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May Builders (413) 522-0501 149 Depot Road North Hatfield, MA 01066 April 2, 2014 Northampton Building Department I request that you grant a modification to waive the requirement for control construction for the project at the Potpourri Mall, 241-243 King Street, Northampton, MA. 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. I have provided a plan of the building section in question, a drawing of our plan and scope of work. Thank you, Kevin D. May License Number CS — 004010 Exp. 12/8/15 6 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: Via L The debris will be transported by: Kb 1, s L The debris will be received by: �I�USta.cJ l tittr�cti� 1� '� Building permit number: Name of Permit Applicant �'�t 4�U1";W'A S Lz' C 0*1-j Date Signature of Permit Appli t Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express.or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7- 2010 Fax#617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 k9i Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information J Please Print Legibly Name (Business/Organization/Individual): �<b M Eli LL'o- Address: ,0,' ty, � g o> City/State/Zip: MAr P1 D Phone #: — — -D Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a e to er with 4. E] I am a general contractor and I y 6. New construction oyees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling 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.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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' 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance 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 certi under the ains and enalties ofperjury that the in ormadon provided above is true and correct SigniatureE Date. 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#: Versionl.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 -------- _.,_M _ ...__._ v ,as Owner of the subject property _ hereby authorize ac n m behalf, in all matters relative to work authorized by this building permit application. R Signature of Owner Oate ! 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. Si ne nd_ the pains d_pena ties,_of_perlury ..... Print Name Y// L/ Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ t4 Name of License Holder: License Number Address Expiratio kate Signature I Telephone SECTION 1 -WORKERS'C NSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be c pleted 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 Versionl.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 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: i Not Applicable 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 .. ... .._.,. _----.. c Address Registration Number i Signature Telephone Expiration Date .......... ....._.............._......_, Name Area of Responsibility + t 4 � i Address Registration Number 6 Signature Telephone Expiration Date Name Area of Responsibility i Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: .... -------- Responsible In Charge of Construction Address -- ? 6l Signat Telephone ' " Versionl.7 Commercial Building Permit May]l2OOO 8. NORTHAMPTON ZONNG Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces A. Has Permit/Variance/Rnding ever been issued for/ onthesite? N DONTKNOY 0 YES 0 F �- -------� IF YES, date issued: | | IF YES: Was the permit recorded at the Registry ofDeeds? NO «��� � DONTKNOVV 0 YES 0 ['----------- r-----��--- IF YES: enter Book Page � and/ Document# �� �� B. Does the site contain a brook, body ofvvaterorwetlands? NO v�� DON7 KNOW x�� YES �_� r IF YES, has permit been or need to be obtained from the Conservation Commission? Obtained | Needstqbepbtained �b��ned Date �~� «�� ' . [___�___-___-1 C. D i exist the property? YES NO Do on s epnope y ��� [------------------------ ..........-'-----'----------- 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: 1 � --........................-----`----`----`---'---`--------------- E. Will the construction activity disturb(clearing,grading, n.or filling)over 1aumorixdpa�ofo common plan that wiUdi�urbover 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ` ^ ~ - Versionl.7 Commercial Budding Permit May l5,2O0O SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations [I Existing Wall Signs [I Demolition 2r-'Repairs El Additions El Accessory Building Exterior Alteration El Existing Ground Sign 0 New Signs El RoofingE] Change of Use 0 Other 0 Brief Description Inter a brief description here.lfh0t.K49- tjaW OfF-RIAC Of Proposed Work: /j 3 ? SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 A-2 A-3 1A 11 B Business 2A 1:1 E Educational El 2B 1:1 H High Hazard 1:1 3A I Institutional El 1-1 0 1-2 1-3 E] 313 M Mercantile E] 4 R Residential El R-1 R-2 R-3 5A U utility El Specify: M Mixed Use El 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(sf) St St nd nd rd 3 rd th Total Area(sf) Total Proposed New Construction (sf) 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 ity of Northampton , + uilding Department AM 212 Main Street Room 100 fort ampton, MA 01060 ` € ' 4 phone 4- -587-1240 Fax 413-587-1272 a3` 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 lf —��� t�1 �1 '�,,,�1^ �� `J Map Lot Unit Vr� l/VL�1� V, V V� t r" L t'L L' Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: nrm Name(Print) Current Mailing Address Signature Telephone 2 2 Authorized A ent:�G..-••-� _.��tr..v C�..�l C,-• _ ...... _ _. .. j . IwP Name(Print) Current MailingAddress Signature �' Telephone f 3 a C J / J SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 2 bd� �0 (a)Building Permit Fee ± 2. Electrical (b)Estimated Total Cost of d� Construction from 6 _w� 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 File#BP-2014-1007 APPLICANT/CONTACT PERSON KEVIN D MAY ADDRESS/PHONE 149A DEPOT RD NORTH HATFIELD (413)522-0501 Q PROPERTY LOCATION 241 KING ST-SUITE 235-237 MAP 24D PARCEL 185 001 ZONE HB THIS SECTION FOR OFFICIAL USE ONLY: t PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction: REMOVE NON-BEARING WALL BETWEEN UNITS-MARKETING DOCTOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 004010 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 Demolition Delay 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.