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DEMJTMEISr O,' BUILDFNC fNSPE TIOi;S `
212 Tram Strcct ?Iumc pal Dmldin� _—
Northampton, Mass. 01060
WOMCER'S CO)UENSATTO
5.1'�/1�7ieh /�t'4��/1'lOhot ,.h!ov/e CD
(li�Jpernitt�)
�"q.Lh z principal plat:. oFbusme-ss/residence zt:
val/oel- 0116156 (phone:')
do hereby certfj , under dicpzins aiDd penalties of perjury, -hat
I a_n employer providin- the iollowine worker's comocnsr:Jon covr2�c For Ind,
eluplovccs wor.�rlg on [iris job:
KA
(L2su Coar� j ;PcLc: Nu_�r) (E--�piraor, Derr)
a sole prooriecor, general cools-actor or homeoy-Der (title one) arld havt hued
the coop actors Lister below Wbo hive the ,Guo%vmg- worker's comoen_�zaon peLcies:
(Nam: o. Comuan)-/"t'cOc; ''um_cr) (r:pi;r oa D-mc)
-- (N=c of CootTactor) (tasuran COInDa ",/Pot'jc Nuocrr) �.n r.uon Dzte)
N,Mm 01 COau2cto,) E nsuranc Company/Pol:cy N;>sL,r) (t\piraoo9 Darc)
(1 =C of C0Qn3MOr) (Insurance Comczn /PaLcy NumtLi) Ex irrUoo Dal,)
(aca�-��.i:;cr..al�.cC L(oc�rr t� mc u� uirc:c2.�ca peri•. �to.11 0�-1_..0-�)
( ; I z, sole Prop,
nor and bave no one worming for me.
( I
=,a home otrner perforTning 21I the wark myself.
NOTE:plc c be na uc lh*4t�c bYPCVtM�wbo cplcry pc o w o c c nr.,o z .d,,--LL_z of
acK ma'c tii.: `rr_ ru in���e tr bofD nc ro 6 o�oa the p-.0 eyr -per.-t.-._r�tDc-c�� oD. -_.�.-z11v«c:c,'.--�i Lo tc
Ioy�ur1� ku�r�z wAz:1 hoc ,,fa-'cam:c p nnr 7�. M
Ic^y-J rV 1.c or c�cr�loyx unc:cr din Wcr4��Cocpocc.11c•¢l�.t
cvy ba fors-ardai tto Dop�rc_��of inc ,j r fr:t-f 'tom
co�cz.o.�cn�ictioa-.Ld tivu L-iJ�-c t4 ccouc'o� -c voC-7;cG�cy 25 ,of MC)L 1 5 a c�Icd w lbc L--PO=w orciy �1 pcail��
CcKa �Oct ai o(Lnq to S I,CO.QQ .I�Nae c v.-7 Fx---r o form or.Std w or:oral..o.; .
100.00 r d:y cP;t:�i me
i
si s[U cz sCc:JT C CYT6 a
Versionl.7 Commercial Building Permit May 15, 2000
SECTIQN 10 STRUCTURAL`PEER RIEVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 :OWNER AUTHORIZATION-TO BELCOMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES F.OR BUILDING PERMIT
I, Cook' Y 6;ckin s/ n on 171aS TccL as Owner of the subject property
hereby authorize Q Gf R. You e- C o/ 5 r/1 u -IloL7 G , _to act on
my be , in all matters rel i o by this building permit application.
Signature of Owner Date
I, /?,5t llln6ph /,?, /7 VA1 Cofis -` UGTio/-7 -�Ch c . as Owne uthorized A en`
hereby dec are 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.
Tiwofh i S .fie/% fiie-r
Print Name
Signature of Ow en Date
SECTION 12 =CONSTRUCTIDNSERVICES' ...
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 72W-&1X/ % S. @I/e 7-1 e _ 066227
License Number
Address. Expiration Date
411,3- 5517 2 500
Signature Telephone
SECTION 13 -WORKERS' COMPENSATION;INSURANCE'AFFIDAVIT(M G t c ;152,>§25C(16'
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida:
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION S,ERICES FO R,BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL P.JRSUANT TO 780 CMR 116lCONTA(NING 'MORE THAN 35;000'G f OF ENCLOSED'SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 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
Signa-ure Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor n n 7
14R W?7012d /'t. �O(JLC I. OhS�/�l/C7�/0�1%I� Not Applicable ❑
Company Name:
�ino 7``i y S.
Responsible In harge of Construction
5 A'1/e r s r Svc//out/�� <57
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
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 14 On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size c16 9, 1/27 8 96 9, 1/27.8
Frontage X'6 5 8 2650'
Setbacks Front 102 / 02- ,
Side L: 88 R: �i'Z L: 89' R: 1/2
Rear /8' /a"
Building Height 1/5 ' '6115
Bldg. Square Footage 1102 S61. % 1/02,86
Open Space Footage %
(Lot area minus bldg&paved
arlar. )
#of Parking Spaces 761 1 76 1
Fill: N/A N�A
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES X
IF YES, date issued: DeC 1�200/
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book 6 501/ Page 239 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:
C. Do any signs exist on the property? YES if NO
IF YES, describe size, type and location: VA h 10 v5
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
Versionl.7 Commercial Building Permit May 15,2000
=SECTION 4 CONSTR1iC7iON-ERVICESFOR�kO3ECTS LESS THAN 35,000
CUBIC:FEET OFNCL�SEDSP�CE r = ti
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
ler ❑ ❑
Exterior Alterations Demolition[] New Signs [ ] Change of Use [ ] Other [ ]
❑ / Accessory Building [ ] Repairs [ ] l D
BRIEF DESCRIPTION: �`Tepl' L�X1S!/��` `>�A cC-' `r() 6%le�(72 /�� iJ 7Ce_� .I/!G7/vG'c'2
SECTION 5 _USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly 10 A-1 ❑ A-2 ❑ A-3 ❑ 1A -,ff-
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 ❑ I-1 ❑ I-2 I-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 1FD3S13NG BUILDING UNDERGOINGRENOUWONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: 1-2 Proposed Use Group: Z-2
Existing Hazard Index 780 CMR 34): y Proposed Hazard Index 780 CMR 34): y
`SECTION 6 BUILDING HEIGHT-AND.AkEA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION " aOF USEflNLY
Floor Area per Floor (so 1 �' fflu
nd
?G
2
1st w?rx E
"' ";y
2nd rd 'i z �aW',
3 pig
3 rd
r, p4 i
4t
4th
ct
Total Area (sf) Total Proposed New Construction (sf) t
Total Height(ft) NIA
Total Height ft---------------
` .
w z
Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton fi
Building Department :tea4
212 Main Street
Room 100
Northampton, MA 01060 a
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECIIONA SITE INFORMATION
1.1 Property Address: kThlssGectorl�toe�ompleted b office 2
r.x "-a�.k. z
w ,if yr-• 'S„e '*'
t?'4• R '�- a 1 r +Y„y -A, ,
�. p.c
512
Y `•^ 7'z's-Y 4^,t,%r' ws»'�,?a..v
C'oo/es� U;ckihsoh Ho Ma ,ark x s
30 �o Paces- �� 4qt � �rx � a4w s
ones , mo t"v t Verla DIstict 0001
h t r< c
.. ���I.�Y#Ll�. �'� :>'•�� a?4� ��I��.l� �S CS��fi� hiA��
5ECTION:>2 PROPERTY OWNERSHIPJAUTHORRED AGENT
2.1 Owner of Record:
Cooley Dickinsoh Alosplro 30i000st St.
A0. C�oX Oa/
Name(P' t) Current Mailing Address:
S'/3- 582 -23/
Signature Telephone
2.2 Authorized Agent:
///NC,thy S. Pe/%;t- ei^ 5/I'I,'//eh St. Luck/out, /y1�_ 01056
Name(Print) Current Mailing Address:
by7 2 Soo
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION cOSTS
Item Estimated Cost(Dollars)to be Offiic al Use OnY_
completed by ermit applicant -
1. Building y el� 8uildmg Permit Fee
2. Electrical 90 {b)1=stimated"Total Gust of
t° -=Constriction from`6
3. Plumbing �v Building Permi- ee.
4. Mechanical (HVAC) Pd d
5. Fire Protection
6. Total = (1 + 2 + 3 + 4+ 5) Number
This Section"For Official Use.Onl
Building Permit Number = Date Issued:
Signature:
Building'CommissionerJInspector of:Buildings Date
I T
File#BP-2007-0767
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 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
Building Permit Filled out
Fee Paid ZW32?� 0112;2013
Typeof Construction: RENO EXISTING SPACE FOR OFFICES&MOVE RECEPTION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066227
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O,W6ATION PRESENTED:
pproved 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 Co ssion
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.
30 LGCLisT sT BI✓-2007-0767
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B-046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category BUILDING PERMIT
Permit# BP-2007-0767
Project# JS-2007-001233
Est. Cost: $54660.00
Fee: $243.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: _ Raymond R. Houle Construction Inc 066227
Lot Size(sg. ft.): 6670_7.7.84 Owner: COOLEY DICKINSON HOSPITAL INC
Applicant: Ray and R. Houle Construction Inc
:30 LOCUS] 5 i
Applicant.9ddress: Phone: Insurance:
5 MILLER ST (413)547-2500 0 _ Workers
Compensation
LUDLOWMA01056 ISSUED ON:21912007 0:00:00
TO PERFORM THE FOLLOWING YVORK:RENO EXISTING SPACE FOR OFFICES &
MOVE RECEPTION
POST THIS CARD SO IT IS 'VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Firing D.P.W. Building Iispector
Underground: Service: Meter:
Footings:
Rough: Rough: t'✓ �)�� , House# Foundation:
12 7/L � � Driveway Final:
Final: Finale
5 i L/ .. - Rough Frame: if
157 o
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0tr -6--93 -4 7
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATI . _ S.
Certificate of Occu anc � Signature-
FeeTvpe: Date Paid: Amount:
Building 2/9/2007 0:00:00 $243.0013434
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Conmiissioner- Anthony Patillo