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KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Contractor's Statement of Responsibility Each contractor responsible for the construction or fabrication of a system or component designated in the Quality Assurance Plan must submit a Statement of Responsibility. The Statement of Responsibility is required for Seismic Design Category C or higher. Make additional copies of this form as required. Project: Contractor's Name Address: License No.: Description of designated building systems and components included in the Statement of Responsibility: Contractor's Acknowledgment of Special Requirements 1 hereby acknowledge that I have received, read, and understand the Quality Assurance Plan and Special Inspection program. 1 hereby acknowledge that control will be exercised to obtain conformance with the construction documents approved by the Building Official. Signature Date Contractor's Provisions for Quality Control Procedures for exercising control within the contractor's organization, the method and frequency of reporting and the distribution of reports is attached to this Statement. Identification and qualifications of the person(s) exercising such control and their position(s) in the organization are attached to this Statement. 16 of 16 • KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Quality Assurance Plan — Seismic and Wind QUALITY ASSURANCE FOR SEISMIC RESISTANCE CHECK LIST [IBC 1705] Seismic Design Category C ❑ FOR SEISMIC DESIGN CATEGORY C OR HIGHER: Structural: ❑ The seismic- force - resisting systems ❑ Steel Braced Frames and associated connections /anchorage ❑ Steel Moment Frames and associated connections ❑ Shear walls: ❑ CMU ❑ Wood ❑ Concrete ❑ Diaphragms: ❑ Floor ❑ Roof ❑ Other: QUALITY ASSURANCE FOR WIND RESISTANCE CHECK LIST [IBC 1706] Wind Exposure Category B A A 0:1 QUALITY ASSURANCE PLAN REQUIREMENTS p a (A Quality Assurance Plan is required where indicated below) 0' Hahw o Q n X In wind exposure Categories A and B, where the 3- second -gust basic wind speed is 120 miles per hour (mph) (52.8 m /sec) or greater. X In wind exposure Categories C and D, where the 3- second -gust basic wind speed is 110 mph (49 m /sec) or greater. 1706.2 Structural Wood: (N /A) Continuous special inspection is required during field gluing operations of elements of the main windforce- resisting system. Periodic special inspection is required for nailing, bolting, anchoring and other fastening of components within the main windforce- resisting system, including wood shear walls, wood diaphragms, drag struts, braces and hold - downs. 1706.3 Cold formed steel light framed construction: (N /A) Periodic special inspection is required during welding operations of elements of the main windforce- resisting system. Periodic special inspections is required for screw attachment, bolting, anchoring and other fastening of components within the main windorce- resisting system , including shear walls, braces, diaphragms, collectors (drag struts) and hold- downs. 1706.4 Wind - resisting components: (N /A) Periodic special inspection is required for the following systems and components 1. Roof cladding. 2. Wall cladding. Prepared by: Building Code Official's Acceptance: 7 / #1 t, ignature D e Signature Date 15 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspections SEISMIC RESISTANCE - STRUCTURAL EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, TASK Y/N PERIODIC, COMMENTS AGENT AGENT COMPLETE IBC Section 1707 SUBMITTAL, QUALIFICATION D OR NONE 1. Special inspections for seismic resistance. Special inspection as specified in this section Seismic Design Category: B is required for the following: a. The seismic - force - resisting systems in structures assigned to N IBC 1707.1 - PE /SE or EIT Seismic Design Category C, D, E or F 2. Structural steel: Continuous special inspection for structural welding in accordance N P IBC 1702.2 - AWS -CWI with AISC 341. 3. Structural wood: a. Continuous special inspection during field gluing operations of N C IBC 1702.3 - PE /SE or EIT elements of the seismic- force - resist- ing system. b. Periodic special inspections for nailing, bolting, anchoring and other fastening of components N P IBC 1702.3 PE /SE or EIT within the seismic- force - resisting system, including drag struts, braces and hold -downs 4. Cold- formed steel framing: Periodic special inspections during welding operations of elements of the seismic- force - resisting system. Periodic special inspections for screw N N attachment, bolting, anchoring and other fastening of components within the seismic - force- resisting system, including struts, braces, and hold -downs 4. Seismic isolation system. Provide periodic special inspection during the fabrication and installation of isolator units and energy N N IBC 1707.8 dissipation devices if used as part of the seismic isolation system 14 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspections WOOD CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.6 SUBMITTAL, OR NONE 1. Fabrication of high -load diaphragms ,,s. a. Verify wood structural panel sheathing for grade and thickness N P IBC 1704.6 - PE /SE or EIT b. Verify the nominal size of framing members at adjoining panel edges N P IBC 1704.6 PE /SE or EIT b. Verify the nail or staple diameter and length N P IBC 1704.6 - PE /SE or EIT b. Verify the number of fastener lines N P IBC 1704.6 - PE /SE or EIT b. Verify the spacing between fasteners in each line and at edge margins N P IBC 1704.6 - PE /SE or EIT 2. Load Tests for Joist Hangers: Provide evidence of manufacturer's load test in accordance with ASTM D1761 IBC 1715 including the vertical load bearing capacity, torsional N S [submit ICBO - PE /SE or EIT moment capacity, and deflection characteristics when there reports] is no calculated procedure recognized by the code. 13of16 • KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspection Services FABRICATION AND IMPLEMENTATION PROCEDURES — WOOD TRUSSES EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.2 SUBMITTAL, OR NONE 1. Fabrications Procedures: Review of fabricator's written procedural and quality control manuals and periodic auditing of fabrication practices by an approved special inspection agency. At the Fabricator completion of fabrication, the approved fabricator shall N S shall submit PE /SE or EIT submit a certificate of compliance to the building code one of the two official stating that the work was performed in qualifications accordance with the approved construction documents. -0R- 2. TPI Inspection Program: Fabricator shall participate in the TPI Quality Assurance Inspection Program, and maintain a copy of the Quality Assurance Procedures N Manual, QAP -90. Submit copy of certificate. All trusses shall bear the TPI Registered Mark. 3. At completion of fabrication, the approved fabricator shall submit a certificate of compliance to the building N S IBC 1704.2.2 - PE /SE or EIT code official stating that the work was performed in accordance with the approved construction documents 12 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspection Services FABRICATION AND IMPLEMENTATION PROCEDURES — STRUCTURAL STEEL EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.2 SUBMITTAL, OR NONE 1. Fabrications Procedures: Review of fabricator's written procedural and quality control manuals and periodic auditing of fabrication practices by an Fabricator approved special inspection agency. At the shall submit completion of fabrication, the approved fabricator shall Y S one of the two SI 1 PE /SE or EIT submit a certificate of compliance to the building code official stating that the work was performed in qualifications accordance with the approved construction documents. -OR- 2. AISC Certification N 3. At completion of fabrication, the approved fabricator shall submit a certificate of compliance to the building Y S IBC 1704.2.2 SI 1 PE /SE or EIT code official stating that the work was performed in accordance with the approved construction documents. 11 (4'16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspection Services: Structural Steel Erection EXTENT: CONTINUOUS, AGENT VERIFICATION AND INSPECTION IBC Section Y/N PERIODIC COMMENTS AGENT QUALIFICATIO TASK 1704.3 SUBMITTAL, F OR N COMPLETED NONE 1. Material verification of high- strength bolts, nuts and washers: a. Identification markings to conform to ASTM AISC 360, standards specified in the approved construction y S Section A3.3 SI I PE /SE or EIT documents. and applicable b. Manufacturer's certificate of compliance required. ASTM material Y S standards SI 1 PE /SE or EIT 2. Inspection of high - strength bolting a: Snug -tight joints Y P SI 1 AWS /AISC -SSI b: Pretensioned and slip - critical joints using turn-of- nut with matchmarking, twist -off bolt or direct Y P AISC 360, SI 1 AWS /AISC -SSI tension indicator methods of installation. Section M2.5 c. Pretensioned and slip- critical joints using turn-of- IBC Sect. nut without match marking or calibrated wrench Y C 1704.3.3 SI 1 AWS /AISC -SSI methods of installation. 3. Material verification of structural steel and cold - formed steel deck: , , , a. For structural steel, identification markings to y I S PE /SE or EIT conform to AISC 360. AISC 360, SI 1 b. For other steel, identification markings to conform Section M5.5 to ASTM standards specified in the approved y S Applicable PE/SE or EIT construction documents. ASTM material SI 1 Standards c. Manufacturer's certified test reports. Y S SI 1 PE /SE or EIT 4. Material verification of weld filler materials: a. Identification markings to conform to AWS I, S AISC 360, PE/SE or EIT specification in the approved construction documents. Section A3.2 SI 1 b. Manufacturer's certificate of compliance required. and applicable Y S AWS A5 PE /SE or EIT documents SI 1 5. Submit current AWS D1.1 welder certificate for all field y S AWS D1.1 PE /SE or EIT welders who will be welding on this project. SI 1 6. Inspection of welding (IBC 1704.3.1): a. Structural steel: 1) Complete and partial penetration groove welds. Y C AWS -CWI 2) Multipass fillet welds. Y C AWS -CWI 3) Single -pass fillet welds> 5/16" Y C AWS D1.1 SI 1 AWS -CWI 4) Plug and slot welds. Y C AWS -CWI 5) Single -pass fillet welds< 5/16" Y P AWS -CWI 6) Floor and deck welds. Y P AWS D1.3 AWS -CWI b. Reinforcing steel (IBC Sect 1903.5.2): 1) Verification of weldability of reinforcing steel other than ASTM A706. Y P SI 1 AWS -CWI 2) Reinforcing steel- resisting flexural and axial forces AWS D1.4 ACI in intermediate and special moment frames, and Y C 318: Section AWS -CWI boundary elements of special reinforced concrete shear walls and shear reinforcement. 3_x.2 SI 1 3) Shear reinforcement. Y C SI 1 AWS -CWI 4) Other reinforcing steel. Y P SI 1 AWS -CWI 7. Inspection of steel frame joint details for compliance (IBC Sect 1704.3.2) with approved construction documents: W a. Details such as bracing and stiffening. y P SI 1 PE /SE or EIT b. Member locations. Y P SI I PE /SE or EIT c. Application of joint details at each connection. Y P _ SI 1 PE /SE or EIT 10 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspection Services LEVEL 2 REQUIRED INSPECTION OF MASONRY CONSTRUCTION (ESSENTIAL FACILITIES) EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.5 Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED SUBMITTAL, OR NONE 1. Compliance with required inspection PE /SE, EIT or provisions of the construction documents and N P ACI 530.1, 1.5 ICC -SMSI the approved submittals. 2. Verification of f and f� prior to N P ACI 530.1, 1.4B PE /SE, EIT or construction and for every 5,000 square feet ICC -SMSI during construction. 3. Verification of proportions of materials in PE /SE, EIT or premixed or preblended mortar and grout as N P ACI 530.1, 1.5B Pr P gr ICC -SMSI delivered to the site. ACI 501.1 PE /SE, EIT or 4. Verification of slump flow and VSI as N C - delivered to the site for self - consolidating grout. 1.SB.l.b.3 ICC-SMSI 5. The following shall be verified to ensure compliance: a. Proportions of site - prepared mortar, grout N P ACI530.1, 2.6A PE /SE, EIT or and prestressing grout for bonded tendons. ICC -SMSI b. Placement of masonry units and PE /SE, EIT or construction of mortar joints. N P ACI530.1, 3.3B - ICC -SMSI c. Placement of reinforcement, connectors ACI530, 1.12; PE /SE, EIT or and prestressing tendons and anchorages N P ACI530.1, 3.4, 3.6A - ICC -SMSI d. Grout space prior to grouting. PE /SE, EIT or ACI530.1, 3.2D - N C ICC -SMSI e. Placement of grout. N C ACI530.1, 3.5 - P ICC -SMSI or f. Placement of prestressing grout. N C ACI530.1, 3.6C - PE /SE or EIT g. Size and location of structural elements. N P ACI 530.1, 3.3F - PE /SE or EIT h. Type, size and location of anchors, including other details of anchorage of ACI 530 1.2.2(e), PE /SE, EIT or masonry to structural members, frames or N C 1.16.1 - ICC -SMSI other construction. i. Specified size, grade and type of ACI 530 1.15; PE /SE, EIT or reinforcement, anchor bolts, prestressing N P - tendons and anchorages. ACI530.1 2.4, 3.4 ICC -SMSI j. Welding of reinforcing bars. N C ACI 530 2.1.9.7.2, - PE /SE, EIT or 3.3.3.4(b) ICC -SMSI k. Preparation, construction and protection of masonry during cold weather IBC 2104.3, 2104.4; PE /SE, EIT or (temperature below 40 or hot weather N P ACI530.1 1.8C, - ICC -SMSI (temperature above 90°F). 1.8D 1. application and measurement of PE /SE, EIT or prestressing force N C ACI 530.1 3.6B - ICC -SMSI IBC 2105.2.2, 6. Preparation of any required grout specimens PE /SE, EIT or and/or prisms shall be observed. N C 2105.3; 1 ACI 530.1, ICC -SMSI 9 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspection Services LEVEL 1 REQUIRED VERIFICATION AND ISNPECTION OF MASONRY CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.5 Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED SUBMITTAL, OR NONE 1. Compliance with required inspection PE /SE, EIT or provisions of the construction documents and the Y P ACI 530.1, 1.5 SI 1 ICC -SMSI approved submittals shall be verified 2. Verification of f and f prior to PE /SE, EIT or construction except where specifically exempted Y P ACI 530.1, 1.4B SI 1 ICC -SMSI by this code 3. Verification of slump flow and VSI as C ACI 501.1 SI 1 PE /SE, EIT or delivered to the site for self - consolidating grout. 1.5B.1.6.3 ICC -SMSI 4. As masonry construction begins, the following shall be verified to ensure compliance: � , Y P ACI530.1, 2.6A SI 1 PE /SE, EIT or a. Proportions of site- prepared mortar. ICC -SMSI Y P ACI530.1, 3.3B SI 1 PE /SE, EIT or b. Construction of mortar joints. ICC -SMSI ACI530.1, 3.4, SI 1 PE /SE, EIT or Y P c. Location of reinforcement and connectors. 3.6A ICC -SMSI Y P ACI530.1, 3.6B SI 1 PE/SE, EIT or d. Prestressing technique. ICC_SMSI e. Grade and size of prestressing tendons and I P ACI530.1, 2.4B, SI 1 PE /SE, EIT or anchorages. ICC SMSI 2. During construction the inspection program shall verify: Y P ACI530.1, 3.3F SI 1 PE/SE, EIT or a. Size and location of structural elements. ICC -SMSI b. Type, size and location of anchors, including other details of anchorage of I P ACI530, 1.2.2(e), SI 1 PE /SE, EIT or masonry to structural members, frames or 1.16.1 ICC -SMSI other construction c. Specified size, grade and type of ACI530, 1.15, PE /SE, EIT or reinforcement, anchor bolts, prestressing Y P ACI530.1, 2.4, SI 1 ICC -SMSI tendons and anchorages. 3.4 d. Welding of reinforcing bars. Y C AC530, 2.1.9.7.2, SI 1 AWS -CWI 3.3.3.4(b) e. Preparation, construction and protection IBC 2104.3, of masonry during cold weather PE /SE, EIT or (temperature below 40 or hot weather Y P 2104.4 ACI530.1 SI 1 ICC -SMSI (temperature above 90°F). 1.8C, 1.8D f. Application and measurement of PE /SE, EIT or prestressing force. Y C ACI530.1, 3.6B SI 1 ICC -SMSI 6. Prior to grouting, the following shall be verified to ensure compliance: , Y P ACI530.1, 3.2D SI 1 PE /SE, EIT or a. Grout space is clean. ICC -SMSI b. Placement of reinforcement and ACI530, 1.13, PE /SE EIT, or connectors and prestressing tendons and Y P ACI530.1, 3.4 SI 1 ICC -SMSI anchorages c. Proportions of site - prepared grout and PE /SE, EIT or prestressing grout for bonded tendons. Y P ACI530.1, 2.6B SI 1 ICC -SMSI Y P ACI530.1, 3.3B SI 1 PE /SE, EIT or d. Construction of mortar joints. ICC -SMSI 7. Grout placement shall be verified to ensure PE /SE, EIT or Y C ACI530.1, 3.5 SI 1 compliance: ICC -SMSI Y C ACI530.1, 3.6C SI 1 PE /SE, EIT or a. Grouting of prestressing bonded tendons. ICC -SMSI 8. Preparation of any required grout specimens, IBC 2105.2.2, PE /SE, EIT or mortar specimens and/or prisms shall be Y P 2105.3 ACI SI 1 ICC -SMSI observed 530.1, 1.4 8 of 16 • KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspections CONCRETE CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.4 YIN PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED SUBMITTAL, OR NONE 1. Inspection of reinforcing steel, including ACI 318: 3.5, prestressing tendons, and placement. Y P 7.1-7.7 SI 1 PE /SE or EIT 2. Inspection of reinforcing steel welding in Y AWS D1.4 ACI SI I AWS -CWI accordance with Table 1704.3, Item 5B 318: 3.5.2 3. Inspection of bolts to be installed in concrete prior to and during placement of concrete where ACI 318: 8.1.3, allowable loads have been increased or where Y C 21.2.8 SI 1 PE /SE or EIT strength design is used 4. Inspection of anchors installed in hardened ACI 318: 3.8.6, concrete. Y P 8.1.3, 21 2 8 SI I PE /SE or EIT 5. Verifying use of required design mix ACI 318: Ch 4, Y P 5.2 -5.4 SI 1 PE /SE or EIT 6. At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength test, perform slump and air y C ASTM C31 ACI SI 1 ACI -CFTT or ACI content test and temperature STT 318: 5.6, 5.8 7. Inspection of concrete and shotcrete placement for proper application techniques ¥ C ACI 318: 5.9, SI 1 PE /SE or EIT 5.10 8. Inspection for maintenance of specified curing ACI 318: 5.11 - temperature and techniques Z P 5.13 SI 1 PE /SE or EIT 9. Inspection of Prestressed Concrete a. Application of prestressing force. N C - PE /SE or EIT b. Grouting of bonded prestressing tendons in ACI 318: 18.20 seismic force resisting system N C ACI 318: 18.8.4 - PE /SE or EIT 10. Erection of precast concrete members N P ACI 318: Ch 16 - PE /SE or EIT 11. Verification of in -situ concrete strength, prior to stressing of tendons in post- tensioned concrete and prior to removal of shores and forms beans N P ACI 318: 6.2 ACI -STT and structural slabs 12. Inspect formwork for shape, location and dimensions of the concrete member being formed. Y P ACI 318: 6.1.1 - ACI -STT 7 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspections SOILS & FOUNDATION CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.7, 1704.8, 1704.9 YIN PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED SUBMITTAL, OR NONE 1. Verify existing soil conditions, fill placement and load bearing requirements a. Verify materials below shallow foundations are adequate to achieve the design bearing Y P SI 1 PE /GE, EIT or capacity. ETT b. Verify excavations are extended to proper PE /GE, EIT or depth and have reached proper material. Y P SI 1 ETT c. Perform classification and testing of SI 1 PE /GE, EIT or compacted fill materials. IBC 1704.7 ETT d. Verify use of proper materials, densities and lift thicknesses during placement and Y C SI 1 PE /GE, EIT or compaction of compacted fill. ETT e. Prior to placement of compacted fill, PE/GE, EIT or observe subgrade and verify that site has been Y p SI 1 ETT prepared properly. 2. Verify driven deep foundation elements a. Verify element materials, size and lengths N - PE /GE, EIT or comply with the requirements. C ETT b. Determine capacities of test elements and PE /GE, EIT or conduct additional load tests, as required N C - ETT c. Observe driving operations and maintain complete and accurate records for each N C PE/GE, EIT or element. ETT d. Verify placement locations and plumbness, confirm type and size of hammer, record number of blows per foot of penetration, PE/GE, EIT or determine required penetrations to achieve N C - ETT design capacity, record tip and butt elevations IBC 1704.8 and document any damage to foundation element e. For steel elements, perform additional PE /GE, EIT or inspections in accordance with Section 1704.3 N ETT f For concrete elements and concrete- filled elements, perform additional inspections in N _ _ PE /GE, EIT or accordance with Section 1704.4 ETT g. For specialty elements, perform additional inspections as determined by the registered N PE /GE, EIT or design professional in responsible charge. ETT 3. Verify cast -in -place deep foundation elements: a. Observe drilling operations and maintain PE /GE, EIT or complete and accurate records for each N C SI 1 ETT element. b. Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock N C SI 1 PE/GE, EIT or (if applicable) and adequate end - bearing strata ETT capacity. Record concrete or grout volumes. c. For concrete elements, perform additional PE /GE, EIT or inspection in accordance with section 1704.4 N - SI 1 ETT 6 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Schedule of Special Inspections Qualifications of Inspectors and Testing Technicians The qualifications of all personnel performing Special Inspection and testing activities are subject to the approval of the Building Official. The credentials of all Inspectors and testing technicians shall be provided to the Special Inspector for their records. NOTE VERIFICATION THAT QUALIFIED INDIVIDUALS ARE AVAILABLE TO PERFORM STIPULATED TESTING AND /OR INSPECTION SHOULD BE PROVIDED PRIOR TO SUBMITTING STATEMENT. AGENT QUALIFICATIONS IN SCHEDULE ARE SUGGESTIONS ONLY; FINAL QUALIFICATIONS ARE SUBJECT TO THE DISCRETION OF THE REGISTERED DESIGN PROFESSIONAL PREPARING THE SCHEDULE. Key for Minimum Qualifications of Inspection Agents: When the Registered Design Professional in Responsible Charge or Special Inspector of Record deems it appropriate that the individual performing a stipulated test or inspection have a specific certification, license or experience as indicated below, such requirement shall be listed below and shall be clearly identified within the schedule under the Agent Qualification Designation. PE /SE Structural Engineer — a licensed SE or PE specializing in the design of building structures PE /GE Geotechnical Engineer — a licensed PE specializing in soil mechanics and foundations EIT Engineer -In- Training — a graduate engineer who has passed the Fundamentals of Engineering examination Experienced Testing Technician ETT Experienced Testing Technician — An Experienced Testing Technician with a minimum 5 years experience with the stipulated test or inspection American Concrete Institute (ACI) Certification ACI -CFTT Concrete Field Testing Technician — Grade 1 ACI -CCI Concrete Construction Inspector ACI -LTT Laboratory Testing Technician — Grade 1 &2 ACI -STT Strength Testing Technician American Welding Society (AWS) Certification AWS -CWI Certified Welding Inspector AWS /AISC -SSI Certified Structural Steel Inspector American Society of Non - Destructive Testing (ASNT) Certification ASNT Non - Destructive Testing Technician - Level II or III. International Code Council (ICC) Certification ICC -SMSI Structural Masonry Special Inspector ICC -SWSI Structural Steel and Welding Special Inspector ICC -SFSI Spray - Applied Fireproofing Special Inspector ICC -PCSI Prestressed Concrete Special Inspector ICC -RCSI Reinforced Concrete Special Inspector National Institute for Certification in Engineering Technologies (NICET) NICET -CT Concrete Technician — Levels I, II, III & IV NICET -ST Soils Technician - Levels I, 11, III & IV NICET -GET Geotechnical Engineering Technician - Levels I, II, I11 & IV Other 5 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Statement of Special Inspections (Continued) Special Inspector's /Agent's Final Report Project: Special Inspector or Agent: (name) (firm) Designation: To the best of my information, knowledge and belief, the Special Inspections or testing required for this project, and designated for this Inspector /Agent in the Statement of Special Inspections submitted for permit, have been performed and all discovered discrepancies have been reported and resolved. Interim reports submitted prior to this final report form a basis for and are to be considered an integral part of this final report. Respectfully submitted, Special Inspector or Agent: (Type or print name) Signature Date Licensed Professional Sea/ or Certification Number 4 of 16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Statement of Special Inspections (Continued) Final Report of Special Inspections (SSIC /SI 1) [To be completed by the Structural Special Inspections Coordinator (SSIC /SI 1). Note that all Agent's Final Reports must be received prior to issuance.] Project: Location: Owner: Owner's Address: Architect of Record: Gregory J. O'Conner Gregory J. 0 'Conner Associates, Inc. (name) (firm) Structural Registered Design Professional in Responsible Charge: Kevin P. Burlingame KPB Engineering (name) (firm) To the best of my information, knowledge and belief, the Special Inspections required for this project, and itemized in the Statement of Special Inspections submitted for permit, have been performed and all discovered discrepancies have been reported and resolved. Interim reports submitted prior to this final report form a basis for and are to be considered an integral part of this final report. Respectfully submitted, Structural Special Inspection Coordinator (Type or print name) (Firm Name) Signature Date Licensed Professional Seal 3of16 KPB Engineering Project: Building Two Atwood Drive Date Prepared: 9/21/12 Structural Statement of Special Inspections (Continued) List of Agents Project: Building Two Atwood Drive Location: Atwood Drive Northampton, MA Owner: This Statement of Special Inspections encompass the following discipline: Structural (Note: Statement of Special Inspections for other disciplines may be included under a separate cover) This Statement of Special Inspections / Quality Assurance Plan includes the following building systems: x Soils and Foundations x Cast -in -Place Concrete ❑ Precast Concrete System x Masonry Systems x Structural Steel ❑ Wood Construction ❑ Special Cases Special Inspection Agencies I Firm I Address, Telephone, e-mail 1. STRUCTURAL Special To Be Determined (TBD) Inspections Coordinator (SSIC) 2. Special Inspector (SI 1) To Be Determined (TBD) 3. Special Inspector (SI 2) 4. Testing Agency (TA 1) 5. Testing Agency (TA 2) 6. Other (01) Note: The inspectors and testing agencies shall be engaged by the Owner or the Owner's Agent, and not by the Contractor or Subcontractor whose work is to be inspected or tested. Any conflict of interest must be disclosed to the Building Official, prior to commencing work. 2 of 16 n.. N wy • • 2. REGISTERED ENGINEERS: KPB Engineering MASSACHUSETTS Kevin P Burlingame, P.E. CONNECTICUT (508) 667 -4159 RHODE ISLAND Consulting Structural Engineers -BANK AND LEGAL 211 FREEMAN ROAD, CHARLTON, MA 01507 INVESTIGATIONS INSPECTIONS - REPORTS Email: KPBEnglneer ing(agmall. cons - COMMERCIAL - INDUSTRIAL - RESIDENTIAL - OFFICE BUILDINGS - ENVIRONMENTAL Structural Statement of Special Inspections -STEEL - CONCRETE - PRESTRESSED Project: Building Two Atwood Drive - MASONRY - TIMBER DESIGN Location: Atwood Drive Northampton, MA - DETAILING SPECIFICATIONS Owner: - INSPECTION SUPERVISION - JOISTS This Statement of Special Inspection encompass the following discipline: Structural - TRUSSES - COMPOSITE JOISTS - ANALYSIS This Statement of Special Inspections is submitted as a condition for permit issuance in accordance with the MODIFICATION Special Inspection and Structural Testing requirements of the Building Code. It includes a schedule of Special MODIFICATION AND P P 9 q 9 P USE IN RIGID AND Inspection services applicable to this project as well as the name of the Structural Special Inspection Coordinator sEMU -RIGID FRAMES (SSIC) and the identity of other approved agencies to be retained for conducting these inspections and tests. - VIBRATION OF FLOOR SYSTEMS The Structural Special Inspection Coordinator shall keep records of all Structural inspections and shall furnish inspection reports to the Building Code Official (BCO) and the Structural Registered Design Professional in Responsible Charge (SRDP). Discovered discrepancies shall be brought to the immediate attention of the Contractor for correction. If such discrepancies are not corrected, the discrepancies shall be brought to the attention of the Building Official and the Structural Registered Design Professional in Responsible Charge. The Special Inspection program does not relieve the Contractor of his or her responsibilities. Interim reports shall be submitted to the Building Official and the Structural Registered Design Professional in Responsible Charge at an interval determined by the SSIC and the BCO. A Final Report of Special Inspections documenting completion of all required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted to the BCO prior to issuance of a Certificate of Use and Occupancy. Job site safety and means and methods of construction are solely the responsibility of the Contractor. Interim Report Frequency: X Upon request of Building Official or ❑ per attached schedule. Prepared by: Kevin P. Burlingame �� VIN P . ,t o� K (type or print name of the Structural Registered Design Ze`1` BUR ti Professional in Responsible Charge) o STRUCTURAL 9/21/12 ll� FO /STE" \ �'� Si ature Date S / pNgL LN Design Professional Seal Owner's Authorization: Building Code Official's Acceptance: Signature Date Signature Date 1of16 ..f 39 — e560 REGISTERED ENGINEERS MASSACHUSETTS KPB Engineering CONNECTICUT RHODE ISLAND Consulting Structural Engineers 211 FREEMAN ROAD, CHARLTON, MA 01507 RECE TEL. (508) 667 -4159 BANK AND LEGAL INVESTIGATIONS SEP 2 5 REPORTS INSPECTIONS Construction Control COMMERCIAL, OF BUILDING W SPE INDUSTRIAL, RESIDENTIAL AND NORrp�� A OFFICE BUILDINGS Project Number: ENVIRONMENTAL AND j MISCELLANEOUS Project Title: Buildin g Two Atwood Drive STRUCTURES STEEL Project Location: Atwood Drive, Northampton MA CONCRETE PRESTRESSED Name of Building: Building Two Atwood Drive MASONRY TIMBER Nature of Project: Structural design of a 3 story 45,600 square foot +/- (15,200 square foot plan DESIGN DETAILING area) building including spread footing foundations. SPECIFICATIONS SUPERVISION INSPECTION In accordance with Section. 105 and 107.6.2 of the Massachusetts state Building Code, 780 JOISTS, COMPOSITE CMR -Ei hth Edition, I, Kevin P. Burlingame, Registration No: 46050, being a registered JOISTS &TRUSSES g ANALYSIS, REPAIR professional engineer hereby certify that I have prepared or directly supervised the preparation of MODIFICATION AND P USE IN RIGID AND all design plans, computations and specifications concerning: SEMI -RIGID FRAMES VIBRATION OF FLOOR ❑ SYSTEMS Entire Project Q Architectural X Structural 0 Mechanical 0 Fire Protection 0 Electrical 0 Other For the above named project I certify that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, 780 CMR -Eighth Edition, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that I, or an authorized associate under my direct supervision and control, shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 107.6.2: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in Chapter 17. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the construction documents and this code. Pursuant to Section 1704.0, I shall prepare a Program of Structural Tests and Inspections which will be included with the permit application. I shall maintain records of tests and inspections provided to me by the Contractor and will submit these together with Progress Reports and pertinent comments to the Building Official promptly upon his/her request. Upon completion of the work, I shall submit a Final Report as to the satisfactory completion for the Program of Tests and Inspections and the readiness of the project for occupancy. Signature: fir_ -°'� 1 7, , IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 -S (2001/08) 2 of 2 #S171830/M165113 uuent #: 14215U HNMAS ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE 2 /YYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sullivan Insurance Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10 Chestnut Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 1010 Worcester, MA 01608 -2804 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Hanover Insurance Company R. P. Masiello, Inc. INSURER B: P 0 Box 742 INSURER C: Boylston, MA 01505 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRC DATE (MM/DD/YYl DATE (MM/DD/YY) A GENERAL LIABILITY ZHN5107086 11/30/11 11/30/12 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRFML4FS (Fa nc:rurrenral $1 00,000 CLAIMS MADE © OCCUR MED EXP (Any one person) $5.000 X PD Ded: $2,500 PERSONAL & ADV INJURY $1,000,000 _ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000,000 7 POLICY n JECT El LOC A AUTOMOBILE LIABILITY AMN5276062 11/30/11 11/30/12 COMBINED SINGLE LIMIT $1'000'000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ — X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) $ X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AU OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY UHN8186751 11/30/11 11/30/12 EACH OCCURRENCE $5,000,000 OCCUR n CLAIMS MADE AGGREGATE $5, 000,000 $ DEDUCTIBLE $ X RETENTION $ 0 $ A WORKERS COMPENSATION AND WHN5470185 11/30/11 11/30/12 X 1 TC i IMTTS 1 I ° FR EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER /MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of Liability Insurance for the Named Insured CERTIFICATE HOLDER CANCELLATION 10 Days for Non - Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 4 Qrw ACORD 26 (2001/08) 1 of 2 #S171830/M165113 KJA 0 ACORD CORPORATION 1988 The Commonwealth of Massachusetts D epartment of Industrial Accidents • �' << Office of Investigations 600 Washington Street .� Boston, MA 02111 www.mass.g,ov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): _ Address: as N CB . ads-x -4z ~I��`EG dN 01. 0/ S City /State /Zip: Phone #: 'i - 656 / Are you an employer? Check the appropriate box: Type of project (required): 1. 1SC I am a employer with ?�- 4 ❑ I am a general contractor and I 6. ® New construction employees (full and/or part- time).* have hired the sub contractors listed on the attached sheet. 7. ❑ Remodeling 2.0 I am a sole proprietor or partner- ship and have no employees These sub- contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ 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. ❑ 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. 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 nave 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: Version1.7 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 as Owner of the subject property hereby authorize , 2_ � ..� .` . % ,1A , __v M.a �... . .. _._..._ _._. . to act on my behalf, �� : re ative to work authorized by this building permit application.__ _ ____ __ , ____ Signature of Owne ate 1 !GClC.a01' _ EP ►rn/iSl Gt10 _._.___.__. ._..__.__._. _ _ .w__' , 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 andpenalties ofserj . . �.....__....,, „ , ____ ._ , .:.... _, ,.w _ ± r'a✓d?_ .m_a_...,.. . . _.___ _ . _ . .. .,_ . ,..__ _ .__ Print ._..__._..___ __v....._. .._.__,__.__ .........._..._. .__ ..._.M._w..___.. Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ..e. ,_ �(4) f CK., - License Number Address Expiration Date Signature Telephone SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M 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 r Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION:.SERVICES --FOR BUILDINGS -AND STRUCTURES SUBJECT TO CONSTRUCTION - CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF -84SLOSED SPACE) 9.1 Registered Architect: _._ ,......_ Not Applicable ❑ Name (Registrant): 33°t YYI &I SC" / ' c� MA 0/66%6 Registration Number Addres q,,.. .._____.- _ E Date Aii./ cab- 757 - / 37 'j ,h Signature Telephone A V( L— 9.2 Registered Professional Engineer(s): Name Area of Responsibility Z l ( f e•G (4t rea{ / 'L C el-E �'Y l✓�1 U /SCSI, w `4 tt_Ga. .... Address - Registration Number Signature I Telephone Expiration Date Name Area of Responsibility Address . Registration Number I Signature Telephone Expiration Date -_ Name . — _.� . _ _ . ._ _. ._.....�� ..... ._ ____�xa Area of Responsibility m._ w , „,. _ ..__. Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 Ge Contractor G4 1_ __ Not Applicable ❑ Company Name: Responsible In Charge of Construction 343 .... .^l sr _ o 1i`Z F .. _� v! Address • Signature Telephone Versionl.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING .o ; Existing Proposed Required by .honing . This column tore filled in by Building Department Lot Size _..._ .. Frontage Setbacks Front 4. Side .�..�. R:.___. L:.___ .. R: _.. ._.T Rear L _ _.. "._ __.._ Building Height ),kor Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved �w.... __r . °-. parking) # of Parking Spaces ` ' Fill: (volume & Location) A. Has a Special Permit / Variance /Finding ever been issued for /on the site? NO ( DONT KNOW YES 4 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES ►® IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO (3 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: _ C. Do any signs exist on the property? YES ( NO 0 W YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • Version 1.7 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 ❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work: SECTION 5 USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business I 2A El E Educational ❑ 2B ❑ F Factory F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ,,,,,,g, 3A ❑ 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 0 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): !,___'_._mm ...., w , SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) 1st - _.. _ . 1 st 5. SF f,,, 42 76 - 0 f) Ulf 2nd 2nd 1 S'Ooc, ' 3 0 G 00 x t 30 ____ __,-- 3rd 3 I c'005Ch. f (6,600 06 4m 4 Total Area (sf) Total Proposed New Construction ._ . _ Total Height (ft) Total Height ft m 13 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood_Zone Information: 7.3 Sewage Disposal System: Public g Private ❑ Zone _____ ,,, „__, Outside Flood ZoneD Municipal (I On site disposal system El Version1.7 Commercial Building Permit May 15, 2000 w Depar use City of Northampton Stat Perk�� _ 4 M i r� Building Department cry Cut� P tttz� t � . 212 Main Street Se /S tlt , od " A Room 100 WaterivielJAyatfabi1it Northampton, MA 01060 T vo She s of gtraeturaGPP � �`ipx { : phone 413- 587 -1240 Fax 413- 587 -1272 PiatISi Plans Oth er 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 -- Z 2 ItlTW'O�J 1 • Map `�' Lot ,FC tIV ;E3 Zone Over y D strict `‘) 1 2 2012 SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT DEPT. OFBUILDWGINS INSPECTIONS NORTHAMPTON. MA 01060 2.1 Owner of Record: r p r a ✓ -C D a Name (Print) Current Mailing Address: _. Li (.3 Z ? `Z.._ _...._ ___.___._.... Signature „ ' — ` __ Telephone 2.2 Authorized A nt: I 1'C1(0 a8 NtI06�t ba�rc ► 0► ____,.......; _ ....... Name (Pr 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 (a) Building' Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) __.._ __ -__e _.0 .: -w "•- 3. Plumbing i Building Permit Fee 4. Mechanical (HVAC) -..... __.._.._ ___.._ ....µ__ ..._.__.., 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 4 a� ex:r,. 0° Check Number 4/493 P $ s i This, Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date • C6N't"& c o Q.. fr f 6 tiAfil (f rJ File # BP- 2013 -0380 APPLICANT /CONTACT PERSON R P MASIELLO (I ADDRESS/PHONE P 0 BOX 742 BOYLSTON (508) 869 -6501 PROPERTY LOCATION 22 ATWOOD DR MAP 39 PARCEL 060 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ' H� r)Ey ( ZONING FORM FILLED OUT f Fee Paid k t n Building Permit Filled out .�/ �j Ati6 Fee Paid / T �/ J E , ti \ Oa Tvpeof Construction: CONSTRUCT 3 STORY 45,000 SQ FT BUILDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 43970 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON Nl'i INF ATION PRESENTED: �'C?;4 e� Iv �± Nr,tj r0 ' 1 -- 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 ALL_ z.45. 2 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. 22 ATWOOD DR BP- 2013 -0380 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39 - 060 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: NEW COMMERCIAL BUILDING BUILDING PERMIT Permit # BP- 2013 -0380 Project # JS- 2013- 000615 Est. Cost: $4000000.00 Fee: $16500.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R P MASIELLO 43970 Lot Size(sq. ft.): 194756.76 Owner: Oxbow Professional Park LLC Zoning: Applicant: R P MASIELLO AT: 22 ATWOOD DR Applicant Address: Phone: Insurance: P 0 BOX 742 (508) 869 -6501 WC BOYLSTONMA01505 ISSUED ON:3/1/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 3 STORY 45,000 SQ FT BUILDING 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 3/1/2013 0:00:00 $16500.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner