23B-046 (106) HF'ht-14—c4�4�S 1S:Ski U UULSY lll C:kl NSUN 41S SLid U21
Contr.Lic. No. 101723
_..w. Proposal -
OUNG Tel. 413-584-1367
Roofing Co., Inc. 413-586-9167
P.O. Box 60056 Fax 413-585-0226
Florence, MA 01062-0056
Customer ; Cooley Dickinson Hospital Date; 12/3 1/02
Address: Mc Callum Building _ -
J6b Location
SPECIFICATIONS:
1. Pull the state in 4 valleys, install new 16 oz. lead coated copper flashing and restate.
2. Install 112 inch fiberboard insulation to the two flat roofs.
3. Install Carlisle's reinforced mechanically attached roofing system.
4. Flash all walls, edges, and roof penetrations with an approved Carlisle detail.
5. Install 16 oz. lead coated copper edge metal.
6. Upon completion of the work Carlisle will inspect the job an issue the owner a Ten (10) year
warranty.
All tnatcrW es gtaranteed to be w spmMed. Any alterations or devtabod ftm above i1
speefioUO09 tnvohnnt(a�s onats eNll be MMutod only uppM written orders,and Vhfl ! Y?n-9-the eathwtt A!l ti®Reraeata hinge upon strdws,acddents or dolays beyeed our control. Owner m cmctiy are wind ather etcessary
ttleteranew• M accounts not patd.dtl+ln so days ere aubJ"to a late dwSe of 1 1/a 96 Atlthonzed RiCt1c1I tt Z.Sident
per month on the unpaid balance. N the event chat inset action is tmtxuted to collect
any Bums due under uua agr eamene the under iped agrees to pay all coats Htearred Signature
[ncludtng reaaortable:two .ran.
Acceptance of Proposal— The above Sipat8
Signature
prices,specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as
specified. Payment will be made as outtined above.
Acceptance
T1ofP n� ArrnntanrP
TOTAL P.02
- :
� 6 ��asaacllttsrlla'
w _
m DEPARTMENT OF nUILDIT(G INSPECTIONS
212 Mau] Street ' Municipal. Building
Northampton, Mass. 01060
WORKEWS ("OM.Ph;NSrl'J'LON INSI-IItAN(;1? Ahli'II)AV1'I'
I,
----- ------
(]iccn-<t&permi(tee)
with a principal place of business/residence at:
do hereby certify, llllder the pains and penalties of'pe.jury, that:
JjO l aII) an en]ploycl providing the f011owins, Nvorl;Cl1S COIl1pCllS lt101) GOVCCas;C for Illy
cnlployccs working on this job:
iA60'7--�533 HC& _ I 1 6
(In=uicc Company) (Polio,-Number) (Expiration Date)
O I am. a sole proprietor, general contractor or homeowner (circle one) and have lured
the contractors listed below who have the following worker's compensation policies:
A4.
r q. (Name of Contractor) (Insurancc Company/Policy Nutnbcr) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
. i
(Name of Contractor) -- (Insurance Compaay/Polic},Number) (Expiration Date)
v
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(AHUa h additioml shoot ifn6ocnzxy to include information pertaining to all oont a r,)
( ) 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 aware the while hemcowncra who cmphoy persons to do mxird�wastuctioo or repair%vorlc on a d%%eUing of
Wt morn than throe unit:in which the homeowner rt"dee or on the grounds appurtenand thereto are not eco rally masidered to be
eml?10 c t undo the worker's eompcas4on Act(GL152,ss 1(5)),aMtim6cra by a homeowner for a llocnte or permit may evidence the
legal rtahla of an employer under the Woriccet eompemation Ad
I underhand that a copy of this etatcmmt may be forwarded to rho Dgwtn,mt of Industrial Ancidcn&Office of Ianuvnco for the
oovcrx verification and that failure to stave covtrage under section 25A of MIL 152 can lead to tha im ion of criminal pcaallies
oomitting of a fine of up to S 1,500.00 and/or imptisoamcrd of up to one year and civil pemtties in tlx form o[a Stop Work Orx1t and a
find of 6100.00 a day agaimt rte
For dgmtrrm'al use only
Permit Ntunbcr
Ivillp# Lot t'
,,r,__ sl 1tllrC 1(X:175 err-rnifirr '----�3tE? � —
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER 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
f' as Owner of file sullied IV
hereby authorize to act or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1' 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
Signature of Owner/Agent Date
SECTION 12 -CONSTRUCTION SERVICES771
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Richard Young 011878
License Number
P.O. Box(d*Florence, MA. 01062 8/14/03
Address
Expiration Date
413-584-1367
Signa ure 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 affidavi*
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... kl No...... ❑
I
I
I
I
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 ❑ On site disposal system ❑
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registr f Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ✓
YES
I
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:
D. Are ere any proposed changes to or additions of signs intended for the property ?YES `
No
i
IF YES, describe size, type and location: I
i
i
Version 1.7 Commercial Building Permit May 15,2000
tt �, , ;fit ?aw
SECTON�9ROFESS�ONI��DESIGNND��N TRUCTION SERVICES FOR BUILDINGS AN DRUG„s ESU, J� T`fiU. -
CONSTRUCTIOf�fOVTROL'PURStIW"T`d8D' 11IR 11x6(CONTAINING MORE TFIAN 3�5;d00 "N' N”,
C
�
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
Young Roofing Co., Inc. Not Applicable ❑
Company Name:
Richard Young President
Responsible In Charge of Construction
P.O. Box 56 Florence, MA. 01062
Address
584-1367
Signat6 e Telephone
}
Version 1.7 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 Existing Ground Signs Additions ❑ Roofing1
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building[ J Repairs ( J
DESCK�P�r ,�: 1 `�I�.� 1 C��� f 1 , av�c�► �a�rti�� S� S�
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A (3
1 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
OFFICE USE ONLY'
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION , • . fin , , , , ,,,•,
Floor Area per Floor(sf) x
Uzi §A r } kst � Fr r
az
15'
,
2nd5t 4
lst
3 rd } AN
41n �E f
3rd €6 e iajAb �3�} � a
th ate is # 4 � a
Total Area (sf) Total Proposed New Construction (sf) �, � � f ; �� � � .
•.,� 3:3 - a KI t 71 M F
..............................
Total Height(ft)
Total Height ft ------------------- ,
Versionl.7 Commercial Building Permit May 15,2000
-City of Northampton S atus ofyPer
Building Department GurbCut%Qwe� e
Yg
212 Main Street
0 Room 100
Northampton, MA 01060 Twd Sets o G
phone 413-587-1240 Fax 413-587-1272 Plota,441le
,
I _ Other�Specify�.'" a+� .,'y),•1.is : :+ `r ItS �°'....
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: $ ; _
Map Lot Unit
Fr „
Zone : Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name i Ut) Current Mailing Address:
5ele 6L 1�- 2,ec( g1
--- 15 '� c2 4313
Signature Telephone
2.2 Authorized Agent:
Young Roofing Co., Inc. P.O. Box 56 Florence, MA. 01062-0056
Name(Print) Current Mailing Address:
413-584-1367
Signature Telephone
SECTION 3 - ESTIMATED,CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Lp-
2. /�� �/� (a) Building Permit Fee
Electrical 11L (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) Check Number
This Section For Official Use Only
Building Permit.Number: Date Issued: .
Signature:
Building Commissioner/Inspector of.Buildings Date
� F BP-2003-1026
GIS#: COMMONWEALTH OF MASSACHUSETTS
*00"1111.1w," - CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category BUILDING PERMIT
Permit# BP-2003-1026
Project# IS-2003-1637
Est.Cost: $10800.00
Fee: $54.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Young Roofing Co Inc 011878
Lot Size(sa. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning:M Applicant: Young Roofing Co Inc
AT. 30 LOCUST ST
Applicant Address: Phone: Insurance:
P O Box 56 (413) 584-1367 Workers Compensation
FLORENCEMA01062 ISSUED ON:S/1 S/03 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL NEW CARLISLE MEMBRANE ROOF
SYSTEM
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 Shmature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/15/03 0:00:00 14917 $54.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo