Loading...
23B-046 (110) GZ t-� _ of 'XiartITUIIIPfoil 6 Aassacitnsctts' DEPARTMENT OF BUILDI7tG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE Al FMAVIT with a principal place of business/residence at: 1`5 �0�-OOP_ C 1 l��t L l�!�=( C G`� M� (phone-'; (strzwi/cz ty/starrla p) do hereby certify, under the pains and penalties of perjury, that: ( I am an employer providing the following worker's compensation coverage for my employees woridng on this)ob: VIN, C (Insurance Company) (PolicJ Number) (Expiration Date) (J� I am a sole proprietor,ipuneral contractor or.krneowner (circle one) and have hired the contractors listed below who have 1f C following worker's compensation policies: ECC-cinlc Gcyl,",-)m',V-�,'j I4z'tfi � - 1 -(,) `I (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) ,, (Name of Contractor) (Insuranct Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparry/Policy Number) (Expimtion Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional shod ifnaaa.vy to include infornutioa pertaining to all coa.r'adon) ( ) I am a sole proprietor and have no one worldng for me. ( ) 1 am a home owner perfornning all the work myself. NOTE:please be aware that while bomeownen who cmpioy persons to do m irrI_ Icni cc co¢z ruction or repair work oo a dwelling of not moco thm throe units is wtxich the homnowncr r=d=a oa the gvjnd3 appurteaani thucto arc not gcocally ooarukc to be employes under the vvmk o=pc=satioa Ad(GLI52-M 1(5)},application by a homcownrs for a Eo=m cc permit may evidcme the legit status of an employer under tha Workeet Compomaiion AeL i I undmtaad that a copy of this rutemcat may ba forwarded to tho Dvpa t�of Iauz ,j Aoadw&Offioo of Insurance for the coverage wrificaiioo and that frail=to secure coverage utsdc sxtion 25A of MGL 152 can lad to the impos—of criminal penaltiat ooQSisting of a f oc of up to S1,300-00 and/or i a iso�of up to oa y=and civil pcmlt cs in the form of a Stop Work Ord-and a firm of st00.00 a day tgziaA M �r�al txac C For only 2) r ��� Permit Number I.at# Versionl.7 Commercial Building Permit May 15,2000 SECTION 10 STRUCTURAL PEER REVIEWN,(780 CMR 110:11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION'll OWNER AUTHORIZATION TO BE COMPLETED 'WHEN OWNERS AGCN F OR CONTRACTOR=APPLIES:FOR'13UILDING'PERIVIIT 1 COO,- as Owner of the subject property c� I hereby authorize kJ �- GEORGE NOL N to act on m be If, in all m ers re tive to work authorized by this building permit pplication. DIRECTOR OF FACILITIES /-7/03 COOLEY DICKINSON HOSPITAL "M..&zr /*-4-/� -ignature of 0 er 6ate 1, �C�k:(�y 1` ��� �\Y�\ �IkJ( , - Z0131 &J as Owne6Auuthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the knowledge and and belief. Signed under the pains and penalties of perjury. Prin me Signature/f Ow er g W Date SECTION l CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ' )d 13\� Po,(-, License Number 1 -- C`t -0 Addres Expiration Date Signatu e Telephone t SECTION 13 WORKERS' COMPEN5AT10N INSURANCE AFFIDAVIT(M G.L c 152, §25G(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...... ❑ Version 1.7 Commercial Building Permit May 15, 2000 SECT#ON..'9 PROCESSIONAL DESIGN AN D.GONSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURES SUBJECT'TQ CONSTRUCT,I0N;C0NTROL PURSUANT T0.7$ 'CMR ii6,,(CONTAINING'' MORE THAN'-35;000.C,F.,OF'ENCLOSED SPACE) 9.1 Registered Architect: (_ L, L ,`; D6?.y Not Applicable ❑ Name(Registrant): 6l �� C !, �j ( ,�� Z ( r/1 G� Registration Number Add Expiration Date Signat e 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 �jc l ti L Not Applicable ❑ Company Name: Responsible In Charge of Constructionr� c ry� a 6V�L G j M� 1 Adqw,6, r--� Signatu e Telephone 1 '` Version 1.7 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 EL. Municipal ❑ On site disposal system ❑ 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 9 (19 Frontage Z�1-55 �. Setbacks Front 162- I L Side L: 'S R: Z- L: Z R: y Z Rear Building Height Bldg. Square Footage o.z 1 Li 1 % `jC Z`Z ` y Open Space Footage _ % (Lot area minus bldg&paved ` (,� (,.7 `�` `i l,�`j( `) 5 , "A parking) #of Parking Spaces �= L Fill: ti/ fv/,, (volume&Location) r A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES �C IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES X IF YES: enter Book 9 \ 6\ Page `\—) and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES ')< — L Lrv\ 6i. 3RGc`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 k NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES_ No X IF YES, describe size, type and location: Versionl.7 Commercial Building Permit May 15, 2000 SECTION°4 CONSTRUCTION SRUfCES FOR PROJECTS LESS THAN 35,000 CIJBlC FE1=1 OF"ENCLOSED SPADE B' k, Interior Alterations Existing Wall Signs Existing Ground Signs [Additions ❑ Roofing ❑ X ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ) Change of Use [ ] Other [ ] ❑ Accessory Building[ ] Repairs [ ] VES 4-P-TZ7 ' 115 C2�ny� ��Ti�R,,� ;fit Tcc �M�= (a� �5 {�c2 0(?.Yt,��,�c SECTION 5 USE GROUP AND CONSTRI)C�"Ip ,TY E �_. USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly 10 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 Institutional M 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 SECTfOIV IF EXIST NG BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CNANGE'JN USE Existing Use Group: S-Z- Proposed Use Group: Z-2 Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION"6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTIONd0�'ko$bj: �urn Floor Area per Floor(sf) Is 2nd 1st 2nd 3rd 3rd 4th 4th Total Area (sf) Total Proposed New Construction (sf) Total Height(ft) �Li _ Total Height ft --- " Version 1.7 Commercial Building Permit May 15, 2000 Citi of Northampton Building Department 212 Main Street FC3 2 0 2003 Room 100 Northampton, MA 01060 phone,413-587.1240 Fax 413-587.1272 «J 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 1.1 Property Address: Th�s'�ection�#o�be�co pleted;ti 'office `` _ �'. ��=i'Z�1�y�t��� �►� G�d(,�, C u� P ver': D s#riot �E -� tE SSG.. SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na e( rint) Current Mailing Address: `- 11� Z - Zvi Z ignature 0 GEORGE NOIAN Telephone 2.2 Authorized Agent: DIRECTOR OF FACILME3 COOLEY DICKINSON HOSPITAL 3 Ci T. Name(Print) Current Mailing Address: `A k-5 -5 Z. 2 - 'Z-5 Signature Telephone SECTION--1=STIMATE6 CONSTRUCTION'COSTS3- Item Estimated Cost(Dollars)to be Official Use;�Only completed by ermit applicant 1. Building -7 QO© _ (a)Budding Permitfee 2. Electrical (b)Estimated 7otalCost of. �- 00 Constructionfrorrr. b 7 —777 3. Plumbing Bmld'ing Pemma#F'e ?F 4. Mechanical (HVAC) _ E 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 's 7 vC� - Check Nurriber + ?I Th is,Section_For,'Of f icial;Use 0n1 ' .. ax ,� Building i?�'<mlt�umber > f�,.n"�'�I� ate Issued % s K ° a " ffliJ' ` Cnm„m►ssioner/lnspector,of.;Buildings„ . DateR ; h r File#BP-2003-0706 APPLICANT/CONTACT PERSON MOWRY&SCHMIDT INC ADDRESS/PHONE P O BOX 135 (413)773-3176 PROPERTY LOCATION 30 LOCUST ST-4TH FLR CRITICAL CARE 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 Typeof Construction: MISC RENOVATIONS AT TELEMETRY 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF91CMATION PRESENTED: _JZApproved 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 COssion 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-4TH FLR CRITICAL CARE BP-2003-0706 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23B-046 CITY OF NORTHAMPTON Lot: -001 Permit: Building Cateizory: BUILDING PERMIT Permit# BP-2003-0706 Project# IS-2003-1145 Est.Cost: $8200.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MOWRY & SCHMIDT INC 075360 Lot Size(sq. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC Zoning:M A-plicant: MOWRY & SCHMIDT INC AT. 30 LOCUST ST - 4TH FLR CRITICAL CARE Applicant Address: Phone: Insurance: P O BOX 135 (41-'A 773-3176 Workers Compensation GREENFIELDMA01302 ISSUED ON:315103 0:00:00 TO PERFORM THE FOLLOWING WORK-KISC—SC TIONS AT TELEMETRY - 4TH FLR POST THIS CARD SO IT IS VISIBLE FROM THE STREET ,\inspector of Plumbing iw ector of Wiring D.P.W. )lding Inspector Underground: Service: Meter: Footings: Rough: Rough: fG j 0��, House# Foundation: !R Driveway Final: Final: Final: y l , f Rough Frame:W C Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: ()Ic Lf'7'o 3 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS, i - , Certificate of Occu anc �' Si nature: , FeeType• Receipt No: Date Paid: Check No: Amount: Building 3/5/03 0:00:00 5899 $50.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo