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39-060 (16)
Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the a edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Cooley Dickinson Hospital Date: 09/22/14 Property Address: 22 Atwood Drive-Northampton,MA Project: Check one or both as applicable: C New construction :9 Existing Construction Project description: The proposed renovation involves installing(2)3'-6"w X 7'-0 11h metal knock down frame opening on the second floor corridors 233 and 240. 1 John A Ferrera Jr. MA Registration Number. 20364 Expiration date: 08/31/15 am a registered design professional,and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [x] Architectural [ ] Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical [ ] Other for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts Stag Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that 1(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 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 if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, 1 shall submit to the building official a`Final Construction Control Document'. tf: Enter in the space to the right a wet or electronic signature and seal: W-W, , y Phone number: 978-407-8848 Email. jaferrera @comcast.net Building Official Use Only Building Official Name: Permit No.: Date: From:Ravmond R Houle Construction 413 547 2544 09/24/2014 11 :48 #243 P_001 /001 The Commonwealth of Massachusetts Department of Industrial Accidents u,p, 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/lndividual):4��amoai •AJ-de- Address: _� � .A I l��a'r (F City/State/Zip: t,,xt Phone#: f 5 Ll Are you an employer`!Check the appropriate box: Type of project(required): 1I am a employer with 4. [] I am a general contractor and 1 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. �emodeIing 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. F�Demolition working or me in an capacity. employees and have workers' g Y P h'• 9. E]Building addition [No workers' comp.insurance comp.insurance.* required.] S. [] We are a corporation and its 10.7 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I L E]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2❑ 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#t must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. !! ff ��,1 Insurance Company Name: — Policy#or Self-ins. Lic. Expiration Date: Job Site Address: 7T � i City/State/Zip: ;iga2k�9 a Y_74 _ 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 der the ;npenalties of perjury that the information provided above is true and correct. pains _ Date: cz� Phone#: L 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#: 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 O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Own e�f t subject property hereby authorize to act on my behalf,in all er relative to work authoriz d by this building permit application. f a e. o r 41311 Signature er Date i. G6,e r T -t V J 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. -t VIA- J Print Name Sig a Owner! ent Date CTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑3 Name of License Holder: License Number Address �j� Expiration ate S 7 Sr- 714 y lure Telephone I 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 80-1 No Q Version l.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 Archhect: NotAlpplicable ❑ Name(Registrant): •T I 03 :J /� Ft r r v r et J r - Registration Number Address 0 31 . Date C Expiration Signature Telephone 9.2 Registered Professional Engine 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 MC �-� �• / cat rC,4.co • Not Applicable❑ Company Name: PA-0f7- � a.,,g-4 y/� Responsible In Charge of Constructlo T— _/ 6- /Y 01-er ST, vet/ew� /Y,t , 0/05� Address Sig a Telephone Version 1.7 Commercial Building Permit May 15,2000 & NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be tilled in by Building DgWUM1 Let Size Frantago Setbaeks Front L R: L• It: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot am mim,s bldg dt paved M of Parki ng Spaces Fill: Odium di Laotioo • A. Has a Special Permit/Variance/Finding ever been issued for/on the site? OGPN NO 0 DONT KNOW YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW YES 0 IF YES: enter Book Page and/or Document# •B. Does the site contain a brook, body of water or wetlands? NO 0 DON-r KNOW (g YES C) IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained O , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES,describe size, type and location: t3ct,t,( 4.-A S tayl L eAt:trl} D. Are there any proposed changes to or additions of signs intended for the property? YES © NO e 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 wil disturb over 1 acre? YES O NO AIN kv If YES.then a Northampton Storm Waler Management Permit from the DPW is required. Version l.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 Alterati ❑ Existing Ground Sign❑ New Signs E3 Roofing[] Change of Use[3 Other❑ Brier Descriptt Enter a brief description here. Of Proposed Wo : �I �Gd Y Q S ti C) SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP Cheek as applicable) CONSTRUCTION TYPE A Assembly 13 A-1 13 A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business M 2A ❑ E Educational ❑ 2B F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1Institutional ❑ I-1 ❑ 1.2 ❑ 1-3 ❑ 38 M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ 8-1 Cl S-2 ❑ 58 ❑ U Utility ❑ Specify: M Mixed Use ❑ Spedfy: S Special Use ❑ Spedly: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Gawp: Proposed Use Group: Existing Hazard Index 780 CMR 34); Pro 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 1" in to 3 3`0 rd 0 4w Total Area(sl) Total Proposed New Construction(sf) Total Height(R) Total Height it T.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private❑ Zone Outside Flood Zone iMunidpalO On site disposal system❑ Versionl.7 Commercial Building Permit May 13.2000 Department use only y of Northampton Status of Permit: SEP 2 ilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability trfc,Plumbing A C ROOM 100 Water/Well Availability. Northern ton, MA rr' spac hampton, MA 01060 Two Sets of Structural Plans 587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 a a Tw o od �r V i✓ Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 0,4 &W Pro SS pir r/f L.L.0 e';' ,30 Si 11,er 57 UA,,;7- 3C Name(Print) Current Mailing Address. .Ay r weq""J -" ey , 0/00 / Signature CO!C S Telephone f,3 — + — 3716 2.2 Authorized Agent: Name(Print) Current MailinnOddress: �C.X, C0 p t'l, /n e'. 0 Signature Telephone t.// ,f - 7 Jq e1 SECTIO 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 3, a G:), 0(, (a)Building Permit Fee 2. Electrical dJc (b)Estimated Total Cost of O a 0 Construction from 6 3 Plumbing Building Permit Fee 4 Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+ 4+ 5) aaa Check Number This Section For Official Use Only Budding Permit Number Date Issued Signature Budding Commissionerlinspector of Buildings Date File#BP-2015-0349 APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 Q PROPERTY LOCATION 22 ATWOOD DR MAP 39 PARCEL 060 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: OPEN 2 WALLS ON 2ND FLR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066195 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 Demolition ay S i g n a6e of Iru iId g fficial 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. 22 ATWOOD DR BP-2015-0349 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39-060 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP-2015-0349 Project# JS-2015-000638 Est. Cost: $5222.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RAYMOND R HOULE CONST INC 066195 Lot Size(sq. ft.): 194756.76 Owner: ATWOOD DRIVE LLC Zonin,: Applicant: RAYMOND R HOULE CONST INC AT. 22 ATWOOD DR Applicant Address: Phone: Insurance: 5 MII LER ST (413) 547-2500 0 WC LUDLOWMA01056 ISSUED ON.912412014 0:00:00 TO PERFORM THE FOLLOWING WORK.OPEN 2 WALLS ON 2ND FLR 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 9/24/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner