32A-140 (2) • :.:,,,,, .,,,,, _ , :„,,. ,_ f . '1 '';'t '.4'-''';' ."' " r". ';'%''''WP.P: '1 ', ': f ' :sf
Louis Hasbrouck i
Building Commissioner '
City of Northampton
212 Main Street 1 3/5/13
Northampton, MA 01060 °EF
" ` LI
RE: 109 Main St, Northampton
Walden Behavioral, Lower Level
Dear Mr. Hasbrouck
I am writing to kindly request that you 9 or the abo �e referenced project at 109 Main
requirement for control construction
Street in Northampton for Pioneer Contractors, of Easthampton, MA, who has
prepared the following project scope of work:
Scope: install 2 -90 min. Labeled doors & frames to separate Walden space from
Owner's basement area
I have toured the project with the project manager and believe the work is
of a minor nature, will not affect health, in that c oticontrol construction
fire safety, or
structural requirements and is impractical proposed work
is considerable when compared to the cost of the p ro p
Please except this stamped letter as consent that we allow for Pioneer
Contractors to oversee the construction and implementation of this project.
Thank you for your consideration.
Respectfully,
Tom Douglas
Thomas Douglas Architects
196 Pleasant Street
Northampton, MA 01060
196 Pleasant Street, Northampton, MA 01060 1 413 585 06412 I tdouglasarchitects.com
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''. .,csa DEPARTMENT OF BUILDING INSPECTIONS , t _ ' jj •
• 212 Main S t reet ' Municipal B u i lding
Northampton, Mass. 01060 ow '
WORKERS COMPENSATION 1NSURANC:E Aleie. iAVIT
I, Pioneer Contractors
(licensrdpermittee)
with a principal place of business/residence at:
P.O.. Box _1145 Northampton., MA_ 01.061 _ (phonet0 586 5491
(6trcet/ci ty/ staie/a p )
do hereby certify, under the pains and penalties of perjury, that:
(i I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Wcc 50059570120W., 6/�0/!r
Assnr^i atPd Employers Insttra a t^r, - - --
(Insurance Company) (Pohiry Number) (Expiration Darn.)
,
( ) 1 an a sole proprietor, general contractor orhomeo \veer (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (ExTiradon Date)
(Name of Contractor) . (Insurance Company/Policy Number) (Expiration Date)
(Name of Contactor) ( Insurance Company/Policy Numbe (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) ( Epiration Date)
(attach additiccat shot ifnoecaary to inc1Ude information pertaining to all contractors)
( ) 1 am a sole proprietor and have no one working for me.
( ) I. am a home owner performing all the work myself.
NOTE: plesac be aware nun wink bccncowners who employ person: to do osaintrasacr, oorrstruction or =pair work an a dwelling of
not mat than throe units in which the bomoovoscrmidcs or oa tha grounds appurtenant thereto arc not goa=ralty considered to be
employee under tbo worker's compensation Act (OL152,ss t (5)), application by a hotacoottxr for license cc permit may cvidcux the
legal stansa of an employer under the - Worker's Compecaatioa Act
1 understand thst a. copy of this mtcmaoi maybe forwarded to the Dopertmcoi of Industrial & its' Office of Insurance for the
coverage verification and that failure to nectar eovcntgo under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine ate? to S 1 ,500.00 and/or imprisocamont of up to coo year and civil pmaltia in the form of a Stop Work Order and a
find of 5100.00 a day against me
For dgA tmatal u►c only
/ Permit Number _ _
i � %1 4 / 4 Z / Maps _Iat
Sipe hire ofLicensee/Permi . - 1� e t__
•
- r
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Trident Realty Corp.
I, , as Owner of the subject property
'Pioneer Contractors
hereby authorize
act on my behalf, in all matters relative to work authorized by this building permit application.
'02/28/2013
Signature of Owner Date
Pioneer Contractors
1, as Owner /Authorized
�_ �. �.p_ _
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 th ms and pen ties , rjury._
Print Name
t>. S L� 02/28/2013
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : David A. Claxton CS- 017890
License Number
P.O. Box 1145 Northampton, MA. 01061 01/19/2014
Address Expiration Date
�P ;(413) 626-7267
Signatur 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 No
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
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
Pioneer Contractors Not Applicable ❑
Company Name:
;David Claxton
Responsible In Charge of Construction
' Box 1145 Northampton, MA. 01061
Address
•///' i g 4 /"'
(413) 586 -5491
Signature Telephone
Version!.7 Commercial Building Permit May 15, 2000
8, NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L. ��., R:'. L: _ ` R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)a�
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES C.) NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. Versionl.7 Commercial Building Permit May 15, 2000
4
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs II Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. Install two (2) new 90 min labeled doors & frames in existing
Of Proposed Work: openings.
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 GI 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A GI
1 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: Business ._`, Proposed Use Group: �Buslness
Existing Hazard Index 780 CMR 34): t 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
2 nd
2nd
3 r d
3 rd
__ .. 4 th
4 th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public p Private ❑ Zone' Outside Flood Zone is Municipal 12 On site disposal system
Versionl.7 Commercial Buildin: Permit Ma 15, 2000
� . i iD ep, ti tus0'01 .k
�---' City of Northampton Si
Building efirot r ",ti „� X0 , * 14 � /i
j Bui lding Department ,G j Ciitil ilV,, / , 'c it `` .14-li
i 2013 r %,,� � ;�, r , A, � u ;
212 Main Street eu f/ o ticAVafla! ilttir vit t z !A1�a; '�
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Room 100 tt�!`���`1�11�1�il�ilit� � ���1� ���i,, , ��,�
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oE�; �, �,�� >� ortham ton MA 01060 Twov � ' tr p , ('�s' kw � ��� t, ,�,A
N �ir�HrdFT'J p e 0 i h ii et i w ii 1 /� /i
phone 413 - 587 -1240 Fax 413 - 587 -1272 0 ef �y 94 ;a
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:
:109 Main Street -- Basement Map Lot Unit
' Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
:Trident Realty Corp. 150 Main Street Northampton, Ma. 01060
Name (Print) Current Mailing Address:
; (413)582 -9970
Signature Telephone
2.2 Authorized Apent:
Pioneer Contractors P.O. Box 1145 Northampton, MA. 01061
Name (Print) Current Mailing Address:
'(413) 586 -5491
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $1,600.00! (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 ` b! �
6. Total = (1 + 2 + 3 + 4 + 5) _ Check Number /�'1JS - 1 0` 17,
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
r
File # BP- 2013 -0792
APPLICANT /CONTACT PERSON PIONEER CONTRACTORS
ADDRESS/PHONE PO Box 1145 NORTHAMPTON (413) 586 -5491
PROPERTY LOCATION 109 MAIN ST
MAP 32A PARCEL 140 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Airs loz
Fee Paid
Typeof Construction: REPLACE 2 BASEMENT 90 MIN DOORS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017890
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFRMATION PRESENTED:
V 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
3 II it 3
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.
109 MAN ST BP- 2013 -0792
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 140 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2013 -0792
Project # JS- 2013- 001355
Est. Cost: $1600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER CONTRACTORS 017890
Lot Size(sq. ft.): 11325.60 Owner: NIS BUILDING LLC CIO HPMG
Zoning: CB(100)/ Applicant: PIONEER CONTRACTORS
AT: 109 MAIN ST
Applicant Address: Phone: Insurance:
PO Box 1145 (413) 586 -5491 Workers Compensation
NORTHAMPTONMA01061 ISSUED ON:3/11/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 2 BASEMENT 90 MIN DOORS
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 3/11/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner