06-039 (12) SAGE ENGINEERING AND CONTRACTING, INC.
__. oD SIGN-BUILD DEVELOPMENT, ARCHITECTURAL ENGINEERING, AND CONSTRUCTION MANAGEMENT
2
C+ 8"A ril 23, 2014
TOW
t
Ia uis Hasbrouck Tel: 413-557-1240
I.— Ildln 9 Commissioner Fax: 413-587-1272
W J 12 Main Street
Northampton, MA 01 OGO
RE: Demolition Permit Application for 31 1 Haydenville Road, Leeds, Massachusetts
01 OG2 SAGE No. 0482-04-13
Dear Mr. Hasbrouck:
On behalf of Zoe Senior Retirement Community, LLC, Sage Engineering and Contracting Inc.
is submitting the enclosed City of Northampton Building Permit Application and Fee for the
demolition of an existing single family home located at 31 1 Haydenville Road. The following
documents are included:
- City of Northampton Building Permit Application
- Certificate of Liability Insurance
- Worker's Compensation Insurance Affidavit
- Demolition Permit Fee of $35.00
- Disconnection Letters from Utility Companies
We are available at your earliest convenience to review the plans and supporting documents
and look forward to working with the City of Northampton Inspectional Services. Please feel
free to contact me directly with any questions that you may have.
Sincerealy,
f
Bryan Balicki, P.E.
Project Manager
SAGE ENGINEERING CONTRACTING, INC.
199 SERV15TAR INDUSTRIAL WAY-SUITE 2
WE5TFIELD, MASSACHUSETTS 01085
TEL: 413-5G2-4884 - FAX: 413-5G2-4899
www.sage-IIC.COm
CITY OF NORTHAMPTON MASSACHUSETTS
A
'
DEPARTMENT OF PUBLIC WORKS
125.LOCUST STREET
1*OIVF IAMPTON,MA 01060
4134587-1520
1FAX 413-58 7-1576
Edward S Huntley,P.E.
Director
May 2,2014
Louis Hasbrouck,Building Inspector
.Municipal Office Annex
212 Main Street
Northampton,Ma 01060
Dear Mr.Hasbrouck:
The water service at#311 Haydenvlle Road has been disconnected from the city water supply and the
water meter has been removed from the premises as of April 29,2014.
Please contact me if you have any questions.
Sincerely }r,
i
I
ory R.Nuttelman.
SiGperintendent of Water
I
i
Cc:Ned Huntley,Director of Public Works �
Jim Laurla, City Engineer
I
i
i
nationalgrid
40 Sylvan Road
Waltham MA 02451
4/30/14
Sage Engineering and Contracting, Inc.
ATTN: Bryan Balicki
199 Servistar Industrial Way
Westfield, MA 01085
RE: Service Removal for Building Demolition.
To Whom It May Concern,
This letter is to confirm that,per your request National Grid has confirmed electrical
service and meter#94829666 has been removed from 311 Haydenville Road, Leeds, MA
01062 as of 4/30/14. If you have any questions or need further assistance, please feel free
to contact me at (508)357-4657.
Sincerely,
,5LF
Customer Order Fulfillment
Order Processing Rep
Ph #508-357-4657
simon.yeung @nationalgrid.com
nationalgrid
WR# 16906027
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 1 Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name (Business/Organization/Individual): Sage Engineering & Contracting, Inc
Address:199 Servistar Industrial Way, Suite 2
City/State/Zip:Westfield, Ma 01085 Phone#:413-562-4884
Are you an employer? Check the appropriate box: Type of project(required):
1. ■❑ I am a employer with 23 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9. E] Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ 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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#I 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:AIM Mutual
Policy#or Self-ins. Lic. #:WMZ-800-8006213-2013A Expiration Date:3-23-15
Job Site Address: 311 Haydenville Road City/State/Zip:Northampton, Ma 01060
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 ins a coverage verification..
I do hereby certify un th and penalties perjury that the information provided above is true and correct.
Si ature: Date:
Phone#: 2-488
Official use only. 1C 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) 1
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
!Zoe Senior Retirement Community,LLC
as Owner of the subject property
1Sage Engineering&Contracting,Inc
hereby authorize –-------- —"-Jto
1---4
act 70�m 1,1half, in all matters-r(Rative to work aWhorizdd by this building permit application.
L5
ure bate
--Emu-
,ge Engineering&Contracting,Inc
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 j!1qpq[qs,_qnd
penalties of perjury.
=Bryan Balicki
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
17rank DeMarinis
Name of License Holder:1 S105714
License Number
199 Serviltar Industrial Way, Suite 2_W-pstfield,Ma 01085 .12/1'—1/2015
Ad . ................f-1
s Expiration Date
",1,3) 562-4884
,.Xgnature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§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 the building permit.
Signed Affidavit Attached Yes No 0
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 0
Name(Registrant):
Registration Number
„_ ..
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
, M. ,_. . �...�. �......_... . .... x..,,. ��f„
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Re istration 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 I Expiration Date
9.3 General Contractor
[Sage Engineering&Contracting,INc Not Applicable
Company Name:
Bryan Balicki
Responsible In Charge of Construction
-199 Servistar Industrial Way, Suite 2,Westfield,Ma 01085
Address
;(413) 562-4884
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8 NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
-
Lot Size
Frontage __..... _...:
Setbacks Front
Side L.` ..._ry R:L. ..... L:= R:= ..... ( _
Rear
Building Height
Bldg. Square Footage ry^._ % m .
Open Space Footage i % 1
(Lot area minus bldg&paved w _ d ___.._..._
parking)
#of Parking Spaces
Fill:
volume&Location) �.e� �.. .�®. a.... ._ . .
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued 03/14/2012~
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES
IF YES: enter Book 10864 Paged 177 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 Q NO
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 Q
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
199IQN-4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE I
Interior Alterations ❑ Existing Wall Signs ❑ Demolition El Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs 1:1 Roofing❑ Change of Use❑ Other❑
Brief Description Complete demolition of the existing single family residential home on the property.
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly E] A-1 ❑ A-2 ❑ A-3 1:1 1A ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational 1:1 213
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 1:1 1-3 ❑ 313 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U utility El Specify:
M Mixed Use ❑ Specify:
S Special Use Specify:
El I
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
—-------- -
Existing Use Group: L_ Proposed Use Group: l_
Existing Hazard Index 780 CMR 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
1,3001
nd 2
nd
2 1,300
3 rd 3 rd
4 th 4th
Total Area(sf) 2,6W Total Proposed New Construction(sf),
Total Height(ft) 25
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'; Flood I Oid Fld ZI Municipal ❑ On site disposal system
Versionl.7 Commercial Building Permit May 15,2000
' �� y/,� e ent use ►1��� ;�
City of Northampton
ii Building Department lar#ay� rrt� r
MW
'1 212 Main Street eu / #ick
201
Room 100
Eie trio, gu Gas
Northampton MA 01060
North n in I@ 413-587-1240 Fax 413-587-1272 Plt i~►I y , ,
'----•_...._, .0 ��/ iii �� ,l �,2 �� y�0:
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
311 Haydenville Road Map Lot Unit
Zone Overlay District
_..-------- Elm St.'District CS District.
SECTION 2'-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Zoe Senior Retirement Community,LLC 31 Brunswick Ave,W. Hartford,CT 06107
Name(Print) Current Mailing Address:
,(413) 562-4884
Signature Telephone
2.2 Authorized Anent:
'Bryan Balicki, Sage Engineering J99 Servistar Industrial Way,Westfield,Ma,_
Name(Print) Current_Mailm Address
x(413) 562 4884
.__ ..... .w .e.._e .......e�,�. . .y_
Signature ` Telephone
SECTIRg ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee I'
$5,000.00
�� . .. . . m ��w d ........... .
2. Electrical E (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 j'
This Section For Official Use Only
Building,Permit Number Date
Issued
Signature:.
� � /L-Itj
s-
Building Commissioner/Inspector of Buildings.
Date /
311 HAYDENVILLE RD BP-2014-1185
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-039 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP-2014-1185
Project# JS-2014-002005
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SAGE ENGINEERING & CONSTRACTING INC 105714
Lot Size(sq ft.): 252648.00 Owner: ZOE SENIOR RETIREMENT COMMUNITY LLC
Zoning: SR(IQQI/ Applicant: SAGE ENGINEERING & CONSTRACTING INC
AT: 311 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
199 SERVISTAR INDUSTRIAL WAY SUITE 2 (413) 562-4884
WC
WESTFIELDMA01085 ISSUED ON.511212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH SINGLE FAMILY HOUSE
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 5/12/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner