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31A-067 (23) cA -11 SMITH COLLEGE Facilities Management Department Memorandum DATE: August 15, 2014 To: Louis Hasbrouck—Northampton Building Commissioner FROM: Peter Gagnon- Capital Construction Director RE: King House Renovations CC: file Dear Commissioner Hasbrouck, This letter is to request that you grant a modification to waive the requirement for control construction for the above mentioned project. The work is minor in nature and will not affect health, accessibility or life safety. For this project,it is impractical in that the cost of control construction is considerable when compares to the cost of the proposed work. The construction work and building modification includes the installation of a single non- load bearing wall and door. There is no structural modification involved in this project. Some re-circuiting and switching of the existing light fixture wiring to accommodate the new wall installation is also part of this project. I hope this satisfies the requirements for control construction in accordance with the building code and that a building permit is issued to the contractor. CC: Wischhof Construction >, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street T �;r Boston, MA 02111 www.mass.gov/dig Workers' Compensation Insurance Affidavit: Build ers/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): \A1%S C/y'1Y0 G C3 ( ?—y2c1�T7t1/(i Address: J 0 CMG �Gu�'T�i�c ,� Cif K-1, / City/State/Zip: -d LSiQI/ Av!r�-c�/OC/&Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with—1 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑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 ❑Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance comp. insurance.T required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions officers have exercised their I❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. o workers comp. right p y � ' ht of exemption MGL P 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.7 Other comp.insurance required.] *Any applicant that checks box, 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:' i�_Ai2 -1 11S Z_ A/-0r7_H -)(•°i.t- L Policy#or Self-ins.Lic. #: - 3 0 J'^�/ `� Expiration Date: Job Site Address:MtT K 1 T City/State/Zip:JS ORJ-,,Ak,4A ,,- ' ,' An 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 aannd penalties of p e jury that the information provided above is true and correct. Signature: Date: Phone#: FOther 01111. Do not write in this area, to be completed by city or town official - -— n: - Permit/License# thority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: Versionl.7 Commercial Building Permit May 15,2000 . SECTION 10-STRUCTURAL,PEER REVIEW(780 CMR11011): Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN . OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, .. ........ - as Owner of the subject property _ r.. _ ...._. hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit Signature of Owner 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 penaltlesrof:perlur Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION.SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �? ... �,.,:.,vM... _.. _ License Number YW/V Address /� Expiration Date Signature Telephone SECTION:13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G 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 Q 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 ENE LOSE©SPACE) 9.1 Registered Architect: _. _.�__,_ _�.....__ _.,_.____..........,.......:_.�.._.._._._._._. ................_�.�.___.._.....�,_.:..�.__._._,.__� Not Applicable ❑ Name(Registrant): I Registration Number Address Expiration Date Signature Telephone_µ 9.2 Registered Professional Engineer(s): Name Area of Responsibility ...._.__a ..._. Address Registration Number Signature Telephone Expiration Date i Name Area of Responsibility Address Registration Number______.. Signature Telephone Expiration Date F Name Area of Responsibility £ F i Address Registration Number i Signature Telephone Expiration Date ................. ,__...__ _,,. a .._ ..a: _ - __._._-M_.. ._. ._._......._ .. ..___.. 1. _. _.. .............__ _ ,_ ..------- ..._-..._....................._.. ...._. ..._.. _ Name Area of Responsibility _,.._.._._ Address Registration Number s Signature Telephone I Expiration Date 9.3 General Contractor �aE"1S Cr4',V 7-/,?1,`C-;77 % ._...._.._ Not Applicable ❑ Company Name: Responsible In Charge of Construction __. _ . Address Signatur Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON.ZONING Existing Proposed Required by honing . This column to e filled in by Building Department Lot Size Frontage Setbacks Front Side Rear --j Building Height l Bldg. Square Footage _. I_— Open Space Footage _ % Lot area minus bldg&paved ' parking) #of Parking Spaces — ••—• Fill: T ,_ . _. ,..._ _._._ (volume&Location) .:. __,... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 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 _ Pagef and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES C 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 a brief description here. AI�51 ,1 N 0AI -- 81519 PJVS -- W q 6 Of Proposed Work A.,1.✓ 0 ©a 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 ❑ 18 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B r ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H-Hi h Hazard ❑ - __ -- 3A ❑ 1 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 S eci ..,._. _..._ _........ __.__..__. __ .. P fY� S Special Use ❑ Specify: , COMPLETETHIS SECTION IF EXISTING BUILDING:UNDERGOINGRENOVATIONS' ADDITIONSAND/OR;CHANGE IN USE Existing Use Group: _ _._.._ Proposed Use Group: Existing Hazard Index 780 CMR 34): w _r 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(so 1st 1st . . .. 2nd 2nd 3rd _:... 3 d 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 7.3 Sewage Disposal System: Public E-] Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system E] Versionl.7 Commercial Building.Permit May 15,2000 �.'} Departure tuse,onlX A City of Northampton Status of Perrprt ® Building Department Curb Cut/Drrveway Permrt,: ' W N 212 Main Street SewelSeptrcAvarlabrrty 4A Room 100 Water/WellAvailabrllfy Northampton, MA 01060 Two Sets of SiructuraE Plans 11, k o L phone 413-587-1240 Fax 413-587-1272 PlotlS to Plans �.' �C �j�> Ofher Specify•. ,.a,, t___APj5LICATIqN 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 _ __. ...__,,... _._...... . :,r � �'L�✓� Map Lot Unit Zone: Overlay District Elm St:District CB District` SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailm-9 Addresses �._ ..._. . ._...._...,..._....., Signature �v Telephone SECTION 3-ES IMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building r /) % (a) Building Permit Fee 2. Electrical /T (b)Estimated Total Cost of a O C/ Construction from 6 3. Plumbing 1 Building Permit:Fee 4. Mechanical(HVAC) 5. Fire Protection _ .. . 6. Total=(1 +2+3+4+5) O check Number t-4031 This Section For'Official Use Only. Building Permit Number Date- Issued Si nature: Building Commissioner/Inspector.of Buildings Date File#BP-2015-0189 APPLICANT/CONTACT PERSON RAYMOND WISCHHOF ADDRESS/PHONE 10 Blackberry Circle HOLYOKE (413)533-2520 PROPERTY LOCATION 186 ELM ST-KING HOUSE-COMPUTER LOUNGE MAP 31 A PARCEL 067 001 ZONE EU(100)/URC(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 Tyoeof Construction:_CONSTRUCT NON-BEARING WALL&DOORWAY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 052126 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 Demof ion elay Sign re 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. 186 ELM ST-KING HOUSE-COMPUTER LOUNGE BP-2015-0189 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 A-067 CITY OF NORTHAMPTON Lot:-00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0189 Project# JS-2015-000344 Est.Cost: $6000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYMOND WISCHHOF 052126 Lot Size(sa. ft.): Owner: SMITH COLLEGE OFFICE OF TREASURER Zoning: EU(100,/URC(100)/ Applicant: RAYMOND WISCHHOF AT. 186 ELM ST - KING HOUSE - COMPUTER LOUNGE Applicant Address: Phone: Insurance: 10 Blackberry Circle (413) 533-2520 Workers Compensation HOLYOKEMA01040 ISSUED ON:811912014 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT NON-BEARING WALL & DOORWAY 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 8/19/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner