32C-165 (43) Initial Construction Control Document
To be submitted with thebuilding permit application by a
Registered Design Professional
for work per the 8"'edition of the
Massachusetts State Building Code, 780 CIiR,Section 107
Project Title: U/�//(,�/ �?� / Date: 2G
property AddrQ5s:
Project: Check one or both as applicable: C New construction ;Existing Construction
Project description: AAQOQ /
I•� !' / MA Registration Number:z� _Expiration date: ,am a
register-e design prnfessioned, and I have prepared or directly supervised the preparation of all design fans
computations and specifications concerning:
Architectural [ ] Structural [ ] Mechanical
[ ] ire Protection [ ] Electrical [ ] Other
for the above named project and that to the best of my knowledge, information, and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the buildin nstruction Control Document'.
ED P
Enter in the space to the right a"wet''or �u
electronic signature and seal: 4
1A
O �
Phone number. �PvFq s`'P
Building Official se y
Building Official Name. Permit No.- Date.
Version 06_11 2013
The Commonwealth of Massachusetts
Department of Industrial Accidents
W Office of Investigations
w
a 1 Congress Street, Suite 100
•�` Boston, MA 02114-2017
S�•� www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A_w
Address: 3� C�-Qk, L SE, /6111446 4RI.&I • 0t
City/State/Zip: Phone #: 0 --
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with a 4. 0 1 am a general contractor and I 6 FJ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling
ship and have no employees These sub-contractors have g_ E] Demolition
working or me in an capacity. employees and have workers'
g Y p ty• 9. []Building addition
[No workers' comp. insurance comp. insurance.1
required.] 5. F1 We are a corporation and its I0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees. [No workers' 13T] Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. p
Insurance Company Name: L U y�L ✓'Ns
Policy#or Self-ins. Lie. #: V V C U g 3 I Expiration Date: l "l
Job Site Address: /0 Sr 4 S a vl �T" City/State/Zip:kopl gAg D 10 t0 0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify und�rC q th'epains andpenalties ofperjury that the information provided true and correct.
Sigrtature: " (t��t7` Date: i I r1 1
Phone#
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
C T'G w l_a A, 0IO&6
Name(Prim 4 v i o Fat tk) No.and Street 'City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the pro e owner's behalf,in all matters relative to work authorized by this building rmit ap2lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out A.ppend 2)
If bwil L- is less than 35,000 cu.ft.of enclosed space"and/or'not under Construction Control then check here Q and sld Sec4on 101
10.1 Rejostered Professional Responoble for Constrarlioonn'Control
N e(Registrant) T.e e hone No. e-mail address Registr lion 14umber
Street Address City/Town State Zip Discipline Expirdtion Date
10.2 General Contractor
Nuio Loa,�,' 3 u t_o eaq
Compan�y Name
Name of Person Responsible for Construction License No. and Type if Ap licable
Street Address City/Town State Zip
�i ;h - T3 • 5 9 e2 r ularu.2s 6�',d 0,i t corn
Telephone No.(business) Te1e hone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATIC?N INSURANCE AFFIDAVTr G.L.c.152§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of th e�'ssuance of the building permit.
Is a signed Affidavit submitted with this application? Yes Cd No '❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ (p 0 G . 0 D Building Permit Fee=Total Construction Cost x—there
2.Electrical $ 6-00 1 V U appropriate municipal factor)_$
3.Plumbing $ U
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �1 3aD s i J (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurat7tthe best of my knowledge and understanding. ��/�Cy
�q� iJ cJvf�tfu 4- 0V/VjE�
Please print and sign name Title Telephone No. Date
TC A vat t S i ��Dtz i Lti ` Uly �"
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
l II
<< I�
'u .1AN 2 B 2014
lee f --- -� The Commonwealth of Massachusetts
F
oeo coons kfj__L_�lDepartment of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building,Permit Number: Date Applied: Building Official:
SECTION 1 LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
141-Z I-Amw
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION Z:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair'fn I Alteration Addition❑ Demolition P(,(Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes W No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
C L/
SECTION 3 COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 4,/.) � �iy
Total Area(sq.ft.)and Total Height(ft - 015_ 3Z
SECTION 5:USE GROUP(Check as applicable)
A. Assembly A-1❑ A-2■ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3 13 I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-40'
Special Use❑and please describe below:
S: Storage S-1❑ S-2❑ U: Utility❑
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IUB ■ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis Site
Public 0 Check if outside Flood Zone 10 Indicate municipal A trench will not be PosaI
required V or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ V Kt i j 9 g&CNN In
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed i% Yes❑ or No$ Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): 2 Type of Construction: Occupant Load per Floor:jgL
Does the building contain an Sprinkler System?: Special Stipulations:
File#BP-2014-0829
APPLICANT/CONTACT PERSON DAVID FORTIER
ADDRESS/PHONE 32 Laurel St NORTHAMPTON (413) 586-8965
PROPERTY LOCATION 125A PLEASANT ST-UNION STATION
MAP 32C PARCEL 165 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid r a •
Typeof Construction: ADD TOILET FACILITIES BARtDfV#DW WAJff&NEW VESTIBULES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO jA1�TION 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 Commission Permit DPW Storm Water Management
e Del
Signature of Building f cial 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.
125A PLEASANT ST-UNION STATION BP-2014-0829
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 165 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-0829
Project# JS-2014-001365
Est. Cost: $84300.00
Fee: $505.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot Size(sq_ft.): 105415.20 Owner: MICKA JEREMIAH
Zoning: CB(100)/ Applicant: DAVID FORTIER
AT. 125A PLEASANT ST - UNION STATION
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC
NORTHAMPTONMA01060 ISSUED ON:21312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD TOILET FACILITIES, BAR, DIVIDING WALLS
& NEW VESTIBULES
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• Date Paid: Amount:
Building 2/3/2014 0:00:00 $505.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner