17D-012 (44) Li 1
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\7 Initial Construction Control Document
Ele 1'41 � � t.�,5 To be submitted with the building permit application by a
iiima t Registered Design Professional
1 for work per the 8th edition of the
:, IUM Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Meadowbrook Apartments Date:8-8-13
Property Address: 491 Bridge Road,Northampton, MA 01062
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Fire restoration of existing apartment building. The building will be repaired in two phases. Phase I
will repair eight resident units as well as the common areas, means of egress, fire alarm,exit signs,emergency lighting.
and fire extinguishers in common areas. Phase 2 will repair four resident units that were more heavily damaged, namely
Units 211, 212, 221 and 231.
I Daniel M. Skolski MA Registration Number: 20038 Expiration date: 8-31-14 ,am a registered design professional, and
I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
X Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
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 if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
3-�R
Enter in the space to the right a"wee'or c
electronic signature and seal: 6 � toe
, 'P f`
P
Phone number: 978-578-5748 Email: Daniel @dmsdesign.com
Mss'
Building Official Use Only
Building Official Name: Permit No.: Date:
, The Commonwealth of Massachusetts ,
-, . Department of Industrial Accidents
1 . � -,= Office of Investigations
i -xi 600 Washington Street
' / Boston,MA 02111
V: 4-' )
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): O� //('/E A. O,q 5 70,Z u G 7/o,
Address: `fie z5O)c 3OIa15
City/State/Zip: -S,'�✓� - t .1 ,e4 O N Phone#: �(3 - 7�� 7 L Sq
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
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. E]Remodeling
_- These sub-contractors'have
ship and have no employees 8. ❑Demolition
working for me in any capacity. employees and have workers'
g Y P h'• 9. Building addition
[No workers' comp.insurance comp.insurance.$ ❑
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
❑ I
J. am a homeowner doing all work ❑
myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.El 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).
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 co py of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do hereby certify under the poi s and penalties of perjury that the information provided above i true and correct.
S ///ignature: 4../17-"--4../17-"-- Date: /3
Phone#: 1'13 53s /5-5
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#:
Versionl.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 0
SECTION 11 OWNER:AUTHORIZATION TORE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _
_ __.. _.. __w.__ __,w_..._.._.__ a _».......__r-,_._.. _r. .. as Owner of the subject property
hereby authorize I 2
act on my behalf, in all matters relative to work authorized by this building permit application.
s f
Signature of Owner Date
- _ _ --
. __.._ ._ ._.._ 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 ofkerlu i,
I
.Yi� Q'gib..' )
Pri Name .. _ _______
t-e—ttt•-■• (51-61/4;--Signature Owner/Agent Date
SECTIO 12-CONSTRUCTION.SERVICES
10.1 Licensed Construction Supervisor: _ Not Applicable ❑
a €
Name of License Holder:l.�r..1G._Y� _.._6.f/4.... 4.�._�.��.�.,�_. ._ ,..
License Number
Address Expiration Date
tfr 3 S 3??1 51
Sig ature 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 ot 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 EICLOSED:SPACE)
9.1 Registered Architect:
,___,..._...,., _ _ _ , Not Applicable ❑
Name(Registrant): 1, _._M
Registration Number
Address 1 .._ _..,._.:,._._. ,. .,..
I Expiration Date
Signature Telephone
9:2 Registered Professional Engineer(s):
____.._,_. — _ __ F
Name Area of Responsibility
i
Address Registration Number
:
Signature Telephone Expiration Date
. i -
I
Name Area of Responsibility
Address • Registration Number
Signature Telephone Expiration Date ,..x.,__._,....:.�._.�,..__,..._..»._
,
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
_._ __ _ -- _.. -- _..___-, f __ ,_
Name Area of Responsibility
f
Address Registration Number
€
Signature Telephone Expiration Date
9.3 General Contractor
..,_.._, -COASTOZO C 11an)
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_Address_ -
�'-- , rL._ 1,14/3 S3 _
Signature Telephone
o
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON.ZONING ,,
Existing Proposed Required by zoning -,
This column tare filled in by
Building Department
Lot Size ,—_ _ wi . € __.
Frontage t . . ..... ._.._._ ._ ,_.•__ _ ._. .
•Setbacks Front _ ....,,., l
Side L: ....„.i R:€.. i L: ......_...__. R:L......,.. I s— .._..?
Rear .._.___a
Building Height _. 1 1„,,,__
Bldg. Square Footage € l�-- j.._ % 1.__._._._._: I I i.. _
Open Space Footage
of area minus bldg&paved
parking)
#of Parking Spaces ! l I...
Fill:
t 1
(volume&Location) . _....._... _. _..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO (3 DONT KNOW 0 YES 0
c.
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 Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES (3 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
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 ❑ Existing Wall Signs ❑ Demolition❑ Repairs73 Additions ❑ Accessory Building❑
Exterior Alteration ❑ xisting Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
,9 . W i .►d,--ups i _ _._.
Brief Descriptio enter a brief description here. . �
Of Proposed Wor :l l\ ,,.,. ,l� 4„,,..„4„,....1. V ._nS.I i 11 � of iC j / - °�i,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) 1 • CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
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 I ❑
U Utility ❑ Specify:
i
.
_____
. . .
M Mixed Use ❑ Specify: rw_ a.v _ _-_ , .._ _ __ _..
. .. .,
s 1
S Special Use ❑ Specify: �._ .,� r_.,_F�___ � _..
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: .....__ __ _,. __ _. I Proposed Use Group: L,..._
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 3
d_._._ _ ._______ _
2nd 2"
-... _...._ _.. ..___.._..._w....___..___. _Ii
I __.. -
w_.__
4m 4
th ,
I 7 1
Total Area (sf) Total Proposed New Construction 1,0
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 ____M „_' Outside Flood Zone Municipal ❑ On site disposal system
Versionl.7 Commercial Building Permit May 15,2000
r - z ,0 z.4 1 Departme(t.use onl s
I of Northampton Status gf�Pernrtif" x, V . f i1 ~
I dpi I epartment Cttrb"CuffDnvewa�i„Perm 4:A ',,, :1z4- ; ,
1 — _ -In Street -vi e(/.�'epti'Avallat3[litya�3'"�w&'4 -ot ,y",. z .. ,. tx z iJ it'!gym 100 Wate�NVell Rvailabllltyk .,xq E
Orf ailif ton, MA 01060 Two n5`ets of,StructurafPtans �� A!„1. ,��w `+=v'
a EleCtr�1 t:. phone 413-5;87- 140 Fax 413-587-1272 Plof/Site Plars.�q ; _ ,`
5
G, . - Jtions Other Specify £ .a> i z P , 4r,x ..r
APPLICATION TO CONSTRUCT,R - -IR,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
ME4be .detZ DK 4.Pq,Q7;4eA 7$ E Map Lot Unit
9/ A/L�r ,� /R cfi44� i
Zone
fob,-rwo ; pa O to6� j Overlay District
i .
. Elm:St:Distric -' C District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1/� 9 /
)111,./D0 ' ” S ✓A7io•�:NSSoc�� 7tS___ '_.4 ,f/ e.-•d-F_'�`/__F/��cnc; M,p ofobz..__.
Name(Print) ' Current Mailing Address: „ __.. W,' • .._...... _ .._
. Signaturztte Telephone
2.2 Authorize A.ent:
E V. 0. /t d € I it �ox eb/2,f s- �� filed az
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 TIMATED.CONSTRUCTION COSTS?
Item Estimated Cost(Dollars)to be ;- Official Use:Only
completed by permit applicant
1. Building S� gel S� (a)Building Permit Fee
2. Electrical (b)Estimated Total.Cost of s,F?/ .SI
•Construction from(6)
3. Plumbing 1 .Building Permit Fee
4. Mechanical(HVAC) _____. __ ..._..,
5. Fire Protection
6. Total=(1 +2+3+4+5) Ss g 2/ r S(. Check Number j/(99 6 143 'p1
This Section For:Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector,of Buildings Date
File#BP-2014-0351
APPLICANT/CONTACT PERSON KEVIN D O'BRIEN
ADDRESS/PHONE 66 GRALIA DR SPRINGFIELD (413)538-1556
PROPERTY LOCATION 491 BRIDGE RD-UNITS 211,221,231
MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 96 t3<?-
Fee Paid
Typeof Construction: REMONVATE UNIT 211 &INSTALL REPLACEMENT WINDOWS IN Unit 221 &231
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 49810
ROL,v4-4 3 sets of Plans/Plot Plan G7i6/C r C'
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
D- ay
111101"
Signature of Bu ding 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.
491 BRIDGE RD-UNITS 211,221,231 BP-2014-0351
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-012 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-2014-0351
Project# JS-2014-000593
Est.Cost: $58821.00
Fee:$352.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEVIN D O'BRIEN 49810
Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP
Zoning: URB(100)/WP(28)/ Applicant: KEVIN D O'BRIEN
AT: 491 BRIDGE RD - UNITS 211,221, 231
Applicant Address: Phone: Insurance:
66 GRALIA DR (413) 538-1556 WC
SPRINGFIELDMA01128 ISSUED ON:10/3/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE UNIT 211 & INSTALL
REPLACEMENT WINDOWS IN Unit 221 & 231
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 10/3/2013 0:00:00 $352.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner