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08-021 (42) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: e f c, /'V Ti 01�� The debris will be received by: '> S S7/$-L— Building permit number: Name of Permit Applicant _ Z� S� Date Signature of Permit Applicant City of Northampton Massachusetts DEPARTIENT OF BUILDING INSPECTIONS y 212 Main Street a Municipal Building Jhs ,tea ,.., Northampton, MA 01060 sNty7�1 INSPECTOR Louis Hasbrouck Fax:413-587-1272 Chuck Miller Building Commissioner Phone:413-587-1240 Assistant Commissioner SECONDARY CONSTRUCTION CONTROL DOCUMENT (For professional Engineers/Architects responsible for a portion of a controlled project) � Project Title: le—, /�19S'c� .,- 7�/�"�` 7—�C�, �`'��1 Date: Project Location: 766 N � '� / Map: Parcel: Zone: �✓�t,-��✓I�ryes�- ��G' �c�c-•��>/� r✓!'-��'l�.-t�-� TZ� (.-��✓1—�Cr Scope of Project: ©N r �'�,� "—f-I c¢ t o /'-- A1c'rJ SM. C rz,ie•' C In accordance with the Eighth edition Massachusetts State Building Code,780 CMR Section 107.6: I, Mass. Registration# being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: [ ] Fire Protection [Architectural I ] Structural [ ]Mechanical [ ] Electrical [ )Other(specify) for the above named project and that to the best of my knowledge,such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all applicable Laws for the proposed project. Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that the above mentioned portions of the work proceed in accordance with the documents approved for the building permit. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory Completion of the above mentioned work. RED IIAC�, �l nature and Seal of Registered Prqfgss' nal A141 MONSON, �= Day of - 20 6r (seal) DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE (continued) (#2 continued)780 CMR 8'h edition,Section 110.6,Approval Required,states work shall not be done beyond the point indicated in each successive inspection without first obtaining approval of the Building Official. Required inspections will be noted on the"Required Inspections Form"and may include,but are not limited to the following: Soil Condition Roofing Footing and Foundation Special Inspections(Sec.1701.1.1)Specify Concrete Floor and Under Floor Mechanical Systems Lowest Floor Flood Elevation Energy Code Compliance Structural Frame Fire Alarm Installation Lath and Plaster/Gypsum Fire Suppression Installation Fire Resistant Wall Seismic Reinforcement Above Ceiling Inspection AAB 521 CMR Compliance This list may be altered by the Building Official,depending on the scope of the project. Other required construction documents(geo-technical reports,structural tests and inspections,etc)may be required prior to accepting an inspection request. Acceptance testing for fire alarm and fire protection systems will be coordinated through the Building Official. #Z- Understood and Agree [ ] 3.Variance from Strict Compliance with 780 CMR or 521 CMR Documents Attached 1 ] - N/A ] ] Indicate if any Variances were received that would alter strict compliance with 780 CMR or 521 CMR Attach a copy of the written decision and docket number. 4. Variance or Special Permit from Strict Compliance with Local Land Use/Zoning requirements: Documents Attacked[ ] - N/A ( ] Indicate if any Variances or Special Permits were received that would alter strict compliance with Local Land Use/Zoning requirements. Attach a copy of the written decision and docket number. Complete this section if applicable: I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning the following: [ ] Entire Project E%/Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other Specify) for the above named project and that such plans,computations and specifications meet the applicable provisions of 780 CMR(8'h edition)the Massachusetts State Building Code,all acceptable engineering practices,and all applicable laws for the proposed project. I shall submit a Construction Control Document for the disci line designated. Page 2 of 2 Version—March 12,2012 x� DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE submit with permit application for Existing Building s Renovation,Alteration, Addition, or Change of Use Per 780 CMR Section 107.3.4—Massachusetts State Building Code Project Title: '. ���`-'�f� T ty} "'C 7-�)lj P-;e,-3�s: Date: 3 ' l , Project Location: - C, (v Scope of Project: t -- '?�l t vn, ! ►�)s rt. J 0: - �� ±A ;, � ! —S A r r ermit# ) —be determined by Building on'Wap In accordance with 780 CMR,Section 107.0,most specifically 107.3.4"Design Professional in Responsible Charge" of the 8th edition of the Massachusetts State Building Code: 1, `R_ Mass.Registration Number Expiration being a Massachusetts Registered Professional Engineer/Architect hereby certify that: I am the Design Professional in Responsible Charge and that I shall be responsible for reviewing and coordinating submittal documents prepared by others,including p w I items,for compatibility with the design of the building and for compliance with the requirements B chusetts State Building Code). Signature and Seal of registered professional?.14 C3 The The following checklist is based on the requirements of 780 CMR 8th edition(Massachusetts State Building Code),is not all inclusive,may be modified by the Building Official depending on the scope of the project,and reflects an acknowledgement by you,as the DPRC,that 780 CMR,8th edition,chapter 34,(IEBC 2009 with Massachusetts Amendments)has been reviewed for code compliance. Said review'includes a review of the required investigation and evaluation report,as well as the"Compliance Method"used for design. 1.) Existing Structure: The design complies with the following 780 CMR,8th edition Chapter 34,(IEBC 2009 with Massachusetts Amendments) Design Methodology- Prescriptive Method [ 1 - Work Area Method 1/1 - Performance Method[ 1 2.) Inspection Requirements and Notitication Responsibility: It is a requirement of 780 CMR that the Building Official be notified,through written documentation,indicating that the work complies with the plans and specifications at the completion of each phase of construction(see 780 CMR 8th edition,sections 107.6.2.2,104.4,110.4 and 110.5). As the Design Professional in Responsible Charge,you will gather, review,and submit to the Building Official any required "Phased Approval Documents"and/or supporting documentation from testing agencies or Registered Professionals responsible for their designed portions of the work. (#2 is continued) Page 1 of 2 Version—March 12,2012 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 5� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ley-ibly Name (Business/Organization/Individual): Address: i3 cq`1 T�ul<1 i4 f" City/State/Zip: 0. 0/ (9t) ~ Phone #: �� S �1K Y_7 Are you an employer? Check the appropriate box: Type of project(required): 1.Vf 1 am a employer with & 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. JS Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.Et'Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.O'Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13T1 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. 3Contractors 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. _ Insurance Company Name: Policy#or Self-ins. Lic.#: 5 3 5 " 3 ) S G 2 3 Expiration Date: (2t— D Job Site Address: 700 Uy 57' City/State/Zip: /`-2/C)ZAP lCij M 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature:-� -� Date: 3 ~ l3 Phone#: �r 3. ��t° `7 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#: 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 as Owner of the subject property hereby authorize ' I' to act on my be f,in al ers relative to work authorized by this building permit application. Signature of 11 ner Date l 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 nder the pains and penalties of perjury. r4-- -3- Print Nanke Signature of Owner/4genk Date SECTION 12-CO STRUCTION SERVICES 101 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder: t�CC� y� ' vG'�` s l� 7 License Number Address I ` FiAJ� Expiration Date Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§25C(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 Ike building permit. Signed Affidavit Attached Yes No 0 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 TO 780 CMR 116(CONTAINING MORE THAN 36,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): `t (/ (/ Registration Registration Number .d J ey.-�- z7 3 Expiration Date ature Telephone C 9.2 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 /�7 � ku kot_\� ,Sk /, l��J s - Not Applicable ❑ Compa y Na Responsible In Charge of Construction Address Signature Telephone Version 1.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning :A/ This column to be filled in by !v 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 q DONT KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES NO O IF YES, describe size, type and location: Te-rj— ,` b 1 kp- D. Are there any proposed changes to or additions of signs intended for the property? YES o NO IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 9�Existing Wall Signs [-'Demolition[9—Repairs U Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ _ � Brief Description Enter a brief description here. /C'� C'•�ti'���' `� ' �" �'�� ��" �S �/�� Of Proposed Work: g'TC_ Oti0,0 Ce v 1 7— 6;Cl l AJ T-q,4 ej,?-, No. `i TIZc r c rZ�AccX w c�/v/�. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 1 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 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so s.4 rvr r'� 1St �j 0 Q 1St 2nd S O 2nd 3"' 3ro 4"' e Total Area(so % a c9cu Total Proposed New Construction(so q 12, 5F Total Height(ft) 'ZJ F1 7 o Total Height ft 7.Water 4upply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage isposal System: Public Private ❑ Zone Outside Flood Znx MunicipatZj& On site disposal system Version 1.7 Commercial Building Permit May 15,2000 Department use only 2 6 90 ill City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - {y ---- - 212 Main Street Sewer/Septic Availability ftt Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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: This section to be completed by office 766 A4 k,,j G S 7' Map Lot Unit S �'[J�' Zone Overlay District /v ��"" � Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �`��/ Name(Print) -rte) J Current Mailing Address: 7/3 7 S- l I S 7> C? v Signature Telephone 2.2 Authorized A e t• ��� � l /- �L� Ate . 5 =. �l4��� Ae4 91 Name(Print) Current Mailinh Address: Signature Telephone SECTION 3-E TIMAT D CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building 3 (a)Building Permit Fee � � i3v v 2. Electrical (b)Estimated Total Cost of (� Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) C CUO Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0985 APPLICANT/CONTACT PERSON TADEUS BUKOWSKI ADDRESS/PHONE 1307 TINKHAM RD WILBRAHAM (413)374-0521 PROPERTY LOCATION 766 NORTH KING ST- 1 ST FLR EAR,NOSE&THROAT MAP 08 PARCEL 021 000 ZONE HB(100)/RI(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 J Typeof Construction: CONVERT 2 UNITS TO ONE DOCTOR'S OFFICE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074299 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 D lit' lay y- 7- H, Sign re of Buil ing fficial 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. 766 NORTH KING ST- 1ST FLR EAR,NOSE&THROAT BP-2014-0985 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 08-021 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-0985 Project# JS-2014-001706 Est. Cost: $190000.00 Fee: $1140.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TADEUS BUKOWSKI 074299 Lot Size(ss . ft.): Owner: PARADISE REALTY PARTNERS LLC Zoning:HB(100)/RI(100)/ Applicant: TADEUS BUKOWSKI AT. 766 NORTH KING ST - 1 ST FLR EAR.NOSE & THROAT Applicant Address: Phone: Insurance: 1307 TINKHAM RD (413) 374-0521 WC WILBRAHAMMA01095 ISSUED ON:41712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONVERT 2 UNITS TO ONE DOCTOR'S OFFICE 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 4/7/2014 0:00:00 $1140.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner