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Zbigniew W. Lewantowicz
Architect
INSTITUTIONAL • INDUSTRIAL COMMERCIAL • RESIDENTIAL
102 East Street
Southampton,MA 01073
(413) 527-0078 Fax(413)527-6735
May 17, 2013
Mr. Louis Hasbrouck, Building Commissioner
212 Main Street
Northampton, MA 01026
RE: Controlled Construction Exemption request
Dear Mr. Hasbrouck:
The following is my professional view and interpretation of Controlled Construction applicability for the
proposed project with respect to obtaining a building permit.
I have personally inspected the existing space to be utilized as a beauty salon space and feel that the
proposed work is of such minor nature that it would be impractical that controlled construction
requirements be required. The 325 square foot space will have a single ground level egress leading to a
public space, a staff toilet facility, and travel distance is less than distance of 25ft. Since the space is
accessible only by stairs it would be impractical to require any ADA accessibility requirements.
It also appears that the cost of the controlled construction requirement will be a considerable expense
when compared to the actual cost of the proposed project work.
Since the proposed work on space will not affect health, accessibility, life and fire safety, or any structural
requirements of its intended occupancy and use I request that your office grants a waiver to the controlled
construction requirements.
If you have any questions on any aspects of my code interpretations and this request please contact me.
Zbigniew Lewantowicz
architect - �''�—
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
r7 600 Washington Street
- y Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):_ I l\) Cu ,k I k 11.)
Address: -7 2 \ 1 ZLv j C)
City/State/Zip: -4'x.11\; 0-ft i.Q Phone#: `Ai3 — 330 L(
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 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
2. t.74 I am a sole proprietor or partner- listed on the attached sheet. 7. VRemodeling
Demolition have t
These sub-contractors ave 8.
ship and have no employees ❑
working for me in any capacity. employees and have workers'
g Y P ty. 9. ❑Building addition
[No workers'comp.insurance comp. in urance.$
required.] 5. [] We are a corporation and its 10.0 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 12.0 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
_. 13.0 Other
employees. [No workers'
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 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:
Policy#or Self-ins.Lie.#: 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 ,ains and penal. ,f perjury that the information provided above is true and correct.
,
S i•nature: Date: / L(/a4`E ? 20 13
Phone#: 913 S30 -
S: ,
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#:
Versionl.7 Commercial Building Permit May 15,2000 t
..
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 1.10.11)
Independent Structural Engineering Structural Peer Review Required • Yes Q No
SECTION 11 -OWNER:AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
\(\1\ v/ _ s w. --.-. _ ,as Owner of the subject property
hereby authorize'. .-.. S?vVV1,¢- _ _��. _ _ _ __ __._ �_ ._._ - — �._ _W,�to
act o �j;,ehalf,in all matter ativ- to work authorized by this building permit application. �(
A.,..... _ , ' a T \ I\\\77
Signature of Owner j . date
67
__�. 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 th i s and penalties a 'u
Print Nam l / / _ _. _
. �c (
Signature 3,----•
Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑ _
Name of License Holder.1.v ‘LL` C7) NI — ,�_£ c----5 L_Wel 5_;l __.. ._
License Number
:7 Z . _fi?ui\l? ,_ Slyz i 6 F t I 0. 1N-1 I . 61011 'o z a j _-_--
_ . T . _�
Expiration Date
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 No
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 Et4SLOSED SPACE)
9.1 Registered Architect:
- — Not Applicable ili
. . I
Name(Registrant):
_. __ _ ____.___.__ *.
Registration Number
Address � __._,....._�,..__.__... _._.......,_..._._.
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
_ _ _._ .. ___. i
Name Area of Responsibility
Address _ Registration Number
I ; 3
I
Signature Telephone Expiration Date
i
Name Area of Responsibility
i
! _
Address Registration Number
I
i
—
Signature Telephone Expiration Date
f
Name Area of Responsibility
Address Registration Number __
1_,... ..,_ ._.._....n_.._,
Signature Telephone Expiration Date
9.3 General Contractor
3
X ) k^l- Apr\_H NI' .,.._- _ Not Applicable ❑
Company Name:
\_6=31" _ CO ! T
Responsible In Charge of Construction _ C1
gddrea&
Signature Telephone
,
Version1.7 Commercial Building Permit May 15,2000
•
8. NORTHAMPTON.ZONING J
Existing Proposed Required by zoning ,
This column tore filled in by
Building Department
Lot Size i _________
Frontage .. _.." _...._._ _.__ __ ___..__ __ _
Setbacks Front { I ' 1_ ' i
Side L: � ` R:i t L:l 1 R:i I l
Rear t___.._
Building Height ,_
Bldg. Square Footage --; I-------- % 1---7 i E
Open Space Footage , % , s
(Lot area minus bldg&paved i i + i i I I
parking)
1 1 ( _ i- j 1
#of Parking Spaces
Fill:
I
(volume&Location) _ ----" __
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 6 YES 0
r
IF YES, date issued: i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW :;:`'D YES
IF YES: enter Book ! ` Page. ' and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ;,l 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 S NO 0
IF YES, describe size, type and location:
0 D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
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 Q NO It
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 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 El Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. vosk i, s a�"'.�,a ,roo' t ;
Of Proposed Work: �chv,c `.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 El A-3 ❑ IA El
A-4 ❑ A-5 ❑ 113 ❑
B Business f4 2A
E Educational ❑ 2B - ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
.
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 El 5B ❑
U Utility ❑ Specify:j
M Mixed Use ❑ Specify:
i
S Special Use ❑ Specify:If I
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):w._. ,,.__:. _ Proposed Hazard Index 780 CMR 34):L.. _. _
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USEONLY
Floor Area per Floor(sf)
1st 1
1
st
2" . ....___ _ 2nd
3rd ._-- .__ .. 3rd =■
4th _ 4th 3__—._—_—_-._.__._ —
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 in Private ❑ Zone'_., ____ Outside Flood ZonefZj MunicipalI_ On site disposal system I=1
Version1.7 Commercial Buildin. Permit May 15,2000
eQ City of Northampton ' - u
QaCj Building Department ,
212 Main Street _ g
203 Room 100 x
MPS m �5 �,
s Northampton, MA 01060 �� � �
of B���Oj�ao°o60 e 413-587-1240 Fax 413-587-1272 4 . - � ff t
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:
iy il
74-4-06,0-
ICt C`�?( S'I�v�� Map Lot Unit
e C11 • i- Zone Overlay District
-- _- ' :'Elm:st District'' CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 O ner of Record: O �"� ___ -\A,45),(z _
Name(Pu Curre t Maili g Address: • O � (S
�, w► 4 t 3 s
.CZ` Signature �,a:,..A�...II. �rra- Telephone
\ , •
2.2 Authorized Agent
Name(Pant) Current Mailing Address: _ „a______..__ . (�/n( .Z
Signature ! Telephone
SECTION 3-ESTIMA CONSTRUCTION! OS1'S
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building i (a)Building Permit Fee
So C,
2. Electrical (b)Estimated Total Cost of
—1 SO i Construction from(6) ;_.__:..______..__..______.__.__......
3. Plumbing .�._._ Building Permit Fee _ ____..____.
4. Mechanical(HVAC)
5
-11. Fire Protection .. .._.____ ._.__U .__.__.._. __..___.;
6. Total=(1 +2+3+4+5) Check Number /220‘) Oi�
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1108
APPLICANT/CONTACT PERSON WILLIAM GIBSON
ADDRESS/PHONE 72 HARVARD ST SPRINGFIELD (413)330-5234
PROPERTY LOCATION 2 CONZ ST-UNIT 14A-MAPLEWOOD SHOPS
MAP 32C PARCEL 067 001 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 /0 Ss S
Fee Paid /„
Typeof Construction: INSTALL EMPLOYEE BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 45988
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Aar
■-- . • •• Delay
= S--,,'—/
nature o Bu ding 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.
2 CONZ ST-UNIT 14A-MAPLEWOOD SHOPS BP-2013-1108
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-067 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-1108
Project# JS-2013-001829
Est. Cost: $9250.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WILLIAM GIBSON 45988
Lot Size(sq.ft.): 30666.24 Owner: MAPLEWOOD SHOPS INC
Zoning: CB(100)/ Applicant: WILLIAM GIBSON
AT: 2 CONZ ST - UNIT 14A - MAPLEWOOD SHOPS
Applicant Address: Phone: Insurance:
72 HARVARD ST (413) 330-5234
SPRINGFIELDMA01109 ISSUED ON:5/23/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL EMPLOYEE BATHROOM
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 5/23/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner