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c� DEPIilRTMEWT OP DUlLD!?\�G (NspECT101:S
212 Main Sticet ' Muoicipal Duildin�
Norlhompton, Mass. 010G0
W O R-I CE R'S C O iWM E N S A TI O N IN S URA_N CCE.
S_ e�1 �lt'4 y� ��o� `
2e r o
.ZZr�c
(li ccasccl pern�tt�)
�IlgLh a pf-mcipal place of business/residence at.
5114,-/%r S 7 . L v�/ow hone:') 113 0r141;7-2500
do hereby cerdi :, under the pPint and penalueS o'L perjury, hat
( I a_n employer providing t it >cllowint wort cis comocns-L�on cove sc Cor my
tLIIP[oVccs W0 13ng on LUIS job.
(Lnsur� Cofln��) (Peke; Lr) (✓:p;rdori Dztr)
( ) I.a_m a sole proorietor, geoeral concraczor or homeo"vDu (cl c'e 02c) z'Jo hEve hired
the cao�aCOrs Lste below who hzve the `ollo�ving workei's com�e,n�2non pa?icies:
(Nam,- o.Co t c,o 1 11n2r�n Comoin�'(Tcjc,' Nlum
-- (N�c of Coo�aclar) (lsisurane Compa.:I�vFotic-y Numcrr) (—Lx Lf—c.t on Date)
(Name of Coaa-aclo;) (Insuranc Company/Po�c}' N,isl ) (t p coon Daie)
(Namc of cc[acmmor) (Ins-uanc-- Comr. J /PoLicy Numb-s) (E:t-pinUoa Dass) .
(n¢ac3:- ::ocJ�-�it n ccc.-� to me u�inforn�a oa pctnia:.as to.11 occn---=,O�) ,
( ) I any a sole proprietor and have no oue wor�g for me.
O I am a home owner performing all the work myself.
NOTE.Ales b ewe c fh k Jc 6cma acn wbo cazplay pewni w ••orX O .d..c1L.Z of
.,mod the)n Cm�rail— x cc tre P-a Zb oa Ca---,py to tc
cploy--ux=Lhc Muir -•,'m Acn(GL 15 2,- (S)} >P7l c000 trf .bommn�ro:bcx .a pc- r`y LL-
c5 l rt"u o cx,Ioyx undc d-',v OA--1,C—p--L5 /cL
I undcr.�.nd >o�yy oC lku+ mi..cmcm o=..y b<fo.--xar..ied to tk D� ori.,i,, J l.cn'c.mi�'offs oo or Lr y
cove rail ctim i d Uu L-J at w tccure'mve�c uo!-r soetjon 25 A of 1.IOL 151 can led to 1h, toe or��pec�t o
oI&Eix o(up w S I}OQ.oo ar.Nor i=aM�o(u p to ox.y-ar r�c�v pcul'j o*n tc corm o(A S.Lw Wort OrdC-Nd A
(on 0(SI00-Co,d_y spina me
For dcq..-gym=-�ux only _
pc-=I Numl>cr :.
Si( rccSCtJPcr7ruttc � -D3te
Version 1.7 Commercial Building Permit May I5, 2000
SECTlON:IO- STRUCTURALIPEER 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
I, Cooley D cki n s/ R. U
o/n� /O.S 71::,,i 7" L as Owner of the subject property
hereby authorize Q G A/o e C O/ S r 0 -t-10 G . _to act on
my be in all matters reI6, ork authorized by this building permit application.
A6-626
Signature of Owner Date
I, 9,51,1//YIOhc�' /�i�Dl1/e CDhS �`l'UCT/O/7 �h 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.
T/ Wofhi S peIle e_t
Print Name
Signature of Ow4gl en Date
SECTION 12 -CONSTRUCT[.O.N SEF VICES-
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : //iYI�J��1% S, �e//e f-i e _ 066227
License Number
A � //e r S T /- ya//D�/. /�i� O/O u�6 07-07- 07
Address_ � Expiration Date
4//-3- 575/7- 0
Sigrature Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT{M;G t c ;152,-§:2SC(5))
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....... R No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT T0,7.80 CMR 116:{CONTAINING MORE THAN 35000,C 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
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor /� // n
fl a /r�On R. h'O(/1 C-' (. D t*),5 1-/> C /D,�? Not Applicable ❑
Company Name:
amino M v S 12p-//R!-tie r
Responsible In harge of Construction
Address
%r3-.5-y7250o
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
7. Water Supply(PM.G.L.c.40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ ( Zone: Outside Flood Zone jB( 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 96 9, 5'27. 8 96 9, y27.8
Frontage 2 6 5 8 0650'
Setbacks Front 102 ' 102 ,
Side L: 88 R: y2 L: 89' R: 5/2
Rear 18' l8
Building Height 6[/5
Bldg. Square Footage Y,12,961_ . % yD2g61.
Open Space Footage %
(Lot area minus bldg&paved l 6 �Q• 6
parking)
#of ParkinE Spaces 761 7
Fill: 1VVA NSA
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES X
IF YES, date issued: Dec 13. 200)
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book 6 50y Page 2 39 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 NO
IF YES, describe size, type and location: VAriovs
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 CONSTRUC7iON_ERVICESTOWPRO7ECTS LESS THAN 35,000
CUBIC.FEET OFNCLO5ED�PCf Y y
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building [ ] Repairrsd [ ]
BRIEF DESCRIPTION: Cohver-r C'ol1PeperJcesjocece To o-rT'iGa S AbM'�liSf(Z.4t)d,-J -66
SECTION S -_USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A -fi�
A-4 ❑ A-5 ❑ 16 ❑
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 TtiIS_ECTIONIFDaSTINGBUILDING UNDERGOING-RENOUA 0 S,ADDITIONS ANDJOR CHANGE IN USE
Existing Use Group: I_2 Proposed Use Group: Z-2
Existing Hazard Index 780 CMR 34): y Proposed Hazard Index 780 CMR 34): y
SECTION:6 BUILDING,HEIGHTANDAREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Apr =,ZFFICUSE ONLY �Y r
Floor Area per Floor (sf) ist
1st 2nd
2 nd d
3 P � ri S y x
4 k
tyN '
3rd
4th
4th `4
-
KSjA��-`"�Yh
Total Area (sf) Total Proposed New Construction (sf) r>
Total Height(ft)
Total Height ft—N��-----
Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton
Building Department
212 Main Street
Room 100 t
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
SECTION=1 SITEZNFORMATION
1.1 Property Address:
ON-
Th�ssecfiottoe omp1eted b�office h�°x *'
s^.R5'7i N.L w '�yti ^
Cooley D ckinsoh f/oSo/tAL f 01 r� �
k t d '-��, ss a a a,�" o 'R �i'r'T.
IVA:�O Ym' '1 c nt, r ,
�O 7- one � 5 + �yeray-Disf�ct4r� R x h, z
a w
'S'4i�,� 'FE '�, ".c~ e���a.�i'4'`�.�@.��x.� �..'^x �'ei' n x' —'sr-f r, ♦'�
SECTION PROPERTY OWNERSHIPJAUTfiORIZED AGENT -
2.1 Owner of Record:
Coo1e v Dickinson Hos oiTu l 30 Z ocvst S Y po. 80'y 00/
Name(P t) Current Mailing Address:
6/43- 5B 2 -Z 3/3
Signature Telephone
2.2 Authorized Agent:
Ti„o.,-hy 5. /°e Ile 7'-eA- 5/I'I,'//eh 57. Luc/ocy, /yJ� U 1056
Name(Print) Current Mailing Address:
5'i3- by7-2 500
Signature Telephone
SECTIO143 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost Dollars
( )to be ( f cial°Use Only
completed by ermit applicant -
1. Building
73 ja) Building Permit-Fee .
2. Electrical {b)Estimated Total Cost of '
=;_Construction from 6 -
3. Plumbing Building Permit.fee. .
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /6 �j Check:Nuniber _
This'Sectiori for Official Use.Onl
Building Permit.Number - DateTssued: .
Signature:
—Building'Comm issioner%Inspector of:Buildings Date
File#BP-2006-0731
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 187 East St SOUTH HADLEY (413)532-9243
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 77,14 7
Typeof Construction: CONVERT ADMIN OFFICES 3RD FLR TO CONFERENCE ROOM
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Commis
to 20a�
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 LOCUST ST BP-2006-0731
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-046 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-0731
Project# JS-2006-1118
Est.Cost: $16573.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Raymond R. Houle Construction Inc 066227
Lot Size(sq. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning: M Applicant: Raymond R. Houle Construction Inc
AT: 30 LOCUST ST
An.r-k"n.. .� cire;�: --� Phone: Insurance:
187 East St (413) 532-9243 Workers Compensation
SOUTH HADLEYMA01075 ISSUED ON:112012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT ADMIN OFFICES 3RD FLR TO
CONFERENCE ROOM
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: �✓r House# Foundation:
Driveway Final:
Final: Finale-)'le14 A j—
Rough Frame:�%r
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Ir SORti.nnr
Final: Smoke_ Final: O/<
THIS PERMIT MAY BE REVOKED BY THE,CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS:;
Y
rte/ �• � - ��, _ ��,
„� i
Certificate of Occupancy ,� �- Signature:
FeeType: Date Paid: Amount:
Building 1/20/2006 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo