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32A-124 (6) The Commonwealth of Massachusetts Department of Industrial Accidents _ 1� Office of Investigations • _:_�a_ 600 Washington Street —°'— Boston,MA 02111 :. °'y� ' www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organi7ation/Individual): / er4--ti 77D �U,y Address: `i /. City/State/Zip: Phone.#: llr S L ,- . © - 2I Are you an employer?Check the appropriate box: Type of project(required): // 4. I am a general contractor and I 1.1:1I am a employer with 6. gi 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. 0 Remodeling ship and have.no employees These subcontractors have g. CI Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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' 13.0 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. tContractors 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). r 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 cfey nder the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: % ` //' • 'o t..3 Phone#: AP ' `34-1 S — e?-0 / Official use only. Do not write in this area, to be completed by eity or town official I . 4 t Y ' , t S 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#: City of Northampton Town of Williamsburg (413)587-1240 office (413) 587-1272 fax On Mon, Aug 12, 2013 at 11:50 AM, Bruce Coldham, FAIA<bruce @coldhamandhartman.com>wrote: Louis, Louis — did you see this(sent previously on Monday Aug 5th last) Thank you for your supportive presence last week at the BBRS hearing. I know that you didn't support the application, but you said positive things about your expectations that this office would handle the project well So thank you for coming down and making the discussion a fulsome affair. I wanted now to apply for a building permit — which I believe I can do(or can have Jack do). I would like to have your review of the drawing set completed so that the constructor, Dave Cody of Cody Construction, can pick up the permit toward the end of the month. I have downloaded the Application and filled it out — except for signatures of the Owner and Constructor — both of which can be applied before the permit is issued. But I have some questions: 1. How many copies of drawings do you need? 2. Do some or all require my signature?(this is a building below the 35,000 threshold) 3. If so, do any require that signature to be"wet", or will an electronically applied signature suffice? 4. Does Ryan Hellwig really need to sign? I put his name there more FYI than for any continued responsibility that he will have. 5. Can the permit fee be calculated and paid as Dave Cody collects the permit? Thank you Bruce FYI —I have now engaged Carl Koslowski of Rybak Engineering to design the 13D system and Jack will review his experience with his current fire alarm service organization and then tell me whether they want to continue with that outfit or change to another. When that is decided I will set about finalizing a design proposal for an enhanced fire alarm system in the while building. (City of Northampton E-mail is a public record except when it falls under one of the specific statut ory exemptions.) (City of Northampton E-mail is a public record except when it falls under one of the specific statutory exemptions. ) (City of Northampton E-mail is a public record except when it falls under one of the specific statutory exe mptions.) Louis Hasbrouck<Iasbrouck @northamptonma.gov> August.13, 2013 9.58 AM To: Bruce Coldham, FAIA<brucecOcoldhamanriherlman,corn> Re:A2Z Addition — building permit application Bruce, Same drawings;just the initial and final construction control document. We don't need Ryan's signature as long as you're assuming responsibility fro his design (he's acting as your consultant). Louis Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413)587-1240 office (413)587-1272 fax On Tue, Aug 13, 2013 at 9:31 AM, Bruce Coldham, FAIA<bruce@icoldhamandhartm an com>wrote: Louis, Does that mean the same set of drawings — one original(wet-stamped)and an electronic copy, along with a construction control affidavit(I have downloaded"Construction Control Document"and will fill it out), and regular(say bi-weekly)reports of construction progress — which could be copies of my job site meeting notes? Does this change the need for Ryan to sign drawings and/or building permit application? Bruce On Aug 12, 2013, at 10:25 PM, Louis Hasbrouck<ft r>brouckt nortiharnptonrna.gov>wrote: Bruce, • I was mistaken in my earlier email. The project will require construction control, with stamped drawings and the control documents.The a2z building, at something over 9000 sf,will exceed the 35000cf threshold. Louis On Aug 12, 2013 4:58 PM, "Bruce Coldham, FAIA"<bmaceeiecoldhamandhartman.corn>wrote: Thanks Louis, Bruce On Aug 12, 2013, at 4:50 PM, Louis Hasbrouck<llrz sbr<u ck,wnortharnhtonma ftov>wrote Bruce, Sorry I didn't get back to you. You are correct that the job doesn't require construction control but we do want stamped drawings. We need 1 set of drawings to sign and an electronic set to store. The original set needs to be signed, and the electronic set can be a scanned, signed set or accompanied by a letter from you that you've prepared them. We don't need Ryan's signatures. We can do the fee when Dave drops off the permit as long as estimated costs are on the applications;the cost will be$6.00 per$1,000 of the estimated costs, including building,electrical, HVAC and sprinklers. Louis Louis Hasbrouck Building Commissioner City of Northampton 'o��cKAMpTO`� S ::'s' S +.. tCt`a r)jf Massachusetts At wi 11 ' DEPARTMENT OF BUILDING INSPECTIONS S1 212 Main Street • Municipal Building Northampton, MA 01060 �sd�y �j ji1 INSSPECTOR Louis Hasbrouck Fax: 413-587-1272 Chuck Miller Building Commissioner Phone:413-587-1240 Assistant Commissioner CONSTRUCTION CONTROL DOCUMENT (For professional Engineers/Architects responsible for Entire Project) th) Project Title: 2 006vr-i-ovvo,i- 5 �� Date: 41VC -- ��7 Project Location: 5 7 <q / e Map: Parcel: Zone: -14 8O° ap• .Scope of Project: d 4jO 5 r"'►f tid t 4 In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 107.6: çf;fVc.-ECoL- '!/ ' `'�! T f��j Mass. •Registration it 769 , Being a registered professional Engineer/Architect hereby CERTIFIES that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] ENTIRE PROJECT 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 practices and all applicable Laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 10.7.6.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed In a matter consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Sign:/re and S=al of s ed Prof- 9 ►" •• ?.`t /3 Day of AVCIU ' 20 r 0 :■•4/1., ; (seal) 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1rAt� V/• v\Y% , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to o k authorized by this building permit application. �'� t _ 1- 2: a - i3 Signature of Owner Date I, f*Ift/ 1h1__J2 41-A4-4 g -..' ' ,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. peVGE` COL.- Di-111<M Print Name (1A1144 " Signature of Owner/ ent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: a 4,"J (c G)/ _ �iy 6?"� / i License Number `� �v°L,i� Qc.'1 /� e(G .4c''Z�W�'� ,C) - c7 — ( 41 Address Expiration Date `/, 1-1/2- 3Yr 0)-0) Sian 41111 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 es No cof S' 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: 45eu r e4v _PA Not Applicable ❑ Name(Registrant): ' ^4rj ,4 4 � g j,` l S Registration Number L q4 Address I 7q4p (AWL—,/ .' . ;/ 4-14375411-361.1 Expiration Date �? g / 31 /2, t4. Sign-i re Telone 9.2 Registered Professional Engineer(s): fyiwki 41.45144/ t4 • 6 eirtt,o-ed. Name A i 1� 1 �, • / h ` #4 Area37sponsibC7' Address — Registration Number NS" ie -ePc'/ 413.58it-4 Signature Telephone Expiration Date Name Area of Responsibility Address Registratio• 'umber Signature Telephone xpiration Date Name Area of Responsibili Address Regist .n Number Signature Telephone Expiration Date Name Area of Responsibility Address Registrati.. lumber Signature Telephone Expiration Date 9.3 General Contractor �Q w, £'b�' to N =S"T Z�CT tO `� v C- Not Applicable ❑ Company Name: /' \f Pip Cwt 1 • Responsible In Charge of Construction -7 c na /5e44 ,,,,, nlif- 01007 Address r '/13-- 5ci(-0),..O( Signature IF Telephone OK Version1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by NO Building Department �f Lot Size 4 5—i 0; " O Ate,& Frontage q 15. N0 4 's*n ye Setbacks Front .54% Side L: RIS_ L: Rear 2S1 Building Height 901 C7 11 Blv 4.Squpg/14te CA 040 °lo Open Space Footage )/ /�' L °Io (Lot area minus bldg&paved /4 7%/ v f , %o 7 parking) Z 2 wTS5We�l #of Parking Spaces (2 77Tl i) -21 L) J/1/ . Zc Fill: (volume&Location) A Hasa qoecial Permit/Variance ending ever been issued for/on the site? NO Cr-0NT KNOW YES IF YES,, date issued: IF YES` Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: nod telole /•/ore C. Do any signs exist on the property? YES NO ute IF YES describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO IF YES describe size, type and location: E. Will the construction activity disturb(clearing, •r.11.1*,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 3 TS 5' Version 1 2 Commercial Building Permit May 15,2000 ,g�q SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 k e''-f1�J,��� ��j c IC/J,,_1C���=Q��``v Q CUBIC FEET OF ENCLOSED SPACE i• 1-.:16.. 'k'FJUGUJ'' ' t4'GJ cad •=:7// ' ' r�,;; f, Interior Alterations Existing Wall Signs Demolition Repairs Additions Accessory Building 35{0 Exterior Alteration Existing Ground Sign New Signs Roofing Change of Use Other Brief Description APP it/o'V oo 5 ,Dodge .1-, 'A rte; � Pgrl err l WeAsai/S/�'P)70L Of Pro osed Work: � AWIS t�� 'r) 4 O/7"/DJI/, L/V/,W OyTx;�p over /c' /J�/ /lik/fi av SPRe 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 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 X 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B I ❑ 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: if 3 (IQ/i#? fl iM� m/x Q Proposed Use Group: gO i a W/ (Nina" Existing Hazard Index 780 CMR 34): N Proposed Hazard Index 780 CMR 34): NA( • SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 15t *5-0 1St 11.3 0 toe gargle) 2nd 2 0 0 2nd 480 (/ ,ior) r 4," Total Area(sf) 7 >r0 Total Proposed New Construction (sf) /0 /0 Total Height(ft) 342 Total Height ft 3 0 7.Wat r upply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewa a isposal System: Public Private ❑ Zone Outside Flood Zone 1/ Municipal On site disposal system 24c Versionl.7 Commercial Buildin&Permit May 15,2000 �° _ Department use only �1 City of Northampton Status of Permit. I Building Department Curb Gut/Driveway Permit - AUG 2 3 2013 212 Main Street Sewer/Septic Availability Room 100 Water/Weli Availabili r DEPT.OF BLit ultiG lti�i'LCT1ONS N•rthampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON,M,: .• _ . ;-587-1240 Fax 413-587-1272 Piot/S to 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 5 7 l<'� t61 5 ""-_. Map Lot Unit • N v . y�M• Zone Overlay e y District (J Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5"7 Zj(wJ-r4Ati-_ ci< 4fe' .. LEA PiN1.1 �- . • Name(Print) Current Mailing Address: ICI, c,i 6 e, Signature Telephone 413 - 5-64 — *T177 (.c. /) 2.2 Authorized Agent �9 bT Name(Print) • (j�W4 5 � y Current Mailing Address: AM f .��� 1- A- v•oZ 11 - ham, V--34/-4 < = G) Signature Telephone SECTION 3-ES (MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / • 3o0 (a)Building Permit Fee 2. Electrical y (b) Estimated Total Cost of 4, �'c Construction from (6) 3. Plumbing / ( 8,a.v Building Permit Fee 4. Mechanical(HVAC) g • O'8'D tcT 5. Fire Protection 15; 700 �� 414 6. Total=( 7-1-10F it-'i. I CYO-its Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0215 APPLICANT/CONTACT PERSON FINN JACK V&PRISCILLA R TRUSTEES ADDRESS/PHONE 57 KING ST NORTHAMPTON PROPERTY LOCATION 57 KING ST MAP 32A PARCEL 124 000 ZONE CBC100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out „.5-03 4938 Fee Paid Typeof Construction: CONSTRUCT ADDITION&INSTALL ELEVATOR&SPRINKLER SYSTEM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License e]t� 3 sets of Plans/Plot Plan '/gyp ' 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 //bi" P/Z;:li 3 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. 57 KING ST BP-2014-0215 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 124 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2014-0215 Project# JS-2013-001524 Est. Cost: $240000.00 Fee: $938.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): Owner: FINN JACK V&PRISCILLA R TRUSTEES Zoning: CB(100)/ Applicant: FINN JACK V & PRISCILLA R TRUSTEES AT: 57 KING ST Applicant Address: Phone: Insurance: 57 KING ST NORTHAMPTONMA01060 ISSUED ON: TO PERFORM THE FOLLOWING WORK: CONSTRUCT ADDITION & INSTALL ELEVATOR & SPRINKLER SYSTEM: NFPA 13D system per BBRS Appeal 7/16/13 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 9/23/2013 0:00:00 $938.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner