 of Former Northampton State Hospital Demo Talia, Building 12 of former Northampton State Hospital, located between Village Hill Road and Mil River is not fed with Verizon cables. This building may have house cable that fed from Admin building, but these are no property of Verizon. Thanks, Kevin Quinlan Verizon - MA OSP Engineering 365 State Street Springfield, MA 01105 (413) 750 -3502 09/04/12 09/0412012 09:05 4137327393 Gl /G1 A.ssociated. Building Wreckers, Inc. 352 Albany St., Springfield. MA 01105 Tel: (413) 732 -3179/ (800) 448 -2822 Fax: (413) 734 -6224 August 28, 2012 TO Jackie Email:jbejune @nisource.cor OF: Columbia. Gas PHONE: 413 7819200 Ext 211.5 Please cut all services of all buildings at the following location as it is being scheduled for demolition: Building 12 of the Former Northampton State Hospital (top of property, located between Village Hill Road and the Mill River. Abandoned building. Formerly known as North Employees Home.) Once disconnection has been completed, please either sign below and fax it to 413 -734- 6224 or send a notification on your company letterhead. Thank you very much for your assistance in this matter. Sincerely, Associated Building Wreckers, Inc. SERVICE AT: l t ir? oi„.„7A, /40--rkt;) HAVE BEEN DISCONNECTED AS OF () 4 PRINT NAME: SIGNATURE: { ��:..�: _ _ 7y/4' / REMARKS, IF ANY: gorimminmomk From:National Grid 17815221067 09'06/2012 13:19 #703 P.0021002 nationa 1 grld The ,cy,4/4-..-r o action Reservoir Woods 40 Sylvan Rd Waltham, MA 02 September 6, 2012 Associated Building Wreckers Attn Talia Fax: 413 734 6224 RE: Service Removal for Building Demolition. Attn: Per your request; National Grid has confirmed there is no electrical service located at Building 12, 0 Village Hill Road in Northampton. If you have any questions or need further assistance, please feel free to contact me at (508) 357-4661. Sincerely, See, i<ef(y nationalgrid Customer Order Fulfillment Central & Westera MA MOffice 508-357-4661 it Fax 888 266-8094 _ . k. Attention: Executive Vice President, Real Estate With a copy to: Hospital Hill Development LLC c/o Massachusetts Development Finance Agency 160 Federal Street, 7th Floor Boston, MA 02110 Attention: General Counsel To the Contractor: Associated Building Wreckers, Inc. 352 Albany Street Springfield, MA 01105 Attention: Andrew Mirkin, President Each party authorizes the other to rely in connection with their respective rights and obligations under the Agreement upon approval by the parties named above or any person designated in substitution or addition hereto by notice, in writing, to the party so relying. (1) This Agreement shall be binding upon and inure to the benefit of the parties hereto and their respective successors and assigns where permitted by this Agreement. IN WITNESS WHEREOF, this Agreement has been executed by the Owner and the Contractor as an instrument under seal and is effective as of the date first written above. AGENCY: CONTRACTOR: HOSPITAL HILL DEVELOPMENT LLC ASSOCIATED BUILDING By and through its Manager, WRECKERS, INC. MASSACHUSETTS DEVELOPMENT FINANCE AGENCY • B L _ , Na e: Richard .J. Henderson Name: Andrew Mirkin Title: Executive Vice President, Real Estate Title: President Approved as to Form Counsel Contract Number: P03001 Contract Amount: $112,315.00 \\ massdevelopment .com \mdfa \bosgroups \legal \contracts \associated building wreckers.doc 5 (i) in compliance with Executive Order 481, which provides that the firm (i) shall not knowingly use undocumented workers in connection with the performance of Owner- Contractor Agreement or any contract with Owner; (ii) shall verify, pursuant to federal requirements, the immigration status of all workers assigned to perform Services under this Owner- Contractor Agreement without engaging in unlawful discrimination; and (iii) shall not knowingly or recklessly alter, falsify, or accept altered or falsified documents from any such worker(s); (j) able to furnish labor that can work in harmony with all other elements of labor employed or to be employed at the work; all employees to be employed at the worksite will have successfully completed a course in construction safety and health approved by the United States Occupational Safety and Health Administration that is at least 10 hours in duration at the time the employee begins work and who shall furnish documentation of successful completion of said course with the first certified payroll report for each employee; and all employees to be employed in the work subject to this bid have successfully completed a course in construction safety and health approved by the United States Occupational Safety and Health Administration that is at least 10 hours in duration, in accordance with Chapter 30 §39S of the Massachusetts General Laws; and (k) as of the time of award of the Agreement, neither the Contractor nor its principals are debarred, suspended, or proposed for debarment by the Federal Government or by the Commonwealth of Massachusetts. ARTICLE 9. GENERAL (a) Laws and Regulations: This Agreement shall be considered to incorporate by reference all applicable federal, state and local laws and rules and regulations of all authorities having jurisdiction over the work as though such provisions were set forth in full herein. (b) Insurance: The Contractor shall effect and maintain insurance in the amounts set forth in Article 16 of the General Conditions. (c) Final Inspection. Upon receipt of a written notice that the project is ready for final inspection and acceptance, Owner shall promptly make such inspection and when Owner finds the work acceptable under the contract and the contract fully performed, Owner shall promptly issue a final certificate in the form attached hereto to this contract at Exhibit B stating that the work provided for in the contract has been completed and is accepted under the terms and conditions thereof and that the entire balance found to be due the Contractor and noted in said final certificate is due and payable. Before issuance of a final certificate, the Contractor shall submit evidence satisfactory to Owner that all payrolls, materials, bills, permit fees and other expenses connected with the project have been paid. (d) The Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts. (e) All notices required or permitted under the Agreement shall be in writing and shall be deemed sufficiently served when delivered by hand if a receipt is obtained therefore, or when actually received if delivered by mail, and if delivered by mail shall be mailed registered or certified first class mail, return receipt requested, postage pre -paid, and in all cases shall be addressed as follows: To the Agency: Hospital Hill Development LLC c/o Massachusetts Development Finance Agency 160 Federal Street, 7th Floor Boston, MA 02110 \\ massdevelopment .com \mdfa \bosgroups \legal \contracts \associated building wreckers.doc 4 Owner acknowledges that the Contractor can perform services for other clients during the duration of this Agreement, provided such clients do not conflict with the services required under this Agreement and subject to applicable law. By signing the Agreement, the Contractor hereby certifies, under the pains and penalties of perjury, that at this time and during the term of this Agreement, the Contractor (i) shall not knowingly use undocumented workers in connection with the performance of the Agreement or any contract with the Owner; (ii) shall verify, pursuant to federal requirements, the immigration status of all workers assigned to perform Services under this Agreement without engaging in unlawful discrimination; and (iii) shall not knowingly or recklessly alter, falsify, or accept altered or falsified documents from any such worker(s). Any breach of the foregoing requirements shall constitute a material breach of this Agreement subjecting the Contractor to sanctions, including but not limited to monetary penalties, withholding of payments, and /or suspension or termination of this Agreement or any contract with the Owner. ARTICLE 8. LEGAL CERTIFICATIONS By signing the Agreement, the Contractor certifies, under the pains and penalties of perjury, that it is in compliance with, and shall remain in compliance with, all legal requirements governing performance of this Agreement and the Contractor's doing business in Massachusetts, and that the Contractor is: (a) in compliance with all Massachusetts laws relating to the payment of taxes reporting of employees and contractors and withholding and remitting child support as required by G.L. ch. 62C, § 49A; (b) a "Qualified Employer" as defined by the Child Care Act and 102 CMR 12.00 -.04; (c) in compliance with all Federal and state laws and regulations prohibiting discrimination, including Executive Order 11246; (d) in compliance with the provisions of MGL c. 15113; (e) not currently debarred or suspended by federal or state government from doing business with any governmental entity; (f) in compliance with federal anti- lobbying requirements of 31 U.S.C. § 1352; (g) in compliance with all laws of the Commonwealth relating to contributions and payments in lieu of contributions under G.L. ch. 151A, § 19A; (h) not employing ten or more employees in an office or other facility located in Northern Ireland and is not engaged in the manufacture, distribution or sale of firearms, munitions, including rubber or plastic bullets, tear gas, armored vehicles or military aircraft for use or deployment in any activity in Northern Ireland; or, if applicable, is employing ten or more employees in an office or other facility located in Northern Ireland and (i) does not discriminate in employment, compensation, or terns, conditions and privileges of employment on account of religious or political belief; (ii) promotes religious tolerance within the work place, and the eradication of any manifestations or religious and other illegal discrimination; and (iii) is not engaged in the manufacture, distribution or sale of firearms, munitions, including rubber or plastic bullets, tear gas, armored vehicles or military aircraft for use or deployment in any activity in Northern Ireland; \\ massdevelopment .com \mdfa \bosgroups \legal \contracts \associated building wreckers.doc 3 The Owner shall pay the Contractor, in current funds, for the performance of the Work, the Contract Sum of: One Hundred Twelve Thousand Three Hundred Fifteen and 00 /100 Dollars ($112,315.00). ARTICLE 5. ALTERNATES The following Alternates have been accepted and their costs are included in the Contract Sum stated in Article 4 of this Agreement: NONE ARTICLE 6. TIME OF COMPLETION AND CERTIFICATE OF FINAL COMPLETION, RELEASE AND ACCEPTANCE (a) The Contractor shall commence Work under this Contract on the date specified in the written "Notice to Proceed" and shall bring the Work to Substantial Completion by December 31, 2012, with a Final Completion date of January 31, 2013. Damages for delays in the performance of the Work shall be in accordance with Article 9 of the General Conditions of the Contract. (b) When the Work is fully complete, the procedure for substantial completion set forth in Article 9 of the General Conditions has been satisfied, and the Contractor has delivered to the Owner all of the deliverables required in the Contract Documents, the Contractor, Engineer and Owner shall sign the Certificate of Final Inspection, Release and Acceptance, in the form set forth on Exhibit B of this contract (the "Completion Certificate). Any of the parties may initiate the process of getting the Completion Certificate signed. The Engineer and Owner shall not sign the Completion Certificate unless and until the Work is fully complete. ARTICLE 7. LEGAL REQUIREMENTS In connection with the execution of the Agreement, the Contractor shall not discriminate against any qualified employee or applicant for employment because of race, color, national origin, ancestry, age (as defined by law), sex, sexual orientation, religion or physical or mental handicap. The Contractor agrees to comply with all applicable federal and state statutes prohibiting discrimination in employment including Title VII of the Civil Rights Acts of 1964, the Age Discrimination in Employment Act of 1967, Section 504 of the Rehabilitation Act of 1973, and Massachusetts General Laws Chapter 151B, section 4(1). If a complaint or claim alleging violation by the Contractor of such statutes regarding the execution of the Agreement is presented to the Massachusetts Commission Against Discrimination ( "MCAD "), the Contractor agrees to cooperate with MCAD in the investigation and disposition of such complaint or claim and to assume all legal fees in connection with the defense of such claim. In the event of the Contractor's noncompliance with the provisions of this Article, the Owner shall impose such sanctions as it deems appropriate, including, but not limited to: (i) withholding of payments due the Contractor under the Agreement until the Contractor complies; or (ii) termination or suspension of the Agreement. The Contractor understands that any person providing services under the Agreement may be a "special state employee," for purposes of M.G.L. Chapter 268A, but shall otherwise be an independent contractor and not an employee of the Owner. The Contractor further agrees to comply with said Chapter 268A, as "special state employee," and to promptly disclose to the Owner any activity under the Agreement by the Contractor or an employee thereof that is or may result in a violation thereof. \\ massdevelopment .com \mdfa \bosgroups \legal \contracts \associated building wreckers.doc 2 HOSPITAL HILL DEVELOPMENT LLC BY ITS MANAGER MASSACHUSETTS DEVELOPMENT FINANCE AGENCY OWNER - CONTRACTOR AGREEMENT This Owner- Contractor Agreement (the "Agreement ") is made and entered into as of the 'A "' day of tc z.)c-rr " , 2012, by and between HOSPITAL HILL DEVELOPMENT LLC, a Delaware limited liability company having its principal place of business at c/o MassDevelopment, 160 Federal Street, 7th Floor, Boston, MA 02110 (the "Owner "), by and through its Manager, Massachusetts Development Finance Agency, a body politic and corporate organized and existing pursuant to Chapter 23G of the Massachusetts General Laws, having a principal place of business at 160 Federal Street, 7th Floor, Boston, MA 02110 (the "Agency" or " MassDevelopment"), and ASSOCIATED BUILDING WRECKERS, INC., a Massachusetts corporation, having a principal place of business at 352 Albany Street, Springfield, MA 01 105 (the "Contractor "). ARTICLE 1. DEFINITIONS Whenever the word "Contractor" is used in this Agreement, it shall be understood to include its heirs, executors, administrators, successors, assigns, employees, agents and representatives. Whenever the word "Owner" is used in this Agreement, it shall be understood to mean Hospital Hill Development LLC, by and through its Manager, Massachusetts Development Finance Agency, acting through its President/CEO either directly or through her properly authorized assistants or agents acting severally within the scope of the particular duties entrusted to them. Whenever the word "Work" is used in this Agreement it shall mean the work to be performed by the Contractor in accordance with this Agreement and the other Contract Documents. ARTICLE 2. SCOPE OF WORK The Contractor shall perform all Work required by the Contract Documents or referred to in the Contract Documents prepared by Tighe & Bond, Inc. (acting as and referred to as the "Engineer ") for the "Abatement and Demolition of Building 12 at the Former Northampton State Hospital" (the "Project ") at Village Hill, Northampton, Massachusetts ( "Village Hill "). ARTICLE 3. CONTRACT DOCUMENTS The following, together with this Agreement, form the Contract Documents and all are as fully a part of the Contract as if attached to this Agreement or repeated herein: The Bidding Documents (including Instructions to Bidders, Form of Bid, Contract Forms (including this Agreement, Certificate of Vote of Authorization, Bid Bond, Performance Bond, and Payment Bond), General Conditions of the Contract, Prevailing Wage Sheet, and Technical Plans and Specifications, and all Modifications issued after execution of this Agreement. Terms used in this Agreement which are defined in the General Conditions of the Contract shall have the meanings designated in those Conditions. ARTICLE 4. CONTRACT SUM This Contract will not be valid until signed by duly authorized agents of the Owner and the Contractor. \\ massdevelopment .com \mdfa \bosgroups \legal \contracts \associated building wreckers.doc 1 Client #: 27633 ASSBUI ACORDr. CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD /VYYV) 3/16/2012 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 NAME: ACT Mary Hoth People's United Ins. Agency MA PHONE - - -- FAx p g Y (A/c, No, Ext�: 413- 786 -6871 (A /C No): 1391 Main Street, 3rd Floor E -MAIL ADDRESS: mary.hoth @peoples.com PO Box 4950 INSURER(S) AFFORDING COVERAGE NAIC # Springfield, MA 01101 Nautilus INSURER A INSURED INSURER B : Great Divide Insurance Company Associated Building Wreckers, INC INSURER C : 352 Albany ST INSURER D : Springfield, MA 01105 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TI IIS IS TO CERTIFY TIIAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TI IE 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, TIIE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IIEREIN IS SUBJECT TO ALL TIIE 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 {MMIDD /VVVY) (M MIDD /YYYY) LIMITS A GENERAL LIABILITY X X ECP0152972411 03/15/2012 03/15/2013 EACH OCCURRENCE f $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 100,000 1 CLAIMS -MADE r X, OCCUR MED EXP (Any one person) $ 5,000 XI Blanket per X X PD Ded. 10,000 PERSONAL BADVINJURY $1,000,000 written contract GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 3,000,000 I POLICY I X PROT - [OC $ _ -.. JEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(Ea accident _ 1 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) S AUTOS �._ AUTOS NON -OWNED PROPERTY DAMAGE $ _ HIRED HIRED AUTOS AUTOS (Per accident) $ A UMBRELLA LIAB X occuR FFX1529725 03/15/2012 03/15/2013 EACH OCCURRENCE $5 X EXCESS LIAB CLAIMS -MADE 02/01/2012 02/01/2013 AGGREGATE I $5,000,000 DED X RETENTION $10,00t) _— _ _ $ B WORKERS COMPENSATION X WCA154516510 02/01/2 02/01/13 X WC STATU- OTH AND EMPLOYERS' LIABILITY _____TORY LIMITS ER Y I N ANY YI PR OPRIET ER /PART E ECUTIVE I1 N / A E.L. EACH ACCIDENT $1,000,000 (Mandatory in NH) N E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT ! $1 ,000,000 III A Pollution Liab X X ECP01529724 03/15/12 03/15/13 $1,000,000 PD Ded. $10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Blanket additional insured status per Nautilus EPCO1004 (10/06): Blanket Waiver of Subrogation per Nautilus ENV2004 (09 /06)Coverage is primary and non - contributory Class 95630 Hazardous Materials Contractors is included in General Liability policy listed above. CERTIFICATE HOLDER CANCELLATION Sample for Bidding Purposes SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p g Ur p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S307215/M307123 MEH \1assachuctts - Department of Public Safct■ Board of Building NC2t1I ttions and Standards Construction Supervisor License License: CS 62382 ANDREW H MIRKIN 299 TANGLEWOOD DR LONGMEADOW, MA 01106 Expiration: 10/31/2013 t'nuunissionc•r TO: 4825 1 The Commonwealth of Massachusetts Department of Industrial Accidents 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 Le ibly Name (Business/Organization/Individual): Associated Building Wreckers, Inc. Address: 352 Albany Street City /State /Lip: Springfield, Massachusetts 01 105 Phone 11-: 413 732 -3179 Are you an employer? Check the appropriate box: Type of project (required): 1. H 1 am a employer with 26 _ 4. ❑ I am a general contractor and I have hired the sub- contractors employees (full and /or part - time). * 6. New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub - contractors have ship and have no employees 8. ® Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition No workers' comp. insurance comp. insurance.+ required.] 5. [ We are a corporation and its 10.0 Electrical repairs or additions 3. n 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MCA, 12.0 Roof repairs insurance required.] c. 152, § 1(4), and we have no employees. [No workers' 13.1 Other comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. ' I lomeowners 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: Great Divide Insurance Company WCA 154516510 02/01/201/ Policy // or Self-ins. Lie. #: Expiration Date: .lob Site Address: '�, .. t ( H. `( Oc -Ad. G ) City /State /Zip: � � u ;., AA 01000 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 line up to 51,500.00 and /or on 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 e violator. 13c advised that a copy of this statement may be forwarded to the Office of Investigation the DIA for i urance coverage verification. / do hereby fy under the r, is a d / tallies of perjury that the information provided above is true and correct. y` Si ,nature: w Mirkin President Date:'` �` �'��: i Phone #: 413 732 -3179 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 #: Version! .7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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 I, , 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 Dale SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Andrew Mirkill 63282 License Number 352 Ibany Street Sping!ield, Massachusetts 01 105 10/31/2013 Addre .s Expiration Date (413) 732 -3179 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 Version 1.7 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 Associated Building Wreckers, Inc. Not Applicable ❑ Company Name: Andrew Mirkin Responsible In Charge of Construction 352 Albany Street Address — -- — — - - - - -- (413) 732 -3179 Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be tilled in by Building Department Lot Size 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 0 DON'T KNOW C) YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW C) YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW C) YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version!.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition Si Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description '- Demolish the building and remove all debris to Western Recycling, 120 Old Boston Road in Of Proposed Work: Wilbraham, MA y ' SECTION 5 - USE GROUP AND CONSTRUCTION TYPE '� `� USE GROUP (Check as applicable) I CONSTRUCTION TYPE A Assembly C3 A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 El F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 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: 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 nd 3 rd 3 d 4 th 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (0) 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 61 Municipal ❑ On site disposal system Version1.7 Commercial Building Permit May 15, 2000 Department use only C ity of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 2 2012 212 Main Street Sewer /Septic Availability Room 100 Water /Well Availability DEPT. OF BUILDING INSPECT .hampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON M,710,060 413- 587 -1240 Fax 413 -587 -1272 Plot/Site Plans OJT 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 This section to be completed by office 1.1 Property Address: Building #12 of the Former Northampton State Hospital ! Map Lot Unit Village Ilill Road Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ilospital Hill Development /MassDevclopmcnt 160 Federal Street I3oston, MA 02110 Name (Print) Current Mailing Address: (978) 784-2917 Signature Telephone 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $112,315.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 3 /11 01 or, This Section For Official Use Only Building Permit Number Date Issued Signature: L Building Commissioner /Inspector of Buildings _ — Date VILLAGE HILL RD BP- 2013 -0511 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38A - 050 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit # BP- 2013 -0511 Project # JS- 2013- 000816 Est. Cost: $112315.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: _ ASSOCIATED BUILDING WRECKERS INC 063282 Lot Size(sq. ft.): 27791.28 Owner: HOSPITAL DEVELOPMENT LLC Zoning: PV(100)/ Applicant: ASSOCIATED BUILDING WRECKERS INC AT: VILLAGE HILL RD Applicant Address: Phone: Insurance: 352 ALBANY ST (413) 732 -3179 Workers Compensation SPRINGFIELDMA01105 ISSUED ON:11/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: DEMOLISH BUILDING #12 FORMER STATE HOSPITAL 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 11/5/2012 0:00:00 $200.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2013 -0511 .� tj ( GJ� �' .2 APPLICANT /CONTACT PERSON ASSOCIATED BUILDING WRECKERS INC , O d4(" ADDRESS/PHONE 352 ALBANY ST SPRINGFIELD (413) 732 -3179 a " A7j PROPERTY LOCATION VILLAGE HILL RD MAP 38A PARCEL 050 001 ZONE PV(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �yd Fee Paid J Typeof Construction: DEMOLISH BUILDING #12 FORMER STATE HOSPITAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 063282 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: t/ 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.