23B-046 (11) b
The Commonwealth of Massachusetts
=-- Department of Industrial Accidents
A. _:4`"_ Office of Investigations •
600 Washington Street
Boston,MA 02111 "
u. ' www.ntass gov/dia
-Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):.Kc l Li moat Q 1 a L lLs}Yu `l c vl I }(IC
Address: 5 cl i k P Y •
City/State/Zip:L: \f)t.;l_ ) t r Oki 2 Phone"#: ) C 00
Are you an employer?Check the appropriate box: : �'
. I am a general contractor and T Type of project(required).
l T am a employer with 4. ❑ g 6. ❑New construction
employees(full and/or part-time).* have hired the sub contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. tg Remodeling
*- ship and have no.employees These sub,contractors have .8. ❑Demolition
working for mein any capacity. employees and have workers' 9 ❑Building addition
(No workers'comp.insurance comp.insurance.1"
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,§1(4),and we have no
employees.[No workers' I3.0 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
1Contractors 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: A M t\.f 6.i `lNj(CI in(Q u )(-,(1 earl iJ1 tt •
Policy#or Self-ins.Lic.#:L)H - S � O) 0)a Expiration Date:• U ra-... t 3\ r t
kb Site Address:
0 la City/State/Zip:. \: ,?`{`rt IGtM ( l c'`` G'i
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
3 - *
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$1,50000 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 DLA for insurance coverage verification.
I do herebffy��certify under the pains and penalties of perjury that the information provided above is true and correct.
Sicnaturet ��Y\ c_'• Z'i Date: ? .. (i
Phone#: L)3 S q '-' +r.. G -
Official use only Do not write in this area,to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF NORTHAMPTON, MASSACHUSETTS
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT NUMBER: 13-055 DATE: August 13, 2013
PROJECT TITLE: Equipment Replacement Radiology Room 6—Ground Floor
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 SHALL PERFORM THE NECESSARY PROFESSIONAL
SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR BASIS
TO DETERMINE THAT 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:
1. 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
)AVIT OF COMPLETION AS TO THE SATISFACTORY COMPLETION AND
c�SAO\"P' - SS OF THE PROJECT FOR OCCUPANCY.
e� KArs <2- `if
<<,. "14, Subscribed and sworn to before me
4t No.8355 0l //1„„, „ .•''•'''•..:. day of �}uC,-u5fi 20 t3
WESTHAMPTON / ''� 1�1-Y A, �
MASSACHUSETTS +r �� �• ..S\,0 10N•F,.F :''
Fq1171 OF M o ” c?4 ry P`blic
----•. K•1 a os,AIA . Co ono ission expires on 11 I i( I
1. Off; . __... ,
'
Version1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes ® No 0
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
John Lombardi
! , as Owner of the subject property
hereby authorize Robert Langevin Jr. to
act on my 0 iii alfin all tters relative to w• authorized by this building permit application.
Signature • OA Date
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
Print Name
Signature of Owner/Ag Date
SECTION 12-CO TRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Robert Langevin, Jr CS-066195
License Number
5 Miller Street. Ludlow, MA C 1 056 12/08/2013
Address Expiration Date
(413) 547-2500
Si 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 0 No 0
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 ENCLOSED SPACE)
9.1 Registered Architect:
Richard Katsanos, AIA 64 Gothic Street. Suite 1. Northampton Not Applicable ❑
8355
Name(Registrant):
Richard Katsanos, AIA 64 Gothic Street. Suite 1. Northampton Registration Number
Address
(413) 584-7224 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
Raymond R. Houle Construction, Inc Not Applicable ❑
Company Name:
Robert Langevin Jr
Responsible In Charge of Construction
5 Miller Street. Ludlow, MA
Address
e' (413) 547-2500
Signat - ,/
Telephone
Version1.7 Commercial Building Permit May 15,2000
S. 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 O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O 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 0 , Date Issued:
C. Do any signs exist on the property? YES ® 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 0
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 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 151 Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description Limited Interior renovations to add lead line walls, door and window for equipment.
Of Proposed Work: •
SECTION 5-USE GROUP AND CONSTRUC ON TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 p A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
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 ❑ 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: 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
3 d 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 ❑ Private ❑ Zone Outside Flood Zone Municipal ❑ On site disposal system
Versionl.7 Commercial Building Permit May 15,2000
cic)\,t --- Department use only
City of Northampton Status of Permit:
2 1 2.013 :uilding Department Curb Cut/Driveway Permit -
auG s 212 Main Street Sewer/Septic Availability
Gas tnsPectton
plumbing& a "1060 , Room 100 WaterNVell Availability
Elect Plum 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
30 Locust Street Map Lot Unit
Cooley Dickinson Hospital
Zone Overlay District
Northampton,MA
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cooley Dickinson Hospital 30 Locust Street. Northampton
Name(Print) Current Mailing Address:
(413) 582-2312
Signature Telephone
2.2 Authorized Agent:
John Lombardi 30 Locust Street. Northampton
Name(Print) —s-D N,,/� r^5.1 Current Mailing Address:
582-2312
Signature �.�J Telephone(413)
SECTION 3-E TIMATE CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $33,600.00 (a)Building Permit Fee
2. Electrical $21,000.00 (b)Et Cost of
Construction stimated To from al (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection $1,800.00
6. Total=(1 +2+3+4+5) � , Check Number i IVIIIIFlfrSS`
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0236
APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC
ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 0
PROPERTY LOCATION 30 LOCUST ST-RADIOLOGY
MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(1)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out -��( d
Fee Paid 0/1/OO"'� o
Typeof Construction: RADIOLOGY-INTERIOR ENOVATION TO ADD LEAD LINE WALLS,DOOR&
WINDOW FOR EQUIPMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: AAA a/� ,(f ,,Q ,. �v
Owner/Statement or License 066195 �/W`^- 4,644 `efLe_ _ zi toe__
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
C--"/"'" /2"---/(1"-ji V 2.8113
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.
30 LOCUST ST-RADIOLOGY BP-2014-0236
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-2014-0236
Project# JS-2014-000390
Est.Cost: $56400.00
Fee:$338.00 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 - RADIOLOGY
Applicant Address: Phone: Insurance:
5 MILLER ST (413) 547-2500 O WC
LUDLOWMA01056 ISSUED ON:8/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:RADIOLOGY - INTERIOR ENOVATION TO ADD
LEAD LINE WALLS, DOOR &WINDOW FOR EQUIPMENT
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 8/28/2013 0:00:00 $338.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner