30B-022 (4) City of Northampton, Massachusetts
Central Services
Memorial Hall, 240 Main Street
Northampton, MA 01060
David Pomerantz (413)587-1238 Fax: (413)587-1248
Director of Central Services
To: Louis Hasbrouck, Building Commissioner
From: David Pomerantz, Director of Central Services
Date: April 18, 2014
Re: Construction Control Waiver Request- Feiker School
I request that you grant a modification to waive the requirement for control
construction for the project at the Feiker School-Nonotuck Day Care Center, 221 Riverside
Drive, Northampton, MA because the work is of a minor nature, will not affect health,
accessibility, life and fire safety, or structural requirements and is impractical in that the cost
of control construction is considerable when compared to the cost of the proposed work.
Thank you for your consideration.
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
F°5~ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I"
employees (full and/or part-time).* have hired the sub-contractors 6. F-1 New construction
-2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑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.El Electrical repairs or additions
3.❑ I 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 12.7 Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
hnsurance Company Name: _
Policy#or Self--ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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:
Phone#:
Of 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#:
L
Versionl.7 Commercial Building Permit May 15,2000
4
SECTION 10-,STRUCTURAL PEER REVIEW(780 CMR;1.10.11)
Independent Structural Engineering Structural Peer Review Required Yes r No 0
SECTION 11 -OWNER AUTHORIZATION-TO:BE COMPLETED:.WHEN
OWNERS AGENT OR CONTRACTOR APPLIES POR BUILDING.PERMIT
�1V1"V!!........__ . ........._.,_ _.... ...... ... _ _,.__..w_. . _V _ as Owner of the subject property
her jerf,rize .._ !_.�. �},.-�`' _...L !!Y ?.-. ._. _.� ri.... ._r.. _ =to
act i II afters relative to work authorized by this building permit application.
Sign ur o ne Date
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 oferlury
w
Print
Signat a of" lAgen Date
SECTI 12 ONST U TIOU SERVICES
10.1 License Construc " n Supervisor: Not Applicable ❑
Name of License Holder: __....... ..
License Number
___,
1
Address Expiration Date
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG
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 0 No 0
. .
Version l.7 Commercial Building Permit May l5,200O
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIONZERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CIVIR 116(C ONTAINING mbPE THAN,35,000 C.F.OF EN
SLOSED SPACE)
9.1 Registered Architect:
Not Applicable D
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Narne Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable F
Company Name:
R�!Rqnsible In Charge of Construction
Ad
tv 66
Sig ature Telephone
^
'
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning .
This column tore filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L.�___._..l R:�—.__.J L:_,.... J R:
Rear
Building Height ,.
----- {
Bldg. Square Footage € ' "" %
Open Space Footage %
1 T t
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
(volume&Location) -•-
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF.YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0.__..
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C 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 0 NO 0
IF YES, describe size, type and location:
........... _.................. _.. .........
_ D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Pennit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 t
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory�B^IingD
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description . ;Enter a brief description here.
Of Proposed Work::
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 ❑
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 F-1 Specify
SSpecial Use ❑ Specify:(...�,....�_.._� ..._.._.-._P_.w...,...,.�,_....�...�._�.-.,....w.-�_���..�.,.,,_.._._..-..��....�..._..�._-°___°_�_ ,
i
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONSAND/OR'CHANGE IN USE
Existing Use Group: Proposed Use Group.
p. .
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(sf)
St 1st
._,,..... __.. ,,,_. _.........__...,. .».,..�, nd ,
.2nd i 2
.,....__... ......_.__...,. ,.,...,_,..,.h" .._.,,
3rd 3rd
4th _..____ _ ,..._._.___,. ....._ _..__ _. 4th
Total Area sf
( ) Total Proposed New Constructionsf)
Total Height(ft)
— - Total Height ft
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❑
Versionl.7 Commercial Building Permit May 15,2000
,-- _ � Departure t_use�onlX
f� City of Northampton status af'Permlt
xv M
Building Department Curb Gut/Clpyevuay F}e �f, •.. "
i 212 Main Street Sewer/SepttcAvatEabrErty ll
B 2014 Room 100 WaterNtlell Ayailablllt i
Y
orthampton, MA 01060 TwoFSets of Stru'cturaE Flans
Electric,Plumbin` g . Gass c44 -587-1240 Fax 413-587-1272 Plot/Site PEans
Northampton. MA ft '
Other 5peelfy r
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
.;Map 0 Lot a Unit
e
I Zone Overlay District
_� —.-•. w. - -- EIm St'District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Prin �lJ ��"N,v)b\QSMLa Current Mailing Address
lA s
Signature Telephone
2.2 Authori d A nt:
Name(Pant) Current Mailing Address_
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use.Only
completed by ermit applicant
1. Building 5� (a)Building Permit Fee
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) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
- .-Signature: -
Building Commissioner/Inspector.of Buildings Date
File#BP-2014-1088
APPLICANT/CONTACT PERSON CITY OF NORTHAMPTON CENTRAL SERVICES
ADDRESS/PHONE Memorial Hall NORTHAMPTON (413)587-1260 Q
PROPERTY LOCATION 221 RIVERSIDE DR-FEIKER SCHOOL
MAP 30B PARCEL 022 001 ZONE URB(,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
Typeof Construction: INSTALL METAL BULKHEAD UNIT
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License 054510
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOYMTTION PRESENTED:
pproved 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
Uwnpli ' n la
Signs re o uil ing 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.
221 RIVERSIDE DR-FEIKER SCHOOL BP-2014-1088
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-022 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-1088
Project# JS-2014-001864
Est.Cost: $500.00
Fee:$0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CITY OF NORTHAMPTON CENTRAL SERVICES 054510
Lot Size(sq. ft.): 45302.40 Owner: NORTHAMPTON CITY OF FEIKER SCHOOL
Zoning: URB(100)/ Applicant: CITY OF NORTHAMPTON CENTRAL SERVICES
AT. 221 RIVERSIDE DR - FEIKER SCHOOL
Applicant Address: Phone: Insurance:
Memorial Hall (413) 587-1260 ()
NORTHAMPTON MAO 1060 ISSUED ON:412312014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL METAL BULKHEAD UNIT
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 4/23/2014 0:00:00 $0.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner