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23B-046 (8) CITY OF NORTHAMPTON, MASSACHUSETTS CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 11-033R DATE: May 3,2013 PROJECT TITLE: Renovations for New Birthing Tub at LDR 1 and related LDR Room Showers PROJECT LOCATION: 30 Locust Street NAME OF BUILDING: Cooley Dickinson Hospital SCOPE OF PROJECT: Limited Interior Renovations IN ACCORDANCE WITH THE MASSACHUSETTS STATE BUILDING CODE, 780 CMR, CHAPTER. SECTION 116, I, RICHARD E. KATSANOS , MASS. REG. NO. 8355 , BEING A REGISTERED PROFESSIONAL ARCHITECT/ENGINEER, HERBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: 'ENTIRE PROJECT ARCHITECTURAL STRUCTURAL FIRE PROTECTION ELECTRICAL MECHANICAL OTHER (specify) FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICE AND ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT. I FURTHER CERTIFY THAT I SHALT-, PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR BASIS TO DETERMINE THAI' 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 116.2.2: i. Review of shop drawings,samples, and other submittals of the Contractor as required by the construction contract documents as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in appendix B. PURSUANT TO SECTIONS 116.2.3, I SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AND AN DAVIT OF COMPLETION AS TO 1141 SATISFACTORY COMPLETION AND s��RE92q .. ►. ESS OF THE PROJECT FOR OCCUPANCY. F • X1'co, '� .'1 A ` Subscribed and swc rn to before me 0' E ct No.8355 this 2' day of `v C;: 2013 ,o'��o0\c, R 2� WESTHAMPTON 4 x • �:��� � �/,Z MASSACHUSETTS idrii /" -- r L\;\-k1).1Akt ° OF MPSS !/ �— Notary Public ? Z.4,4 0 \f;� .'o ,% /s E. atsanos., 4IA My Commission expires on_ T •,'9RY PAC,' '' O0.(1VJ-f pJ,O � y I. �, Portl7umpton 1 fj: r�I�€ 3taa+.rhnsr(le' _ is DEPARTMENT OP BUILDING INSPECTIONS • 212 Main Street - Municipal Budding Northampton, Mass. 01060 IMO «'ORIQ R'S COMPENSATION UNSUlm NCE AFTIDAVIT (li ccnscrJpermn ttcc) with a principal place of-business/residence at: &��tom;, Mia ( \C (Phone=') 4i6-SA-1 -a5a-) (sr=t/c i ty/statcla p) do hereby certify, under the pains and penalties of-perjury, that X) I am an employer providing the following worker's colnocnscuon coverage for Ind' employees worong on'tiiis job. A.T.A. mat.--\ � ,.(0 . eu .. • ,a- tA.111 • (Insurum Comr..sv) (Policy Number) (r xpiration Date) ( ) Izm a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's coope,n_tadon policies: (2`Janjc of Concrnctor) (In--anc; ColnoanyfPoiic; NumbCT) ( _xviraecn Drib) (Name of Conu-acior) (tnsurnea ComDanyiPo!icv Number) (..voiration Date) (Name of Coan-aeto;) (1n ur-ane: Company/Policy Nturbu) 1Expirbon Date) • (Name of Contractor) (Insurance Company/Poticy Number) Date.) (a txb Air;ocaJ Mom f oeoci.:-y to Cockade infort.n oo pertaining to all war_eora) • ( ) I arc a sole proprietor and have no one working for me. ( ) I am.a home owner performing all the work myself. NOTE:plcsc bc ew are tcZ..t-Jc bcmcrn+txn.vbo employ pctoat to do m_a_cm.muttoa,ccs woo e ft-,Air aof as.d.cWo of 0n1 more tla>;taste tai., a uajieb the botnooa-D0 rendo or 001E4 grouoda zppuricnz tbceo i-c co(ga--ilty oecnidard to bc employes,rrr'r the wiz-S="1 c c •,'m Act(G1-1.52_=1(5)),a pi3naoo by.bomroava for c bed_or permit tncy c vdeocc the Icgzi ciaoaa of m reaployer under ciao Wor4sla Coo pom.tioa Aux. I undo-o oc1 Mai a copy of tail ml.cmcn2 may be for-arurd.ed to tbo D•ganmcat of I.+a"rricl Acbdmte OIOoo of tcauanoe for the coverage vcrtrieyoo and that L•iliac to smtrc Mveca.Et under soczioo 25A of MOL 152 an lad to the izrxaitioa of azmtaJl pcttothct coo:sing of a fine of up to S1,500.00 arldror imprisoemocmi of up to ooc year e.od dvia pen do io the form of.Stop Wok Or and a rtnt o(S I WOO.dy ag7Liaa cx. / For dcoartm=LI uac only IPA Lot g Pei-mit NuinbCS Signature_of Li._ •c cc --�i3�te ls :: 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 0 SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 SLo ,i.∎^V , as Owner of the subject property hereby authorize Robert Langevin, Jr to act on my behalf,in al atters relative tle•r• = thorized by this building permit application. 05/08/2013 Signature of Owner / Date 1 John Lombardi , 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. John-Lombardi , i I. UNee\ Print Name / •Aif, � Pr , / 05/08/2013 1 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Robert Langevin, Jr CS066195 License Number 5 Miller Street 12/08/2013 Address Expiration Date (413) 547-2500 Signature Telephone SE • 13-WORKE- 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 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: '/ ` �y �y HPr 1 hf d \1 L v>� 1 Lhc rCJ f�ot1�.x..1► �1,�S Not Applicable ❑ Name(Regi trant): S W 6U 1 I/ C ' N o t-Crn p��n ` 1� Registration Number Address 1 J v J 413-s�s- �s Expiration Date � is 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 Raymond R. Houle Construction, Inc Not Applicable ❑ Company Name: Robert Langevin Jr. Responsible In Charge of Construction 5 Miller Street. Ludlow, MA Address (413) 547-2500 Signature Telephone Version1.7 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. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 Q 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 Q 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 0 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. 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 151 Existing Wall Signs ❑ Demolition 0 Repairs II Additions ❑ Accessory Building 0 Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Renovate existing shower rooms 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 I ❑ A-4 El A-5 ❑ 1B 0 B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional © I-1 p 1-2 El 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-i ❑ S-2 ❑ 5B J ❑ 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) 1st 1st 2nd 2nd 3rd 3rd 4th 4th 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 ZoneD Municipal ❑ On site disposal system 0 Version1.7 Commercial Building Permit May 15,2000 Department use only RECEIVED City of Northampton Status of Permit: 7 Building Department Curb Cut/Driveway Permit - V�V g 2013 i 212 Main Street Sewer/Septic Availability L �aN Room 100 Waterfell Availability T.OFBUILDINGLNSPECTIOJorthampton, MA 01060 Two Sets of Structural Plans 1•, - • c-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: Cooley Dickinson Hospital , Map Lot Unit 30 Locust Street 013 6014X. Zone Overlay District Northampton,MA y "' 1 `' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J i .-‘ 30 Locust Street, Northampton Name(Print) Current Mailing Address: (413) 582-2313 Signature Telephone 2.2 Authorized Agent: Robert Langevin Jr. 5 Miller Street. Ludlow, MA Name(Print) Current Mailing Address: (413) 547-2500 Signature /� �III Telephone SECTiefg3 STIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $70,600.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing $15,400.00 Building Permit Fee 4. Mechanical(HVAC) $17,500.00 5. Fire Protection 6. Tot -(1 +2+3+4+5) ' 1 1 5 i COO UU Check Number Slid 9I 7 7 C/ This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-1081 APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 0 PROPERTY LOCATION 30 LOCUST ST-OB UNIT 1ST FLR MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED E ZONING FORM FILLED OUT Fee Paid Building Permit Filled out alt�-}� � Fee Paid ,c G Typeof Construction: RENOVATE OB UNIT 1ST FLR SHOWER ROOMS New Construction Non Structural interior renovations - - Addition to Existing Accessory Structure - - Building Plans Included: Owner/Statement or License 066195 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASE' IN ATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ _ _ Intermediate Project: Site Plan AND/OR Special Permit With ' ,n Major Project: Site Plan AND/OR Special Permit With S. .a 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 i\ 1 ity Septic Approval Board of Health Well Water Potability Boar.'. ; :11th Permit from Conservation Commission Permit from CB Architect. r ::mittee Permit from Elm Street Commission Permit DPW Storm Watc r Lment j. .'tio- Delay ∎ ‘57-1 --(5 Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply I)' ing requirements and obtain all required permits from Board of Health,Conservation C, ,n,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40,'.. .:t Office of Planning&Development for more information. Ammanionminnommew 30 LOCUST ST-OB UNIT 1ST FLR BP-2013-1081 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B-046 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-2013-1081 Project# JS-2013-001782 Est. Cost: $115000.00 Fee: $690.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYMOND R HOULE CONST INC 066195 Lot Size(sq.ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC Zoning:M(99)/WP(21)/URB(1)/ Applicant: RAYMOND R HOULE CONST INC AT: 30 LOCUST ST - OB UNIT 1ST FLR Applicant Address: Phone: Insurance: 5 MILLER ST (413) 547-2500 () WC LUDLOWMA01056 ISSUED ON:5/20/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:RENOVATE OB UNIT 1ST FLR SHOWER ROOMS 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 5/20/2013 0:00:00 $690.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Anow