23B-046 (105) |
'
Fri
cfj
CIO
C4 77"
ci
CD
CD
Cl
71 1
HEALTHCARE
FOR: 1iZU ARCHITECTS INC.
NORTHAMPTON, MA55ACHU5ET75 NORTHAMPTON. MASSACHUSETTS 01060
/
tt/M P
�
Gt o�f XXSXaaCIr{n6fCf11ttt5
ntptat1
DEPARTMENT OF BUIL.DI�G INSPECT
IONS -
212 Main Street ' Municipal Building
Northampton, Mass. 01060 /
WORK EX S COMPENSATION INSURANCE AFMAVIT
with a principal place of business/residence at:
L' rr (Po 3` X 13`�� � (=L � �� (phoney) `-�1i3 '��3 � 7
(&U C--t/ci ty/s'aie/n P)
do hereby certif),, under the pains and penalties of perjury, that:
(xl I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(�C�I � u-�cF oolL4 Zit
(insurance Company) (Polio Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workel's compensation policies;
(V) MoCZA lv A`>"`rL1 }C-'E p
(Name of Contractor) (lnsurancc ConTany/Policy Number) (Expiration Date)
(Name of Contactor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contactor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Nuwlxs) (E)piration Date.)
(attar aemtioml zhai ifnercxzsary to include infrxmsfioo pertLimng to all ooeoaciors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awuc thzi while homoownaa who employ pc:om t4 do ma aS tn3 O=Z-U Yioa Cr hair work on X dwelling of
not morn stun throe units in which the lwmeowncr xt=da or on the gouav+s ap74rtcrsatthada ace not f,enctzlly coandvtd to be
cmployerx under the wocka's compcas4aa Act(GL152,a 1(5)�applita6m by a homcowna for a ticcnse or permit may evidcncti the
Icgzl rtsnsa of an employer undertho Workoet Compomation Act
S n8cre d that i copy of this c-tzf cmccd may be foemuded to tbo Departmasi of In husial A.&=&Offioo of Icssurwoo for the
eovertge vaifieation and that failure to senor coverages under section 25A of MGL 151 can lead to the imposition of a-urinal penalties
oomistiag of a fine of up to S1,500.00 and/or irn to of up to ow year and civil penaitia in the form of a Stop Work Ord'--and a
firm a(3100.00 t day tgait>ill ux.
. For dcputrmtz!star easy
Permit Number
Version 1.7 Commercial Building Permit May 15,2000
SECt,ION 10—STRUCTURAL,PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......
SECTION 11 OWNER AUT N TO BE COMPLETED
WHEN
OWNERS,AGENT OR CONTRACTOR APPLIES,FOR-1131 ILDING PERMIT !
a,<
as Owner of the subject property
(hereby authorize to act on
y be If, in a rs re tive work authorized by this building permit application.
na?7r e of ner Date
as Owne Authorized A en
hereby declare that the statements and information on the foregoing application are true and accurate, to the eG s�oTmy
knowledge and belief.
Signed under the pains and penalties of perjury.
12a13-f K� �j : PP-C\JQ S
�- 244�Prin
5 A 3 O
Signatur of wner/Agent V tate
SECT N,12 CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: n Not cA,pplicable ❑
Name of License Holder :�U y �I ��'JU� c ) ��S 3`/
,o
� License Number
% -31
Add r Expiration Date
Signatu e Telephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G 1 c 152;§2aC(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...... ❑
Y S/P CA,
Version 1.7 Commercial Building Permit May 15,2000
SECTION,'9 PROFESSIONAL DESIGNAND CONS-RUCTION SERVICES 1`OR BUILDINGS AND,STR,l1CTURES,SUBJECT TO,.
�. o .
COIVS7RLlCTION ONTROL Pl1RSt)ANTT '780'CME2 116(Gt�NTA1NING:IYIORE THAN 35 OQ0 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
I
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
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Addr �
Signatur Telephone
r
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 EIX site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
c} Building Department
Lot Size J b� 69 Il 2
Frontage 17>
�� > (�j
Setbacks Front 1 p_Z Vic-Z
Side L: R: Z- L: 6 R: ) Z
Rear I E 9
Building Height L y 19,
Bldg. Square Footage �O 1-j t . o %
Open Space Footage %
(Lot area minus bldg&paved S L? )—'2?,
parking)
#of Parking Spaces
Fill: I-A tti
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book ai� Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 X NO n
IF YES, describe size, type and location:_ CL-)\ Si6Q 0` �TM�-(tic N<7 ✓1RC-CTlu 1j
• S tC�1�1 S
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* CONSTRUCTION SERVICES VOR PRUJECTS LESS T, AN 35,000'
CUBIC FEET OF ENCLOSER SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
X ❑ ❑
Exterior Alterations Demolition❑ New Signs [ j Change of Use [ ] Other [ ]
❑ Accessory Building[ ] Repairs ( ]
DE� -TZ MSC Rc \c� �;� o N 3 �' L 2 M c
SECTION 5 USE,GROUF?AND CONSTRUCT ION$TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A 91
A-4 ❑ A-5 ❑ 113 ❑
B Business- -K 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F•2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1.2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential 10 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 Bq"ING UNDERGOING RENOVATIONS ADDITIONS ANDIOR CHANGE IN 11SI
Existing Use Group: yj Proposed Use Group: Ny F C\ r.�G(E
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA,
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf) St
nd
2
1st �<
2 nd 3 rd
3rd
4th
4th
Total Area (sf) ZyG Total Proposed New Construction (sf)
no N
Total Height(ft) t
Total Height ft .... X-1S 37\ 'v b
ti
Version 1.7 Commercial Building Permit May 15, 2000
City of Northampton
Building Department
212 Main Street h
Room 100
Northampton, MA 01060
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 SITE INFORMATION
„ti: _r.. ... . .�,
" Thrs_sect�on o be cotnplbtedby bfftce� #
1.1 Property Address:
'So I.00�51T w
c r
Q r(�(�(� U�C('0 C) rrer a istrict :
Y A
SECTION 2 PROPERTY;OWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authoriz d Agent: QUo`GY Di c.+�\ �� 11U SPA L
Name(Print) Current Mailing Address:
Signature Telephone
SECTIOd-ESTIMATED CONSTRUCTION~COSTS
Item Estimated Cost(Dollars)to be cial Use D;nly x
completed by perm it a pp Iicant
1. Building (a�BuildtngPPerrniPee
2. Electrical ,� �� (b�fs#�matedTotal host of
. G i MUCtion from 6 ,
Building Permit Fee
3. Plumbing
�j v�
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3 +4 + 5) 00 Check=NQrnljer
R X ._
f
°..' � ThtsSection'For:Offcial"Us'e OnI " °` `'
Bi�acTrtig Petrntt7umber Date Issued
-f
File#BP-2003-1062
APPLICANT/CONTACT PERSON MOWRY&SCHMIDT INC
ADDRESS/PHONE P O BOX 135 (413)773-3176
PROPERTY LOCATION 30 LOCUST ST-MCCALUM BLDG 3RD FLR
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
T_ypeof Construction: 3RD FLR RENOVATION-MACCALLUM BLDG
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure -
Building_Plans Included•
Owner/Statement or License 075360
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF99MATION 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 S t Commission
c'_CJQ
Signature of Bui ding 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 MCACf' Lf)CG1 Ft 1t BP-2003-1062
GIS#: COMMONWEALTH OF MASSACHUSETTS
" ' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1062
Project# JS-2003-1687
Est. Cost: $45600.00
Fee: $140.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MOWRY & SCHMIDT INC 075360
Lot Size(sa.ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning:M Applicant: MOWRY & SCHMIDT INC
AT. 30 LOCUST ST - MCCALUM BLDG 3RD FLR
Applicant Address: Phone: Insurance:
P O BOX 135 (413) 773-3176 Workers
Compensation
GREEN FIELDMA01302 ISSUED ON:612103 0:00:00
TO PERFORM THE FOLLOWING WORK.-3RD FLR RENOVATION - MACCALLUM BLDG
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• Receipt No: Date Paid: Check No: Amount:
Building 6/30/03 0:00:00 6297 $140.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo