31A-112 (4) City of Northampton
fMassachusetts
' DEPAR"ONT OP BoILt)INO XKSPBCTTo s
212 Main street • Municipal building IR11 ,111
Northeopton, WA 01060
INSPECTOR
Louis Hasbrouck Fax:413-587-1272 Chuck Miller
Building Commissioner Phone:413-587-1240 Assistant Commissioner
CONSTRUCTION CONTROL DOCUMENT
`/ (For professional EnglneerslAmhltects resporwMe for Entire Project)
Project Title: Y�F'tbN S'�• 5C440-Ct�• �-a R KA fate: -7 LZ$Z1�'
Project Location: 5(P V�ao» S t. Map: Parcel: Zone:
ScopeofProject 1 P�-t•c 1�0'rl611G fi PAC 1l�D C°rt p�,T
In accordance with the Eighth edition Massachusetts State Building Code,780 CMR Section 1^^0777.8:
1, A-4 K • b� V F-AtlSt- Mass.Registration# I ,
Being a registered professional Engineer/Architect hereby CERTIFIES that i have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
Yf ENTIRE PROJECT
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 shaft 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 and shall be responsible for the following as specified in Section 10.7.6.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the
construction documents as submitted for the building permit,and approval for the conformance
to the design concept.
2. Review and approval of the quality control procedures for all code-requlred controlled materials.
3. Be present at Intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine,in general,K the work is being performed
In a matter consistent with the construction documents.
I shall submit periodically,in a form acceptable to the building official,a progress report together with pertinent
comments. Upon completion of the work,I shall submit to the building official a final report as to the satisfactory
completion and readiness of the project for occupancy.
Signature and at of Revistered Professional
2 Day of J U l.. 20 14'
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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 Legibly
Name (Business/Organization/Individual): &&; 1'F'C ��i �) 0 Y10G?-M,pn t C
Address: 1 -7 C0Ykal SL(--e 1e
City/State/Zip: N� ( 010`71 Phone #: �tC 3 `S 3q-0 3q U
Are you an employer? Check the appropriate box: Type of project(required):
L]AI am a employer with q, 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'
[No workers' comp. insurance comp. insurance. 9. E] Building addition
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.m se o workers comp. right of exemption per MGL
Y � ' p 12.rgRoof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 131-1 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: Guard ,CcJ►�tlhC�' CUF F
Policy#or Self-ins. Lic. #: Z U)G Expiration Date:a q/,-g/ r 1
Job Site Address: S(r U S City/State/Zip: 1y�nAwt.rJI7M.
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 pder the pains an penalties o perjury that the information provided above is true and correct.
Sijzna fore: Date: -7 /!
Phone#: 13' 3 Li ` o-s Gl U
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 O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. d' 1Z Tb1 escvoj0 m; as Owner of the subject property
LL
h b authorize 1 V '""� C—' to
a o b If, i I matters relative to work authorized by this building permit application.
Si na ure dwner X L Date
1, 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 of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: wu c� p i CS t✓�
License Number
( � coyiol( Skeet Sow 66d(p),r omits C:S -v
Address
Expiration Date
Lf13-534 -03cf0 // r -� !'
Signature ` Telephone l O` 1;i/l S
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 1Z 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 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:: .
J-qC (IM SIC' e /�V f �'S P /Te.0 1�'t f-e C(J Not Applicable ❑
Name(Registrant):
i f
0 1 / 1 l lJ�1 J't.f �'� S ✓��^S/���c�r /��1 Registration Number
Address l.= !� /"If
Expiration tion Date>-sips
Signature Telephone
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 ��//��
rCG�C i--p4wi( /2� l'&i"e`n,-,�,><; -.Zn c Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Z na S Sash 1�
Add
r3 s-3 -03r,v
Signature t 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: 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 O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW Q YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES Q NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O NO O
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 a brief description here.
Of Proposed Work: 1e.aj(61 G,PMpn F of u S(ka J f S h'Y1SUJ 0r d GPPIf
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 ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
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(sf)
1st 1St
2nd - 2nd
3rd 3`d
4th 4th
Total Area(sf) Total Proposed New Construction (sf)
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 E]
Versionl.7 Commercial Building Pemiit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
((� �J 212 Main Street Sewer/Septic Availability
v Room 100 Water/Well Availability.
VA �i N rthampton, MA 01060 Two Sets of Structural Plans
P a 87-1240 Fax 413-587-1272 Plot/Site Plans
�c
Gas��So6o Other Specify
PPL 9V STRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
gee°�r �0�th OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION —7
1.1 Properly Address:
This section to be completed by office
V of novz S 4-r Y-e-t S Gvw Cl Map Lot Unit
S(c U e rrtc i C 1r-e *-t-
N 0r.et vh f�yl� 0 tc/(p U Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Cif( d C A)0f+1V kM P f-Vrh `(U Ault n S Nrla 1; �UO� iwl�lvh .
Name(Print) C e h iy-a i ✓C c.e.S Current Mailing Address:
413 ° 5'3 71 040
Signature Telephone
2.2 Authorized Agent:
Ndi, kdLvra( 4acf( Mara kn-nll-Ac I,`2 CC�✓�a� Sid fra° Shirr n i l��2yj OCGZ!
Name(Print) Current Mailing Address:
C� _ �� Lill -53Lt-41 to
Signature Telephone
SECTION 3-ESTI ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building `I a 7'F ` 00 (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=(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-2015-0083
APPLICANT/CONTACT PERSON ARCHITECTURAL ROOF MANAGEMENT INC
ADDRESS/PHONE 17 CANAL ST SOUTH HADLEY (413)534-0390
PROPERTY LOCATION 56 VERNON ST
MAP 31 A PARCEL 112 001 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 v
r
Typeof Construction: REPLACE SHINGLES&CPPM ROOFING
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building-Plans Included:
Owner/Statement or License 38267
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
ti Dela
Si ure 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.
56 VERNON ST BP-2015-0083
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A- 112 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catego!y: ROOF BUILDING PERMIT
Permit# BP-2015-0083
Project# JS-2015-000146
Est. Cost: $126178.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ARCHITECTURAL ROOF MANAGEMENT INC 38267
Lot Size(sc. ft.): 100492.92 Owner: NORTHAMPTON CITY OF VERNON STREET SCHOOL C/O CITY
PROPERTY
Zoning: URB(100)/ Applicant: ARCHITECTURAL ROOF MANAGEMENT INC
AT. 56 VERNON ST
Applicant Address: Phone: Insurance:
17 CANAL ST (413) 534-0390 WC
SOUTH HADLEYMA01075 ISSUED ON:712812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SHINGLES & CPPM ROOFING &
REBUILD PARAPET
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 7/28/2014 0:00:00 $0.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner