23B-046 (28) CITY OF NORTHAMPTON, MASSACHUSETTS
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT NUMBER: HAI-08-10 DATE: January 28, 2008
PROJECT TITLE: Renovations for New Toilet Room at Boiler Building
PROJECT LOCATION: 30 Locust Street
NAME OF BUILDING: Cooley Dickinson Hospital
SCOPE OF PROJECT: Interior Renovations
IN ACCORDANCE WITH THE MASSACHUSETTS STATE BUILDING CODE, 780 CMR,
CHAPTER, SECTION 416, I, RICHARD E. KATSANOS , MASS. REG.
NO. 8355 , BEING A REGISTERED PROFESSIONAL ARCHITECT/ENGINEER,
HERBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE
PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS
CONCERNING:
ENTIRE PROJECT ARCHITECTURAL STRUCTURAL
FIRE PROTECTION ELECTRICAL MECHANICAL
OTHER(specify)
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 PRACTICE AND ALL APPLICABLE LAWS FOR THE PROPOSED
PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL
SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR BASIS
TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE
DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE
RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.2.2:
1. Review of shop drawings, samples, and other submittals of the Contractor as required by the construction contract
documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required controlled materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in appendix B.
PURSUANT TO SECTIONS 116.2.3, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS
REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AND AN
AFFIDAVIT OF COMPLETION AS TO THE SATISFACTORY COMPLETION AND
READINESS OF THE PROJECT FOR OCCUPANCY.
�5kEp ARC Subscr andsVorn to before me M
thisay P ,._;a•�i..��,q��
C) ho.0355
EASTHAlJlPTON, ,�, Nota Public �°j
is rd E. Katsanos,AIA °y MA My Commission expires on Q
'Tay OF 9�5s @G �'qpy P���
The Commonwealth ofMassacRusetts
Department of Industrial Accidents,
Office of Investigations
d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeZibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. F� I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.
$ 9. �Building addition
required_] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 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.] I
'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 file
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 under the pains and penalties of perjury that the information provided above is true and correct
Si.mature: Date:
Phone#:
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#:
Ve6ionl.7 Commercial Building Permit May 15,2000
r
SECTION 10-:STRUCTURAL PEER RE171c1N"(780 CMR 19D 1j
Independent Structural Engineering Structural Peer Review Required Yes Q No Q
SECTION14=OWNER AUTHORIZATION-TO-'BE`-COMP.LErEO WHEN
OWNERS AGENT OR CONTRACTOL?-415kiES•FOR BUIL�TNG`PERMtT
I, 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
COI J /t � y�
f, C7 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.
Si ned un a pains and Dena.o dedurv.
j
Print Na
Z D �
Signature of(5wner/Agfek Date '
SECTJOE+[ 12-COASTRUCTl0MSERNICES
10.1 Licensed Construction Supervisor. Not Appficable Q
Name of License Holder:
License Nu ber
D OG(/ v/I-( cl ld ZO r �-9---
Address Expira on Date
Sg Z 3 !�
Signature Telephone
sECTION 13-11UORK 'GOMPEPISATfON INSUIUICE AI=FIDA/I�QII!
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
r
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSION.L DESIGN AND CONSTRUCTIOAtSERVICES-FORBUILDINGSrAND STRUCTURES° 1163ECTTO
CONSTRUCTION CONTROL PURSUANT'TO T80-CMR 116(CONTAINING_MORE THAN135,D00.C.F.OF ENCLOSED-SPACE)
9.1 Registered Architect:
Not Applicable ❑
i
Name(Registrant):
Registration Number
i I i
Address i
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
1
Name Area of Responsibility
Address !! P.egistration Number
t y j
Signature Telephone Expiration Date
j
Name Area of Responsibility
Address Registration Number
_ l
Signature Telephone Expiration Date
i
I
Name Area of Responsibility
Address Registration Number
i
Signature Telephone Expiration Date
9.3 General Contractor
i Not Applicable❑
Company Name:
E �
Responsible In Charge of Construction
r j
i I
Address
i
Signature Telephone
r .
Version 1.7 Commercial Building Permit May 15,2000
Al
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i � 7 '
Ez : ,
Frontage
Setbacks Front
r
Side L:' R: L: R:'
Rear j
But mg et s
Bldg. Square Footage S7,7,- F 1 %
Open Space Footage %
(Lot area minus bldg&paved
azldn )
#of Parking Spaces
Fill:
i
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued: G
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'f KNOW 0 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 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 i NO
IF YES, describe size, type and location: j
E. Will the construction activity disturb(clearing,grading,ex vation,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.
r
Jk
Version 1.7 Commercial Building Permit May 15,2000
SECTION1 CONSTRl7CTiON�EFtVICES"fORPROJECTS�ES$THAN 35,000
GtIBIG-EEET bOOCL(35ED Sl?ACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description lhnter a brief description here. Ro I lct 00- 13w J;; nd U1-1-7 )7Ai/ —/4,c
Of Proposed Work: 13o `,G ('UI
SECTION-5 USE-GROUP-AND-CONS ON WYK,
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A 71 ❑ A-2 ❑ A-3 ❑ 1 B ❑❑
A-4 ❑ A-5 E]
B Business ❑ — 2P` ❑
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:
0
M Mixed Use ❑ Specify.s
S Special Use Specify.
COMPLETE THIS_SEGTIT�N TF F,XISTlNG BUILDING 11NDERGOIIG RENOVATIONS;ADDITIONS ANDiOR CHANGE IN USE
Existing Use Group: 1 Proposed Use Group:
Existing Hazard Index 780 CMR 34).1 E Proposed Hazard Index 780 CMR 34):
SEC110N"'6 BUILDING,,HEIGHT ANDAREA;
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION =
Floor Area per Floor(sf)
ho
st � F
sr 1
nd
2js
3rd
3rd
4th ! 4th
Total Area(sf) I Total Proposed New Co struction s � r �� � ~
Total Height(ft) -
Total Height ft
7.Water upply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewa a Disposal System:
Public Private E] Z Outside Flood Zone Municipal On site disposal system E]
Versionl.7 Commercial Building Permit May 15,2000
City of Northampton `
B •ding Department
Main Street
21 -
�cl Room'100
';, ampton, MA 01060
P
-587-1240 Fax 413-587-1272
APPLICATION TO Cb�1S, RUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
r OTHER THAN A ONE OR TWO FAMILY DWELLING
l O`
SEC110TISITEt ^ ORMATION
ML
EM Q
111A olo 41-
� x� :S'Itis'sect►onto-be comp7etedb�office,
Slone �arerla�rD�snctT
SECTION 2 ,PROPERTY OWNERSHIPlAUTHORIZED AGENT
2.1 Owner of Record:
sue► s , , -� o 0C s�
T
Name(Print) Current Mailing Address:
{
Signature Telephone
2.2 Authorized Age nt:
Name(Print) Current Mailing Address:
r
i
Signature Telephone
SECTION--3----ESTIMATE NS UCTION�COSTS
Item Estimated Cost(Dollars)to be pfficial:Use{)rly
completed by ermit applicant -
1. Building Building,-Permit Fee
,
2. Electrical ; , (b)Estimated Total,Cost of`
�� C Construe onfrom:6
3. Plumbing Builriiig PeRnitl=ee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) -Chedk-Number !f
u is"Section For.:Offic�a!°Use On1
Bu�ldi49 Permit Number
Issued
Signature:
Building<Commissioner/inspector of-80dings Date
(�T-,)-v S /v-r–� /?o,V,4— "cwzl
File#BP-2008-0791
APPLICANT/CONTACT PERSON Scott Johnson/CDH /� IV
ADDRESS/PHONE 30 LOCUST ST NORTHAMPTON () 582-2313 Q
PROPERTY LOCATION 30 LOCUST ST
MAP 23B PARCEL 046 001 ZONE M
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny Permit Filled out
Fee Paid
Typeof Construction: BUILD OUT BATHROOM IN NEW BOILER ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 082324
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Signature of Building Officia 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.
30 LOCUST ST ju8-079 i
GIS #: COMMONWEALTH FMA-S, USETTS
Map-lllock: 2313- 046
CITY OF NOR-14 A."Nle,Fl-rON
Lot: -001_ PERSONS CONTRAc'rrNG W11-11 CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARAN'T-Y FUND (MGL c.142A)
CateL,orv: H-.WNG PERm'MIT
Permit# BP-2008-0791
Ploiec[ -1 JS-2008-001219
.!. l. Cost: S 18000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Scott Johnson/CDH 082324
Lot Size(sq. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zo—lllm-l-1 Applicant: Scott johnson/CDH
4 T- 30 1
-.O(',LJST CT
Applicant Address: Phone: Insurance:
30 LOCUST ST O 582-2313
NORTHAMPTONMA01060 ISSUED 0N.312512008 0:00:00
TO PERFORM THE FOLLOWING fVORK:BUILD OUT BATHROOM IN NEW BOILER
ROOM
PAST TijlS CARD SO IT ISV!SIBLE FROM THE STREET
Inspector of Plumbing Inspector of'Wiring D.1).'A'. Building Inspector
Underground: Service: Aleter:
Footings:
Rough: House It' Foundaflon:
Driveway Final:
Finji: 44 '511 r1l B Rougli Frame. O-e YIA -jl!?J-4��
Gas: Fire Department Fireplace/Chimney:
Rou,ih- Oil: Insulation:
Final: Smoke: Fi n a 1: f
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
5
Si2lillit Ire:
Certificate of Qcq llcVC�-l---LL
k� —L.ipa
FeeTvve: Date Paid: Amount:
Fiuilding 3/25/2008 0:00:00 $90.00105809
112 Main Street,Phone(413) 587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo