25A-185 (8) The Commonwealth of Massachusetts
Department of Industrial Accidents
ii
=.s, - l Office of Investigations
=itt
° 1 Congress Street, Suite 100
e` Boston, MA 02114-2017
,;s�•v
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Gagne Mechanical Corporation
Address: 1156 Middle Road
City/State/Zip:Clarksburg, MA 01247 Phone #:413-662-2225
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 7 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub-contractors have 8. Li Demolition
working for me in any capacity. employees and have workers' 9. [' Building addition
No workers' comp. insurance comp. insurance.t
required.] 5. Q 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, §1(4),and we have no
employees. [No workers' 13.1=1 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 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:AEIC
Policy#or Self-ins. Lic. #:WCC5006822012013 Expiration Date: 1/27/14
Job Site Address: 45 Industrial Drive City/State/Zip:Northampton, MA 01060
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 certi under the pai and penalties of perjury that the information provided above is true and correct.
7/10/13
Signature: c 41 14&)L--- Date:
Phone#: 413662-2225
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes o No 0
SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l ,as Owner of the subject property
hereby authorize to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
N tS Li MA AM& ,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.
� ,,eiNk ) �,' iill.tIVI\4,
Print Nam
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: bay id 6003 17 0/7
License Number
/ Morin 24. , Mon roe , Iv q 0 1350 T( 13 'Ai
Address---. p Expiration Date
11�� (�.1vV\ ‘40-141-11 -19-10
Signature "�1 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 Q No O
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 i` ,A� / -1115V L l i)17144(Y) 1�y��/�{- Area of Responsibility
CIS`- W i A+I rJV ) C"L 1 1�4 /r
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
V-i`):3N41,3 45 Lv MN-NI k;"t- . Not Applicable 0
Company Name:
Responsible In Charge of Construction
tk 1Y-i ,-( sue "ST. Atn
Address
I-,)61-Q
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
Ii. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
CC ,y-}��p�This column to be filled in by
�Jfjt?. � of%ov 1 Building Department
+ � f f 1
Lot Size . ; _i
Frontage ,
Setbacks Front
Side L: -, R:' L:1 -- R•' 2
Rear >.__
Building Height
Bldg.Square Footage % --- ---
Open Space Footage
(Lot area minus bldg&paved t `
parking) -
#of Parking Spaces
Fill: i , t
(volume&Location) '' `
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 04‘.v, YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , 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 O NO
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 0 Existing Wall Signs 0 Demolition 0 Repairs 0 Additions 0 Accessory Building.
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use 0 Other 0
Brief Description 1Enter a brief description here.
nev,, -pre-Engine.°rea s4e.g.I buk.i I dirl 30' x"Ito'
Of Proposed Work:! E feCf icy)
,_A-o hOUS1- t)Aa.6-4-c_Locti--er -Weal-men-I. fac.i I sly. f
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly 0 A-1 0 A-2 0 A-3 0 1A I 0
A-4 0 A-5 0 1B
0
B Business 0 2A 0
E Educational 0 2B I 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 1-1 0 1-2 0 1-3 0 3B 0
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 0 R-3 0 5A 0
S Storage 0 s-i 0 S-2 0 5B
I 0
U Utility
Pk Specify:40 IN_ ere a<'c), On ColkMadiOir\ -Lincter
. ,
M Mixed Use 0 Specify: St..°os cot, __es Aki--t-
1
s Special Use 0 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 I
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
A at , 1th 07 agoaf
- -
2nd,
rcl '
4th ,
4th .
Total Area(sf) ; Total Proposed New Construction(sf)
'(91 agQ_ST
Total Height(ft) 1,
Total Height ft '304— Pea IC
. -
7.Water Supply(M.G.L.c.40,§64) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Private 0 Zone, : Outside Flood Zoned Municipal 0 On site disposal systems
Versionl.7 Commercial Building Permit May 15,2000
__� ~ '— Department use only
RECEIVED City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
JUL.2 20I3 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
DEPT.OF BUILDING INSPEC77014
Northampton, MA 01060 Two Sets of Structural Plans
�,�,droN_„amneahone 413-587-1240 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:
145 T—OCkiLS±ri a.4 br.1 VC— Map Lot Unit
N O(-fhOLrn(-fov1 , NW of at.D Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CUCD�. - Co i0..._cti:/-`64 VihI A)..c., 4S t:-a`s ,J\-(_. i \xx ., . , ,,i„,tp MIiwk
Name(Print) •12_.r..),j l5 W ` WV-5 Current Mailing Address:
Signature —. WS - Telephone
2.2 Authorized Agent:
%.11.1J r l)v76.. t
Name(Print) WcX74f )` Cu\PZar--'; kisl`--. Current Mailing Addres
C f.
Signature ---- --..w'''°-*– Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 4 icy Lob, Q`l (a)Building Permit Fee
2. Electrical 00 l (b)Estimated Total Cost of
Construction from(6)
3. Plumbing
19 r /-15- 00 Building Permit Fee
4. Mechanical(HVAC) 00 5.Fire Protection ' aO(,US(a . U
6. Total=(1 +2+3+4+5) _ / _ Check Number _ /
i- ion For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
GAGNE MECHANICAL CORPORATION
1156 MIDDLE ROAD
CLARKSBURG, MA 01247
RECEIVED
July 18, 2013 JUL : 2 2013
DEPT.OF BUILDING INSPECTIONS
NORTHAMPTON,MA 01060
Mr. Louis Hasbrouck, Building Commissioner
Puchalski Municipal Building
212 Main Street
Northampton, MA 01060
Re: Coca-Cola Refreshments, Inc., 45 Industrial Drive,Northampton
Dear Mr. Hasbrouck:
Enclosed for your review and acceptance please find a completed Commercial Building
Permit for the above-referenced address. This permit is to erect a pre-engineered steel building
on site in accordance with the permit granted to RH White for the foundation. Also enclosed
please find a stamped set of plans issued by Northern Building Systems, our Workers' Comp
Insurance Affidavit and a check in the amount of$1,140 for the permit fee.
Please do not hesitate to contact me should you need anything further to move ahead with
this permit.
Thank you for your assistance with this matter.
Very truly yours,
o
�z w ✓7 1 rtea.._r
■
Stacy Gagne .�
File#BP-2014-0081
APPLICANT/CONTACT PERSON WOODARD&CURRAN
ADDRESS/PHONE 980 WASHINGTON ST DEDHAM (781)251-0200
PROPERTY LOCATION 45 INDUSTRIAL DR
MAP 25A PARCEL 185 001 ZONE GI(101)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid +�� �f
Building Permit Filled out �rCJ d W
Fee Paid
Typeof Construction: CONSTRUCT 30 X 76 WASTE WATER TREATMENT FACILITY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolition Delay
4--j6-32 11113
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.
45 INDUSTRIAL DR BP-2014-0081
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 185 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2014-0081
Project# JS-2013-001315
Est. Cost: $442793.00
Fee: $1140.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WOODARD & CURRAN
Lot Size(sq. ft.): 948344.76 Owner: COCA COLA COMPANY THE ATTN:KYLE CARUTHERS
Zoning: GI(101)/ Applicant: WOODARD & CURRAN
AT: 45 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
980 WASHINGTON ST (781) 251-0200
DEDHAMMA02026 ISSUED ON:8/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 30 X 76 WASTE WATER
TREATMENT FACILITY
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 8/5/2013 0:00:00 $1140.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner