31B-004 (10) Initial Construction Control Document
To be submitted with the building permit application by a
++l I Registered Design Professional
• ? for work per the 8th edition of the
. Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Clarke School Restoration & Renovations Date: October 1, 2013
Property Address: 47 Round Hill Road, Northampton,MA
Project: Check(x)one or both as applicable: New construction (X)Existing Construction
Project description: Structural repairs to existing wood and steel framing within existing sub-basement of Rogers Hall
Building. Refer to drawings SK-1 prepared by TEC Engineering and dated September 20, 2013.
I Anthony J. Papa MA Registration Number:46231 Expiration date: 6/30/2014 ,am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans,computations and specifications
concerning': SK-1 prepared by TEC Engineering and dated September 20, 201 3
Architectural X 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'.
,.v
Enter in the space to the right a"wet"or 04OF 1140,14
electronic signature and seal:
ANTHONY
PAPA
UGTUAL
Phone number: 860.522.3970 Email: ajpapa @tecengineering.net O�9�QISTSO∎
`8/ONAL0
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen,
provide a description.
Version 06_112013
The Commonwealth of Massachusetts
�._ Department of Industrial Accidents -
a° Office of Investigations
=e=f(�rIS .
-, r- 600 Washington Street
Boston,MA 02111
°„M www.mass.gov/dia •
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organi7ation/IndividuaI): " /I')at—f,Q £O4. f!`!/df'vh
Address: L 3 6 o_ -k,,in ir-e_ J e .
City/State/Zip: „‘,9cj ttdi /7i . Of 2' hone.#: 03 —3 7'V —3 9 ?2
Are you an employer?Check the appropriate box: Type of project(required): /,.
1.IA I am a employer with ill 4. 0 I am a general contractor and I
* have hired the sub-contractors 6. 0 New construction
employees(full and/or part-time).
2.El am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling.
ship and have no employees These subcontractors have. g. ®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.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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.
I do hereby certify the pains and penalties of perjury that the information provided above is true and correct
Signature: zlet, Date: /0 —'t " /3 .
Phone#: t/13 ~3 ?-Y-3, 7? -
Official use only. Do not write in this area,to be completed by city or town official.
i ! , , i , r 4 ■ .A . 1 f
i •
I ,
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
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
, as Owner of the subject property
hereby authorize to
act on my behalf,in all matters relative to work authorized by this building permit application.
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 of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:
.{� � t,/„Not Applicable ❑
Name of License Holder: P� J I t Y Lpte 'f, 7 "0 7 7/0
License Number
A 3 43 eks h«e, /Iv - 1.44c.h. X14 /M0443/3
Addr- Expiration Date
4. IA _14■11116. /J 3? -- 9??
gnature 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
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:
-P6 6 74Trm,h6n Not Applicable ❑
Name(Registrant):
Registration Number
Address
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..33 /
General Contractor
`r AV f r Lgrt;e 1 Not Applicable ❑
Company Name:
£Pcwf 4r`1i/)
Responsible In Charge of Construction
a3 Beek sh;re 54vi.hwilck 44.
.
Addr-
.� Alt JP VS-.37.Y-3P?
Signature Telephone
Versionl.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: 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 Q DONT KNOW 0 YES
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 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES Q NO
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
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 ® 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 EZ Repairs® Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. A�14�, a„ 8 e. .ms C tno( add 6()pp rr
Of Proposed Work: ad/urn n.S • L•o l' a■nia re p o i c 5 TI.€( Go4 a�
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 I ❑
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 ❑ 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
3rd 3`d
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 El Municipal ❑ On site disposal system❑
Version1.7 Commercial Building Permit May 15,2000
(� Department use only
l.E C ; i . y of Northampton
I OCT _
status of Permit:
,' I ': tiding Department Curb Cut/Driveway Permit -
1 212 Main Street Sewer/Septic Availability
2013 1 Room 100 Water/Well Availability
`id'o hampton, MA 01060 Two Sets of Structural Plans
Electric Run'
.,,,9&G r•r•: r o13 587-1240 Fax 413-587-1272 Plot/Site Plans
A O �rO
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
1.1,1Property Address:
7 This section to be completed by office
7 goo ! N 1'J' Rd Map 31-3 Lot 1 Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ksfro r t c. (Loynd/ X1,7) Svmmi# /776. /r144;./ -57` „4or1e5 a
Name(Print) Current Mailing Address:
11/3 - 7 .A6 _ 9 SO
Signature Telephone
2.2 Authorized Agent:
a,ni i Dodo,e />r6 /r414' $1 ,'r,ey 6''aid
Name(Print) Current Mailing Address:
e- 4'13 - >? - q 70 9
•
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building , IA) Co° (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 l jc� 0 7T
6. Total=(1 +2+3+4+6) Check Number 1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature: / f� /3 ae........,
Building Commissioner/Inspector of Buildings Date
47 ROUND HILL RD BP-2014-0389
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:renovation BUILDING PERMIT
Permit# BP-2014-0389
Project# JS-2014-000676
Est.Cost: $12500.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL MARTIN 077109
Lot Size(sq. ft.): 311018.40 Owner: HISTORIC ROUND HILL SUMMITT
Zoning:URC(100)/ Applicant: PAUL MARTIN
AT: 47 ROUND HILL RD
Applicant Address: Phone: Insurance:
23 BERKSHIRE AVE (413) 374-3927 0
SOUTHWICKMA01077 ISSUED ON:10/2/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 2 BEAMS & ADD SUPPORT
COLUMNS, CUT & REPAIR 5 STEEL COLUMNS
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 10/2/2013 0:00:00 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner