Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
23B-046 (232)
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 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): ---- - Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility p P -"; � tozo fe f - .. _ .. .... ._.. {W0� - Address Registration Number zYA 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 /{1Wt,/ /�l SOy�.4.. �//c'►'NZtMt Not Applicable ❑ Company Name: C5-(06 16 Responsible In Charge of Construction Address SoS SoS�Sa3� Sign a Telephone Version 1.7 Commercial Building Permit May 15,2000 S. NORTHAMPTON ZONING Existing Proposed ! Required by Zoning This column to be filled)/by 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 0 DONT KNOW 0 YES J IF YES, date issued: „�,�wQ„✓ 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 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 0 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. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description 'Enter re. �,pl,LA-/ /v/i foe sc s' fv s4.sp 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 I ❑ 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 ❑ Specify: I S Special Use El Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: I .a., _.. _ a Proposed Use Group: Existing Hazard Index 780 CMR 34): E 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 A 1st � 1 - . .� A114 2nd 2nd .a.._ ] .. . rd - " 4 — - 4th /� .r Total Area(sf) ��k Total Proposed New Construction(sf) Total Height(ft) 1 _ _ 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❑eeec Version 1.7 Commercial Building Permit May 15,2000 "Department,use only City of Northampton StatusofPermit: Building Department Curb Cutlt veway Permit' 212 Main Street Sewer/Septic Avatlabilky .er Room 100 Water/W6(1 Availability C% Northampton, MA 01060 Two Sets of StrucfUral Platys .� phone 413-587-1240 Fax 413-587-1272 Plot/Sife Mans n Other Specify r� PPL ION 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 �D Lo C S� Sfnc t Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: a Z o 3 c L c.. Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: ?T 3 Signature �� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant . . _.. 1. Building (a)Building Permit Fee l5' 2. Electrical ) (b)Estimated Total Cost of Construction from 6 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 mis er nspector of Buildings Date File# BP-2015-0060 APPLICANT/CONTACT PERSON TOWER RESOURCE MANAGEMENT INC ADDRESS/PHONE 16 CHESTNUT ST FOXBORO (781)929-6150 PROPERTY LOCATION LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(l) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid to / /J s Building Permit Filled out Fee Paid Typeof Construction: SWAP EXISTING ANTENNAS FOR NEW MODELS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106586 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Demolition Delay , ;L 7 f 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. 30 LOCUST ST BP-2015-0060 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B-046 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Building BUILDING PERMIT Permit# BP-2015-0060 Project# JS-2015-000120 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TOWER RESOURCE MANAGEMENT INC 106586 Lot Size(sq. ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC Zoning: M(99)/WP(21)iURB(1)/ Applicant: TOWER RESOURCE MANAGEMENT INC AT. 30 LOCUST ST Applicant Address: Phone: Insurance: 16 CHESTNUT ST (781) 929-6150 Liability FOXBOROMA02035 ISSUED ON.712312014 0:00:00 TO PERFORM THE FOLLOWING WORK.-SWAP EXISTING ANTENNAS FOR NEW MODELS - METRO PCS 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 7/23/2014 0:00:00 $90.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):rdwtr Re5durce Aka«ed!...•n Address: City/State/Zip: 61f q 3 Z6(, Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.F1 am a employer with 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 8. ❑ 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.E] 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: r<<�. /� e•d ew w►S, Ce Policy#or Self-ins. Lic.M_ W(_1112410 -61 Expiration Date: 3[11/5- 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 enalties of perjury that the information provided above is true and correct. Signature: Date: � /3 Phone#: $1' Z Y' 92S 3 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#: TOWER-1 OP ID: MM CERTIFICATE OF LIABILITY INSURANCE DATE 03103120`1YY) 03!0312014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTAC Phone:614-848-3000 NAME; Mary Ellen Mathews Insurance Agencies of Ohio Fax:614-848-7698 PHONE 6 FAX 7100 N High St Ste 300 LAIC,No Ext: 14-848,3000 A/C No): 614-848-7698 Worthington,OH 43085-2333 E-MORE Ralph L Guarascl SS:mmathews@insagenciesoh.com INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:Cincinnati Insurance CO 10677 INSURED Tower Resource Management Inc INSURER B:Zurich American Ins Co 979 S High St INSURER C:Illinois National Ins Co Columbus,OH 43206-2525 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYY MMIDDIYYYY LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CPPOS17213 01/01/2014 01/01/2015 REM! 0 RENTED PREMISES JEa occurrence $ 500e00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,00 X Contractual PERSONAL&ADV INJURY $ 1,000,00 X XCU Included GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO- LOC $ JE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ A X ANY AUTO CPP0817213 01/01/2014 01/01/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS Ix NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS CLAIMS-MADE CPP0817213 01/01/2014 01/01/2015 AGGREGATE $ 5,000,00 DED I X I RETENTION$ Nil $ W ORKERS COMPENSATION X WC LIMIT FR /P AND EMPLOYERS'LIABILITY T RY ATUL R B ANY PROPRIETORARTNERIFECUTIVE Y I N C9172410-01 MA,MD,NH 03/01/2014 03/01/2015 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ NIA CT, DE,M E,NY (Mandatory in NH) ,VA E .DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 A Installation Float CPP0817213 01/01/2014 01/01/2015 Inst Fltr 300,00 C Prof Liability 015937975 12/0512013 12/05/2014 E&O 2,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate Holder is named as an Additional Insured as per GA233 - utomatic Additional Insured CERTIFICATE HOLDER CANCELLATION SAMPL-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN This is a Sample certificate ACCORDANCE WITH THE POLICY PROVISIONS. To receive notice of cancellation please call us at AUTHORIZED REPRESENTATIVE Insurance Agencies of Ohio 12"14le 1:-�C4,„ _ - ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 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 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, T�e�e�►'l� ,/li�r ,�,� G�C as Owner of the subject property hereby authorizer to act on my behalf in all m te.-,,_relative to work authorized by this building permit application. Sign L ner Date as Own uthorize 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 of perjury, Print Name i Signat r of Owner Agent 'Dafe SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date i Signature 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 0 No 0