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CITY TH . T $�
Construction sebris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
----- -cover-ed=by a-Building Permit-shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A. , r
Address of Work:
The-debris-will be-transported S�y�A
The debris will be received at: •
Signature of P rmitA ficant l
— — `Date q� �ji` 3
Building Permit Number:
•
•
design
September 19, 2013
Mr. Chuck Miller
Assistant Building Commissioner
Office of the Building Commissioner
Puchalski Municipal Building architecture
212 Main Street
Northampton, MA 01060 design
planning
RE: Proposed Selective Demolition Work
Rogers Hall graphic design
Historic Round Hill Summit LLC branding
47 Round Hill, Northampton, Massachusetts
strategic consulting
Dear Mr. Miller,
research
I request that you grant a modification to waive the requirement for
controlled construction for the Selective Demolition Work being
proposed at Rogers Hall, 47 Round Hill, Northampton, MA. The
demolition work in question involves the removal of existing, non-
structural ceiling finishes on the third floor of Rogers Hall. This
request to waive the requirement for controlled construction is due to
the fact that the work is of a minor nature,will not affect health,
accessibility, life and fire safety, or structural requirements.
Thank you for your consideration.
Respectfully,
sstiilED �y£y
PH E ZERO DESIGN INC ce KIk
1
SJ•
M.'s Kimball, Jr. �4 t rx t)i A:As1;F
Pri cipal
Phase Zero Design,Inc.
Eight Wilcox Street
Simsbury,CT 06070
t 860 264 1624
f 860 264 1628
www phasezerodesign corn
.,-; The Commonwealth of Massachusetts
2
P- w-- Department of Industrial Accidents .
p ~'"'�T
k Office of Investigations
Huh rI .�-` t.
1" 600 Washington Street
x a
..� Boston, MA 02111
y, _�-' '� www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
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._ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
g Y p h'• 9. ❑Building addition
[No workers' comp.insurance comp.insurance.t
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. Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §I(4),and we have n o 13.❑ 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.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.
do hereby to pains and 'es of perjury that the information provided(above issttrue and correct.
Signature: Ste'' ` Date: `L �V
l
Phone#: 14 � — ? 34(1
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#:
Version1.7 Commercial Building Permit May 15,2000
J
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110 11)
Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0
SECTION 11 -OWNERAUTHQRIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR'BUILDING PERMIT .
1, - m__...... _ ,as Owner of the subject property
to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, _ ___ ._-.____._.....—. ._._. ,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 penalfies_ofwperjury.___ _,___ - ________ ,,.u.___._._:. ___..___.,
,
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.. .� _...._. K. .._...._, _. _.
License Num r
Addres p Expiration Date /�
.1.------ CI( C IV/d Signature Vz 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 EI!F,(',LOSEDSPACE)
9.1 Registered Architect:
`;----:_ ._.__._.._..._ Not Applicable ❑
j
Name(Registrant): ---
_.__..w,...._.___.___..........._..._.—._.___...._
Registration Number
Address
Expiration Date
i
Signature . Telephone
9.2 Registered Professional Engineer(s):
Name • Area of Responsibility
.. ...... ..:.. ...._ ..._......_-____.._._....... _..._________.__ ..w.__ .. _ _ w.M _. _ ___ _ _ _..._--_____..# _.__..__.._w.___.__....___._.._...._.____......._..._.___.._..._..._. .___.
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
1
Signature Telephone Expiration Date
Name Area of Responsibility
Address .___._ _ _.., Registration Number ___.._. .
i ,
,
Signature Telephone Expiration Date
.3 General Contractor
w S_
_---- __._ --- Not Applicable ❑
Company Name: _ _
Responsible In Charge of Construction
Conzfl
Address
i _________,
Signature .., Telephone
taLI 1
i
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by zoning ,
This column Mt.;filled in by
Building Department
•
Lot Size ___ __ _
Frontage . _ ,,.._:.__.._._.._.. ___ ._ _ ._ .._._. .. ..._�
Setbacks Front ,
Side L r._✓i R: — L:t�,_.J R ., J L
Rear
Building Height _ I „N
Bldg. Square Footage
Open Space Footage ,_
(Lot area minus bldg&paved 7 L
parking)
#of Parking Spaces --- I
Fill:
(volume&Location) _ . _
• A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
.IF YES, date issued: 4
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued: N µ
C. Do any signs exist on the property? YES (3 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.
A'
4
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 ❑ Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. << Z� - ��/
Of Proposed Wo — i
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ . A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - 1 ❑
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-i 0 S-2 ❑ 5B ❑
U Utility ❑ Specify:
i
M Mixed Use ❑ Specify:
S Special Use ❑ Specify ._�.__ ..._-,., .- _. ..w.�y_-.._ . ,....�__._.._.._.
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): ',..u___- __,_,w_ _ „..__...,...
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
,
st r..........,....
i
151 -
. ...._._- _ ...W...._.,..._._._..__.._...._...................
2nd 2nd }
3� _ _ _ 3rd _ __�
____ _.. _
4' 1 4th _.._.-------- _____—___ __—___
Total Area(sf) Total Proposed New Construction(sf)__
Total Height(ft) i -
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 ZoneD Municipal ❑ On site disposal system
4. t
Version1.7 Commercial Building Permit May 15,2000
17)plibilitiettt;uSeOfilyIl&lWV'i:0,:-.:-I:.t::'i.
V/ li'''' ' •
Status trtIR': fl.P4rrtliF4'.*- ,.. Ari,,'4, '`z,-,- Z'',.,*;M'.',!Aik0*-;]'-:,': :''''''-:k';:6:
r E C FA _._ i:.. jT. cub,/of Northampton 1;t42 , t
[...) i',, ;; uilding Department ei: ,,pvey,eyoiy,F71,. ; ,,z;z,:.::,.:,-,-,-.:=;;:::,.;;;; ;:h74,.
SEP 2
E0 2013.__
212 Main Street
'...,:kr.'::#!/$er:qq'MPYOOtti,,Y'IT:Y'P.:.'.'"*.''''- ':''I'''''''':' ,:. =e';: :::-c.
_..-1 No hampton, MA 01060
7riiii*.$0elotstructitrO',.Plops ,,,,,,,,,...„,,,,,, ,,.,,,,„.„.
Eiectric, Piurnbrig Fc,
-G0-144iiiic1111 87-1240 Fax 413-587-1272 i01441;;001-:a5qM.P:i' ::.,:;,k',:,.A.:6,',:;ti,'40;,.*:.A'i;i:-:::
Northan-Tton N,
96',01;',$1:aiN>f,4AfAt'4:-:4:AF;-,.FS:g,.',:,:',:%;;;:.:,:, :',,,,1:1,V;;;:i.,.,,N:;t:44;I:..,- ;.:,:..
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: ".....--- .2C. F...47.,.. .,....___JA.1.....L._,„,
6/6, '..--- ONO t-lt.(--.L- e-e0 i Map . Lot Unit
.,.
ciane.• Overly District
-- -- — -; Elm District St ., : CB District
...,
.. :. .... ,.. .: : ......,.,... ......._:-..:
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED..AGENT. : .:...:...:.
2.1 Own r of Record:
m
__________
_ ____ ____ ....,
Name(Print) e..........._ Current Mailing Address:
<-
- --F IP D C--)E. ,7 , , 11„__ P_..,E._.. ..„- -)::14
----7 i,,------_a:iikr-
Signatur- „„gaggilitf _-_1,-," Telephone 1413 - Q (9,- -)3444
2.2 Authorized Agent
7-- 1
T--- -- ..--- ------- ------- 4. -' 1
•: t pvrvi ......t------ -!------ i
Name(Print) Current Mailing Address: ,
1 Signature )?J 1T e Telephone (_41.3 __ 2j (.2,- -7 3 4
SECTION 3-ESTIMATED CONSTRUCTION COSTS:.•,. ...
Item Estimated Cost(Dollars)to be ...- .-. :. . . -:. Official Use Only
completed by permit applicant I:. ..-. . ::::.. • :' - : _.__._. _ ___.
1. Building
..._._. _ ..___ .
' (a) Building Permit Fee , . i • /....,_,., _____.... ,
,..„_._„,.,...S9...„.c.!,...._.. _.,,....
4 2. Electrical '''.---------- --77 (b).:Estimated.TOtal:COst of
I •• -
Construction•from(6)
3. Plumbing 7--- ---- I BOilding•Permit.Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5)
Check Number
This Section.Foe.official Use Only .
Building Permit Number . pate.
ilSsued
•
Signatur Opp
7----,e79(3
I/Mr V
B 43PirCommi sioneE/Inspector of Buildings Date
46 ROUND HILL RD-ROGERS HALL BP-2014-0348
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2014-0348
Project# JS-2014-000587
Est. Cost: $3000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CONRAD CHAFFEE 83320
Lot Size(sq. ft.): 311018.40 Owner: CLARKE SCHOOL FOR THE DEAF
Zoning:URC(100)/ Applicant: CONRAD CHAFFEE
AT: 46 ROUND HILL RD - ROGERS HALL
Applicant Address: Phone: Insurance:
131 BOWDOIN ST (508) 864-1941
SPRINGFIELDMA ISSUED ON:9/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:SELECTIVE INTERIOR DEMOLITION
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 9/20/2013 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner