38A-061 (4) L.A. Home Improvement
92 Beauregard Terrace
Chicopee, Ma. 01020
413.563.3355
Licensed& Insured
MA Reg#150361
lahorneimprv(a yahoo.corn
August 13,2013
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
I request that you grant a modification to waive the requirement for construction control of the
project at Smith College, Equestrian Center because the work is of a minor nature,will not affect health,
accessibility, life and fire safety,or structural requirements and is impractical in that the cost of control
construction is considerable when compared to the cost of the proposed work.
Thank you for your consideration.
Respectfully,
Karl F. Ferguson
The Commonwealth of Massachusetts
*_ Department of Industrial Accidents
lr y
;� ►� l Office of Investigations
_ 1 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: c�
A 1
City/State/Zip: \ y 'Phone #:q )3_ ;"(C),
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
Air a sole proprietor or partner- listed on the attached sheet. + 7 Ia Remodeling
s and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.111 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]+ employees. [No workers' 13.11 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 their workers'comp.policy information.
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#:
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 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, " ,__\� .`k \ 'C, `C.`<.. ` As...\ as Owner of the subject property
hereby authorize y1�`t,<....9 \` \'-<; ..Q\'> '(J ,.=� \` `S'C,,Q-'. .. .6�()tQ' R-S'-14vS'lto
act on my behalf, in all matters relative to work authorized by this building permit application.
S Fri BA £ 1f
Signature of Owner Date
I (�r'���_ (��� C , 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 he pains a d pe ies of perjury.
Print Name V
K�et F F� .6c soJ 22 %'C /3
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ` C--N...`( ..— V.. ..`C (..a.1/4',:...,4.• .M ( V ) 1
License Number
ls 3...S.'l< ,c („.\ L 4`C , S-,\`�\e_ ')\.' )Ci ) ').. ..)1..''
Address t7(02U 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 0
Version 1.7 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(Re.'.trant)
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professio •I Engineer(s):
Name ` Area of Responsibility
Address N Registration Number
Signature Telepi"ione 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 Registraation Number
Signature Telephone Expiration Date
9.3 General Co tractor
j`. Not Applicable ❑
Company tame:
Responsible In Charge of Construction
Address
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:
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 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book Page d/or Document#
B. Does the site contain a brook,'bociy of water or wetlands? NO 41 DONT KNOW YES
IF YES, has a permit been or need to'be obtained from e Conservation Commission?
Needs to be obtained Obtained 41111 , Date Issued:
C. Do any signs exist on the property? YES '`",,,NO
IF YES, describe size, type and iota in
D. Are there any proposed chang-. o or additions of signs intended for the property? YES NO
IF YES, describe size, We 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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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 PO Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. =' k '-'z-'`\''..�� \Z-`J., c a` ,
Of Proposed Work: �.�`� ∎\\ 't\� � k NCNO , � "C3 CV-t-',a - `S'� '''...r....-\.\\ c \ .\7 t
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE _
A Assembly I:3 A-1 ` ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ r --`. ~' 1 B ❑
�
B Business ❑ " 2A ❑
E Educational ❑ 7' 2B
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ 1-2 ,li I-3 ❑ 3B ❑
M Mercantile ❑ _ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ -2 ❑ 5B [ ❑
U Utility ❑ - cify:
\
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): 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)
-
st „*.,
1st 1 ,4
2nd >
3rd
3rd
th .�.`y
4th 4 ti
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 ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal systems
Version 1.7 Commercial Building Permit May 15,2000
1ECE 'r Departmentauseonly,
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
AUG 2 k ' I 212 Main Street ewer/SeptioAvaila ility
Room 100 Water/Well Ava lab lity
, o`�b Northampton, MA 01060 Two Sets of Structural'Plans , :.
phone 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
1.1 Property Address: This section to be completed by office
V( c \ \ Map 3 Lot Cp ( Unit
$ � �,� cZa� • Zone Overlay District
0/0(P's-3 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
< *k-- . Jk--K‘y'`c\ \ ,D(_ - v\3
Name(Print) Cj\■ tV. Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) 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 0 (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 _
6. Total=(1 +2+3+4+5) ? 5c:_ CO .CR Check Number //9'
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0221
APPLICANT/CONTACT PERSON KARL FERGUSON
ADDRESS/PHONE 92 BEAUREGARD TERR CHICOPEE (413) 563-3355 Q
PROPERTY LOCATION 178 WEST ST(EQUESTRIAN VIEWING ROOM)
MAP 38A PARCEL 061 001 ZONE URC(110)/RR(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �� 5
Fee Paid / ///���"`���
Typeof Construction: CHANGE CEILING TILES&INSTALL REPLACEMENT WINDOWS,DOORS&
CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 60171
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOvIATION PRESENTED:
4--"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
4000 it o itio_ Delay
/A#1.... (
. _AO' Ilir ' Z-;1 7:-.-/
Sig re of Buil a mg 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.
178 WEST ST(EQUESTRIAN VIEWING ROOM) BP-2014-0221
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-061 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-2014-0221
Project# JS-2014-000135
Est. Cost: $5900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KARL FERGUSON 60171
Lot Size(sq.ft.): Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning:URC(110)/RR(0)/ Applicant: KARL FERGUSON
AT: 178 WEST ST (EQUESTRIAN VIEWING ROOM)
Applicant Address: Phone: Insurance:
92 BEAUREGARD TERR (413) 563-3355 0
CHICOPEEMA01020 ISSUED ON:8/29/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CHANGE CEILING TILES & INSTALL
REPLACEMENT WINDOWS, DOORS & CABINETS
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 8/29/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner