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23B-046 (21) Standard General Contractors& .r Builders Construction Managers Since 1949 Standard Builders,Inc. 52 Holmes Road Newington,CT 06111-1708 Tel 860-594-7143 Fax 860-594-7151 www.standardbuilders.com 11/24/08 Cooley Dickinson Hospital 30 Locust Street Northampton,MA Early Interior Demolition Phase List of Sub Contractors for Permit information Mechanical Contractor to make"Safe"(Time and Material Basis) HVAC/Plumbing M.J.Moran 4 South Main Street Haydenville,MA Phone: (413)268-7251 Fire Suppression Allied Fire Protection 11 East Fisk Ave. Springfield, MA 01 107 Phone: (413)788-9038 Electrical Renaud Electric&Communications Providence Place Sutton,MA 01590 Phone: (508)865-1300 Serving Connecticut and Massachusetts The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 5-16-,a 1. ,e czg 1/V L Address: 62 4OLM&S. �� City/State/Zip: N 1yJ(�s d Phone#: (9&o)54--7J4-S Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ZI 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. WRemodeling ship and have no employees These sub-contractors have g. E]Demolition working or me in an capacity. employees and have workers' g y p �'• 9. E]Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. We are a corporation and its 10.El 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, §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 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: X1 "1-L�l � �l�sy�4s-1 ct-7 Policy#or Self-ins.Lic. #: vV l� �� 0�2��'j Expiration Date: © t� Job Site Address:So L (-UST S-r- City/State/Zip: 1��2 n�P�•J l�\r'C 010tiCD 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 er the p ns and penalties o erjury that the information provided above is true and correct. Signature: Date: Phone#: �/4__� 02T & 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 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property eby authorize act on my behalf, in all matters relative to ork thorized by this building permit application. ft— dan 224u�tq Signa ur of er Date Steven Glanzrock , 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 _ 11 L� O� _ Signature of O et Agent \ Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: Ed Ackley CS051113 License Number 52 Holmes Road,Newington, CT 061111 p 09/10/2010 Address Expiration Date (860)982-1895 Signature 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 Client#: 10084 STABU ACORDTM CERTIFICATE OF LIABILITY INSURANCE 10103108D"YY"") PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION RC Knox$Company,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE One Goodwin Square HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Hartford,CT 06103 4305 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 860 524-7600 INSURERS AFFORDING COVERAGE NA1C# INSURED INSURER A: National Fire Ins.Co.of Hartford Standard Builders,Inc. INSURER B: Valley Forge Insurance Company 52 Holmes Road Newington, CT 06111 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MMIDDIYY DATE MM/DDIYY LIMITS A GENERAL LIABILITY U2079807210 10/01/08 10/01/09 EACH OCCURRENCE $1000000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED s300 QQO CLAIMS MADE �OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY 0 PRO- JECT LOC B AUTOMOBILE LIABILITY 2079807224 10/01/08 10/01/09 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-_EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESSIUMBRELLA LIABILITY 2079807241 10/01/08 10/01/09 EACH OCCURRENCE $10000000 X OCCUR FI CLAIMS MADE AGGREGATE $10,000,006 DEDUCTIBLE $ X RETENTION $10,000 $ B WORKERS COMPENSATION AND WC279807238 10101108 10/01/09 X WC STATU- m- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SAMPLE CERTIFICATE DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30-_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE IL Corn pe- q ACORD 25(2001108)1 of 2 #M419489 DRD 0 ACORD CORPORATION 1988 Versionl.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: ,` n^•, �IL1G �f�'�'aF'risOS— ►'t�'PtL�TNL/}2!.'" ['�1G�.�kl 1 t �/.�� Not Applicable ❑ Name(Registrant): 6H ih r1iIC' C+T .So,W IAAM'PjDn3 M Registration Number Address f!� "j )3 Expiration Date Signature Telephone J� 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Arlo e-V 14b2 Signnaatur�eA Q / Telephone Expiration Date Name p , A� Area of Responsibility Address Registration Number ft; y13 IA5q/ 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 Standard Builders,Inc. Not Applicable ❑ Company Name: Steven Glanzrock Responsible In Charge of Construction 52 H ewington, CT 06111 p Addres Telephone Signature Version 1.7 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 DON7 KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON7 KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 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, grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO + 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❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description ;,Enter a brief description here. Of Proposed Work: 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 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 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 1 St _ 2nd 2nd 3rd 3`d 4m 4 m 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 Department use only City,of Northampton Status of perm it - Building Department curb Cut/Driveway Permit 212 Main Street Sewer/SepticAva11ab11{ty' "r`/ 2 ;; Room 100 WaterNVe})Availabili#}i Northampton, MA 01060 Two Sets of Structura{Plans phone 413-587-1240 Fax 413-587-1272 PlattS{te,;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 This section to be completed by office 1.1 Property Address: Cooley Dickinson Hospital] Map Lot unit 30 Locust Street Zone Overlay District Elm St.District` CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ Cooley Dickinson Hospital Name(Print) Current Mailing Address �1orZ��2N, ado gnature Telephone �- 2.2 Authoriz Agent: Steven Glanzrock 0 52 Holmes Road,Newington, CT p Name(Print) Current Mailing Address: (860) 594-7143 Signature Telephone SECTION 3 -ESTIMATED CONSTRUCT%N COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant y 1. Building 1)16G f" } / �} (a)Building Permit Fee G k� 2. Electrical (b)Estimated Total Cost of Construction from 6 - 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) Cc VA M f ( C it Z00 C 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0559 APPLICANT/CONTACT PERSON STANDARD BUILDERS ADDRESS/PHONE 52 HOLMES RD NEWINGTON (860)594-7143 PROPERTY LOCATION 30 LOCUST ST-NEW LINEAR ACCELERATOR MAP 23B PARCEL 046 001 ZONE M(99)/URB(1)//WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INT DEMO-BASEMENT NEW LINEAR ACC New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/Statement or License 051113 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 10 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. r <; t tTgT = W LINEAR ACCELERATOR BP-2009-0559 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0559 Project# JS-2009-000796 Est. Cost: $60000.00 Fee: $200.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin STANDARD BUILDERS 051113 Lot Size(sq.ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC Zoning M(99)/URB(1)//WP Applicant: STANDARD BUILDERS AT. 30 LOCUST ST - NEW LINEAR ACCELERATOR Applicant Address: Phone: Insurance: 52 HOLMES RD (860) 594-7143 WC NEWINGTONCT06111-1708 ISSUED ON:121212008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INTERIOR DEMOLITION AND UNDERFLOOR PLUMBING - BASEMENT NEW LINEAR ACC 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 12/2/2008 0:00:00 $200.0050211 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo