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18D-060 (6) Ccmrens ru MINO AABI. li Interior Walls to add two office spaces, create meeting area. 155A Industrial Drive (Pioneer Valley Books building, previously owned by Tiger Press) Prepared by Excel Builders Co, LLC t /Vd 61-114-1 November 4, 2014 Excel Builders Co., LLC Box 604 Hadley, MA 01035 To: Northampton Building Inspection Services RE: 155A Industrial Drive Dear Representative; I request that you grant a modification to waive the requirement for controlled construction for the project at 155A Industrial Drive in Northampton, because the work is of a minor nature,will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of controlled construction is considerable when compared to the cost of the proposed work. Thank you for your consideration. Respectfully, Andrew Klepacki Excel Builders Co., LLC Box 604 Hadley,MA 01035 r lb Versionl.7 Commercial Building Permit May 15,2000 f SECTION 10-;STRUCTURAL.PEER REVIEW,:(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes No 0 SECTION 11 OWNER AUTHORIZATION-.10.:BE C.:.OMPLETED.WHEN. OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ... ►, ._� ..^.Q �4 w. e_ .... ^C. v._ ,_. .. ._Y_: w _....____ .. as Owner of the subject property hereby authorize act on my behalfjjiAll matters lative tow r uthori y this building permit application. Signature of Own _ Date I,: . ...... _ 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�erlury i Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Supervisor: - Not Applicable ❑ n / � Name of License Holder: License Number Address Expiration Da e Signature Telephone SECTION 13=WORKERS`-COMPENSATION INSURANCE AFFIDAVIT 10 f 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 The Commonwealth of Massachusetts Department of Iiidustrial Accidents tea Office of Investigations 600 Washington Street — y Boston,MA 02111 www.nzass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J t1/Wit G Address: H City/State/Zip: I O f&3S Phone#: 41r3 olq 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 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. ❑Building addition [No workers' comp.insurance comp. insurance.* . required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions �.❑ I am a homeowner doing all work ❑ 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'. 13.7 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: VC Policy#or Self-ins.Lic.#: expiration Date: Job Site Address: o y SA CZ:R L City/State/Zip: Vo ti O 1 a d 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 der the ains andpenalties ofperjury that the information provided above is true and correct. Siizna ture: ( Date: -Phone#• ( t 3 t -73 Of 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 l.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIOWSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION.CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F..OF EN LOSE©SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant):V Registration Number Address i _.._........_.._ ..._.__. .......... Expiration Date Signature Telephones 9:2 Registered Professional Engineer(s): Name Area of Responsibility. , Address Registration Number R E Signature Telephone Expiration Date Name Area of Responsibility Address _ R29,istration Number -- Signature Telephone Expiration Date i l I i Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date I d .... .__. _ __ .............. .._.__. __.. _.__ _.... ......._...._.% Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction _Address___ _ Signature Telephone f Versionl.7 Commercial Building Permit May 15,2000 8_ NORTHAMPTON ZONING. Existing Proposed Required by Zoning . This column tore filled in by Building Department LotSize .:,..._._�.._.�.._.._.._.�. �,....� �.....�:..a ._.�...� _.......��..�_�._,__��.___ 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/Fint1ing ever been issued for/on the site? NO 0 DONT KNOW YES 0 :IF,YES, date issued: ~ ~ .'IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 DONT KNOW Q 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 NO IF YES, describe size, type and location: ?�___�..w� ___....._._..._._..�...�..___..W__._. ,_......�.�,.___..�..._.. _ .._._......-........................_....._........._.........-........-.-....................................... .. D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 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: b 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 ❑ 113 ❑ B Business 2A ❑ E Educational ❑ 2B ❑ 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 ❑ 58 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: C SSpecial Use ❑ Specify:�'.w__m_____...,-.�...�_.._._.._.___.,.,._.�.,,......_,.„ .....�,..�_._._.-......,._.�- .._._-..........._ , COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS ADDITIONS ANDIOR::CHANGE IN USE Existing Use Group. _w_ M_.� I 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 USEONLY Floor Area per Floor(so St . ....... _ _......._.... _.. _.._. ... ._._ 1 St r--”-�--....r..._....-._.._...,_.._-.w _ ._„. lidi__.,. ...�,.,_.�..,.,.. 2nd ___ __,_..,_. 2 .. .........__...,_................. . ...: 3 33rd 3 M th Total Area(so Total Proposed New sfl Construction _._......._................_...__..._ _.._.__ � . _._....._.._.__._...____..._...__........... .... 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❑ .r Versionl.7 Commercial Buildin Permit May 15,2000 flity of Northampton stattt sciPY 't �� �� ��z Building Department CurbCit/DnvewayPermlt. }�kn � 212 Main Street SeWerlSeptic AVatlabtlFty � si ` t s n ,. s ROOM 100 Water/1tr/ell �Oi4 rt ampton, MA 01060 TwQ�� egSQfStructutaEPlansEt ta' _ � 3-, 7-1240 Fax 413-587-1272 Electric, Fiur binq Gas lrsoeciio 6{, erSpeClfy n 3 niC�n N1 1\ 160 + .a. CATION 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 L `f�l1 , Map gr2 Lot Unit Zone° Overlay District -- - -.•-. °-- - M e -° - _•• - Elm'St:District CB District" SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owne f Record: _ _t Gh/ 1 "C .lz _ .__ Name(Print) {t /ty � 2 L / Current Mailing Address: Signature IL4 14. .... Telephone 2.2 Authorized Agent: __ Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED-ONSTRUCTION COSTS., 777 Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building / '1�bpd (a)Building Permit Fee 2. Electrical pig (b)Estimated Total Cost.of O Construction from 6 3. Plumbing ,�j� 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 Commissionerllnspectorof Buildings Date File#BP-2015-0529 APPLICANT/CONTACT PERSON ANDREW KLEPACKI ADDRESS/PHONE P O BOX 604 HADLEY (413)214-2338 PROPERTY LOCATION 155A INDUSTRIAL DR MAP 18D PARCEL 060 001 ZONE GI(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 Typeof Construction: CONSTRUCT 5 WALLS FOR OFFICES&CONFERENCE ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 091132 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 Sig re 6fBuiIdKdOffi&al 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. 155A INDUSTRIAL DR BP-2015-0529 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D-060 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0529 Project# JS-2015-000998 Est.Cost: $14100.00 Fee: $85.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ANDREW KLEPACKI 091132 Lot Size(sg. ft.): 104108.40 Owner: SHAFII REAL ESTATE LLC C/O HAVOC LLC Zoning: GI(100)/ Applicant: ANDREW KLEPACKI AT. 155A INDUSTRIAL DR Applicant Address: Phone: Insurance: P O BOX 604 (413) 214-2338 WC HADLEYMA01035 ISSUED ON.111712014 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT 5 WALLS FOR OFFICES & CONFERENCE ROOM 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 11/7/2014 0:00:00 $85.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner