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17D-012 (54) GP Plytanium®plywood sheathing is ideal for residential and light commercial construction, and provides outstanding performance for walls and roofs. It adds proven performance and durability to new homes, room additions and renovations. Available Sizes(Sized for 4'x 8') Square Edge 3'-117/a"(1.216 m)x 7'-117/8"(2.435 m) Building Code Performance Categories, Panel Thickness • 3/8 CAT, 0.354"(8.99 mm) • 15/32 CAT(3-ply), 0.451"(11.45 mm) • 15/32 CAT(4-ply), 0.451"(11.45 mm) • 19/32 CAT, 0.578"(14.68 mm) • 23/32 CAT, 0.703"(17.85 mm) Specifications Length/Width Tolerance +0,—1/18"(+0, -1.6 mm) Straightness Tolerance t1/i6"(t1.6 mm) Squareness Tolerance ±1/8"(t3.2 mm) Primary Species Southern Yellow Pine Testing Agency APA®-The Engineered Wood Association Classifications Exposure 1-Plywood suitable for uses not permanently exposed to the weather. Panels classified as Exposure 1 are intended to resist the effects of mositure on structural performance as may occur due to construction delays, or other conditions of similar severity. Exterior-Plywood suitable for repeated wetting and redrying or long-term exposure to weather and other conditions of similar severity. Code Fire Classification Class III or C Flame Spread Rating 76-200, smoke-developed index<450 Building Code Compliance PS 1-09 or PS 2-10 Other Information _ Forestry Certification Plytanium plywood panels are made from wood sourced SUSTAINABLE Certified Sourcing through a system that is third-party certified to the FORESTRY - -- INITIATIVE www.sfip;egrar❑.arg Sustainable Forestry Initiative®procurement standard. Green Building Programs See our Plytanium plywood Sustainability Fact Sheet available at www.builditbetter.com for more information on potential e point contributions towards specific green building programs. a NGBS Green Certified Plytanium plywood is Home Innovation NGBS Green Certified Innovation for Resource Efficiency and Indoor Environmental Quality. ;,KEEN C;;RTIFIE[) 1E Oupcf It EtvC. Please visit Homeinnovation.com/Green for more information. R FNVIP a TAB Q Wk 1 Kigiavoorjami) weamersuip Nits Extreme Temperature Door Jamb Weatherstrip Kit PrIum ia antncrent I::iI a!prod u_ i .bens ly,:)1 ,t Flet -crew ir, , ,,d or steei f,,—Jo,rs Faste–.rs•ndh,jdje on ;ro p F e I re sea s fle-lb at 4 �eg'ee_ :sis ry aid c I ackin In t perati re e,j faster z'r-e a e list I-, ea sv I afior I i adjusirle,1: UM FINISH urf 01 84 SC Pt I 1 1 F Universal Door Jamb Weatherstip Kit s i[to nwi,and vi nv .36 tasteners fn f,ame dc,,,:s,screw 11 I - I ��;�[up _1 sre� fIiI�je 000i� ��t,–ers �srali lv� e,note,cr--,easy wsE�!llc,, i:o,ad lrT ew I, noe: Ito!' 640 c ,84'N-': ALJWr-T V 3,, , 1q CREWS MChLl- 10 0I I l(l 84,c' PP[V0 V FINISH 36 .0,REWS M 10 M P 1`t 1271 X 84'S R BRIGHT ppr lr"IlStl PROUD J?B7EMCnH MftnUFHC-TURER OF WERMERIZINTIOn tr FX0OJ0nG PRODUM FOR OVE& ERRS ii–and Tral-I,,wq e,vice Phn ,0J-6648,1'A http://www.mdteam.com/index.php/products/weatherstrip/rigid-door-jamb-weatherstrip-kits 6/5/2015 1-Lr ,IVA WH 11 11) 87;n7 8" BRO',A,'N ZO Wood&Vinyl Door Jamb Weatherstrip Kit Wood n,tt n e xt b I e v 1,, 11 n P fO V1 lie S A A erl i g h f,,l i?,ita i I s on dw -,:P.Pre �JVVOO(J M Y PWnted colo, ji %AILS i'IMFF) WOOD Compression Weatherstrip w/Wood Stop Door Jamb Kit Sri aqh }ained eec I with foarr yl sear Per d.dential t; F m. 1,1 JnSta;] "e is!,?,Place J0:) pre wed i)u may o,-Ioted D-t C,r X 84 "RP 4WED \N01"', 84" 0,11-41TF 1 A M ED 'A'O(--'P Flat Profile Door Jamb Weatherstrip Kit ,q,,j!,a,,vinyl Fix ;-,rewlnrne,!JAN!;_, 1,or Te'sident'A' ppbcl-i! ., S'-,ew fa re.0 000 or me:tl frame d�, Fa s nr:,ded Inst,'a"-,', —,4siop Slotted hr l,,,, -re c'T," ',-Li Desc. --L11, `4 �CREVVS L;M i N U N11 3('X'- '-JEqvs- :,7 l Z E kL[vV[jM Pill.1L, , X 84 P,?;MMIVI FINISH 11, 84 SCRF% ERM 10 PRENY1 M f http://www.mdteatn.com/index.php/products/weatherstrip/rigid-doorjamb-weatherstrip-kits 6/5/2015 1,-Ir,Lu l-,VVI JW11V WT MAIN MENU Rigid Door Jamb Weatherstrip Kits top oterr sin I'll ',,or)g,,,tn c.-Dottom ;: ta!!atic)n -fdocs,hr jl,eat[le-stnp,11,�jj ease oor me,s eu r,r c.en iy by re. u gips arn,�, entr,, E MI-D Pri �,t rnbP,Odn,1h I j any n F: jPj Products .,num Shap-,F.Meta, ,v�t, Steel Door Magnetic Weatherstrip "'l— -mg Fo, erty d7r,, 1,sta[ied rn aerr !ut in doo-z- ; Magnet [�c, �,iionq t, exit)le q� ,,�jneven-— P;- ing F,j,-As For doo,I w,th k-[,-�a,least ei,,,StOF,s j! or Tn,ee, -, V p ,,I.9 Do, .,.the Itr v,ber ""r, 1• C"Io, A VV $Covers f, 3g;, 0,J -t),,,,,t,cIn 7:FR TURF FTj- ripe FOR V� ,.AIL & 36"X E R I,qJAIN r. R T I!P� E 3gring i ',g VaeaJ,Brstnp Kas S', `)!FOR VAGNI I l�RSTR:f Olt, P " uudd,g;1"'dL Cori- �;e 4"Or VI's", D FOAM I LIL L DOOR SEARCH VACN e , search... LEARN MORE wd Compression Weatherstrip w/Aluminum Stop Door Jamb Kit W,,f and j or comme, res,c, iaete" IfICILIded 1 in op —suip easy atior,and DescnF t:,, Color 0, 36' EWS F X 84, Compression Replacement Weatherstrip (Ilended fr, rzl d Or 'Ise http://www.mdteam.com/index.php/products/weatherstrip/rigid-door-jainb-weatherstrip-kits 6/5/2015 Reflectix, inc. P.O.Box 108(#1 School St.)Marldeville,IN 46056 Phone: (765)533-4332 or(800)879-3645 Fax: (765)533-2327 - Web:www.refledixinc.com E-mail:customerservice @reflectixinc.com REFLECTIX® BULLETIN (Material Safety Data Sheet) This is in reference to your request for a Material Safety Data Sheet for our Reflectix°Bubble Insulation. The OSHA Hazard Communication Standard,29 CFR 1910.1200,requires that manufacturers and distributors of mate- rials containing hazardous components provide Material Safety Data Sheets(MSDS)and container labeling to their cus- tomers in the manufacturing division SIC codes for such products sold after November 25, 1985. Reflectix has carefully investigated the applicability of the OSHA standard to plastic films and metalized polyester which we produce for our industrial customers. From this,we have concluded that OSHA would define these products as Articles,therefore,they are exempt from the Standard and are not required an MSDS or label.For your information, listed below is OSHA's definition of an"Article." OSHA'S DEFINITION OF AN "ARTICLE" (From 29CFR 1910.1200) ".... 'Article'means a manufactured item: (i)which is formed to a specific shape or design during manufacture; (ii) which has end use function(s)dependent in whole or in part upon its shape or design during end use,and (iii)which does not release,or otherwise result in exposure to,a hazardous chemical under normal conditions of use." For further questions,please contact Technical Services at 1-800-879-3645. TI Revised 0612 -- - ►Effective Thermal Performance j Uerior stud walls are often designed to achieve a nominal thermal resistance value. This methodology, which is based on insulation alone, assumes a consistent rate of heat transfer along the wall. However,froming members typically have a higher rate of heat transfer than the areas in between them. High heat transfer along the studs,or thermal bridging, leads to a lower thermal efficiency for the overall wall assembly. Therefore, it is better to consider the combined effect of the framing materials and insulation in the assembly and calculate the effective R-value (RS1). The following tables demonstrate the improved thermal wall performance using Enerfoil compared to other traditional sheathings. Building owners benefit from reduced energy costs,for both heating and cooling. i i R n sula#io.n fn Studs - 5/$° (,13 mm) Gypsum.Board' R3 9 (RSI 0:69) R1;6'.86 (R51,2.97) 1/16P(}1 mm)_Plywood - -. 84.03 (RSI,0.71) ^,816..98 (851'2:99) -8, —_ !Z6(RSI 1 05) Enerfoll R9 65 (RSI 1.70 823 1;1 (RSl 4.07) ( ) ( ) R2r :3 (RSl 4.d4) R9 R5l T 5-.9 Erirerfp�f R12 72 RSI 2.24 - _ _. __ _ , ftT2 (RSI 2 l:p}Enerfof[ ::R15,73. (R512:77) 82 41--(851 • I f it sula#iota In Studs 1. 5/bW'.(1.-3,mm),Pypsurri Board:. _ R3 97.(R51 0.70} 87 .89(9511.39}: 1 7/T fi (T 1 rnrrt) Plywood R4.03---(RSf 0.7:1) R8 0:� (RSI l'.4.7 . — -- - —_ — - R6. 851 l 05):Enerfoi[ R9 48 (RSl 1:67 814`2(RS(Z 50) _ t R9'(R51 1 ` Q) EnerfoiL : 81.29 (RSI 2°.20) 817 2 (8513=03} ' R12 (R51:2.10) E-nor ci . . R15.44(R51 2.72) RMT6 (RS1 3:55) i The above tables demonstrate that using a minimum 1"(25 mm)fnerfail instead of traditional non-insulating sheathings will improve the exterior wafts` effective thermal performance by at least 35%in wood-frame construction. For steel-frame walls,the percentage change is two-fold that of wood frame improvements. I `Reference:Calculations based upon Model National Energy Code of Canada for Buildings(MNECB)or Houses(MNECH)Appendix S. 1 Stud framing percentages derived from listings in Table C-1 of MNECB or MNECH. "Wall assembly with aluminum or vinyl siding and 1/2'(12 mm)interior gypsum board finish.Adjust thermal value by R 0.80(RS1 0.14) 1 when substituting veneer with 4"(100 mm)brick and a 1"(25 mm)air space- "'Wall assembly consisting of 4"(100 mm)brick veneer exterior finish and including a 1"(25 mm)air space. Interior finish is a U2" (12 mm)gypsum board, i - i .Codes & Compliances - - t AS7rAil X289 Type 1,Class ] _ f CANAU_L " 0_Type 1,Class 1 - i45 _&4.. _0 Flarne Spread<55 - J t Smoke Density Index e100 R illf� fi'Wi -- Gi4[ # --.' 13188-L i:. 3 1 t _ t ®i I I I l ffKOA ) *Applicaflons - Cont'd 1 CMU I Eerfoil-is affoched a-ainsf block wall using construction- rade adhesive compatible with air/vapor barrier. B ands are cut to friction i Enerfoit Insulation fit between Building Code approved masonry ties. AquoBarrier AVB I i Note:In order to reduce exposure fo the elements, if is important _ to apply the exterior veneer over Enerfoill as soon as practical, Brick Veneer following its installation. If left exposed for an extended period = i of time, keep a protective covering over the sheathing. -= Air space 1'(25 mm) - Flashing i weep holes Gypsum Board s ' Min.1/2"(12 mm) Corrective action should be taken where evidence of moisture-related problems exist,This may include the replacement'or repair of framing V4.Reiarder members;increased ventilation or installation of a vapor retarder.- Install Enerfoi)vertically and butt all edges. Secure boards with Joint Tape {as required} washered fasteners and penetrate framing members a minimum of 3/4"(20 mm). Install new siding according to manufacturer's busting veneer ' instructions. Enerfail Insulation Batt Insulotion 1 New Siding Batt Insulation When used in interior ceiling and wall applications, Erlerfoll J [nerioil insuiation II must be protected from the building interior by a minimum 1/2" i (12 mm)gypsum board. The use of an interior vapor retarder may not be required if the seams are taped. Consult your local Building Code. For walls,install Enerfoll vertically with edges in Gypsum Boar m} direct contact with the framing members. Install using washered g fasteners spaced 12"(300 mm) on center and penetrating the Stitt Insulation framing a minimum of 3/4" (20:nm), A minimum 1/2" (12 mm) Enertaillnsuiat;on -- gypsum board is to be installed over the Enerfoii. Joint Tepe (as required) e' Gypsum Board - Min.1/4 (1?mm) 1 i ■ �r r MEMO _ sheathing Paiisocyanurate Insulation De mription t facer amino in cifed Enerfoit by KO is o rigid polyiso Manufactured lK0}s state of the a 1SO 9001-2000 registered - 1 on the top and bottom side. Math facility,1't1H1'fdtf is a sheathing that: RSI 1.05 per 25 mm}for improved energy efficient performance of watts: a Provides high thermal resistance of R6 Per inch( P as a smaller thickness !Hetps decrease the eco�e same Ruction(Des of other types of-Insulation. it footprint of their buildings, of Enerfoil ache consumption.C,s 3 is environmsr+tally friendly.No ozone-depleting HCF that S clearly c ntributes totreducingnenergy' onsu a.o6siteeEtaetfoil product.Enerfoil's Energy Stara certifica provide moderate,buse•resistaQfenstallation. s is user-friendly.Laminated(ricers on bath sides of the sheathing p wall applications.Eneffoil's facings is lightweight&easy+o cut,thus reducing labor costs on site.Stud indicators impro for cavityc Provides versatility. Foil facings Provide the long•terin moisture resistance necessary _. materials,which can attack and compromise the performance of other thermoplastic insu at+ons: ore also.compatible with solvent-based airs ace requirements in cavity wall applications: 12 mm 3/4"(T 6 mm), 1"(25.mm), 1-1/2" (38 mm),2"(50 mm), it Has a uniform thickness for consistently maintaining A 16 mm)and T (25 mm). 3 Is available in 4'x 8'boards with the fnila 4'x tfi+boar ses 112"h ( ) 2=tf2"(63 rnrn),3��(Z5 mrn)-Available in 4'x 9'boards with the following thicknesses:3I4" EJ 11EEafEf©i1i5 �� Metal or Wood _ •.� Siding `-- '- Comer Bracing Gypsum Board For wood framing,corner bracing is aecommended at corners and Min.112'(12 mm) around large openings. EtnerfOit is fastened to the studs using Vapor Retarder _n washered Waifs. Ensure that the fastener penetrates a minimum Batt Insulation - of 3/4" (20 mm) into the framing. Steel aslenersawtlth metal ^fosters. _ EnerfoilInsulation fastened to the studs using mechanics Sheathing is installed with fasteners spaced 12" (300 mm) o.c. in ti the flat,8"(203 mm)o:c:around the perimeter. Consult your joint Tape local Building Code for requirements pertaining to air barriers, Siding joint treatment and strapping. Flashing Foundaton Metal or wood — - — CornerBradng� For wood framing EnerEaif is-fastened to the studs using washered Gypsy Boar mm) nails.Ensue that the fastener penetrates a minimum of 3/4"(20 mm) - _ d into the framing.Steel stud wails have Enerfoil fastened to the vapor Retarder • studs using mechanical fasteners with metal washers, Sheathiirig Batt Insulation m) a.c.in the flat, B" is installed with fasteners spaced 12" (300 m Enerfojl Insulation Approved masonry ties must (203 mm)o.c.around the perimeter•App Masonry Ties be spaced and installed as per maaslon y re !�< S�tsin (l 00 sq. joint Tape expanding foam to create tight se - g mm)} penetrations through the exterior envelope and irregularities Brick or Stone Veneer at wall intersections.i.4aintain air space requirements. Flashing Foundation - Thermal Protection 07 21 19 Foamed In Place Insulation . TEON DATA MEET Use all chemical contents within 30 days at 800-325-6180 or FAX 636-349-1708 for 9.TECHNICAL SERVICES of initial dispensing. distributor information. Technical assistance,including more detailed information, product literature, Keep out of reach of children.Always Cost test results, assistance with preparing wear proper personal protective Contact Convenience Products for local project specifications and application equipment, including gloves,clothing and distributors who can provide cost and training is available by contacting eyewear. Use in well ventilated area. delivery information. Convenience Products. Refer to manufacturer's Safe Use, Storage 7.WARRANTY 10.FILING SYSTEMS and Handling For Low Pressure Spray Convenience Products warrants its Additional information is available from Foam Products brochure prior to handling Touch'n Seal products to be free of defects the manufacturer upon request. Touch`n Seal materials.You may request in workmanship and function. a copy of this document from Customer Convenience Products is not liable for any The information contained herein was Service at 800-325-6180 or by incidental,consequential or any other accurate at the time of publishing. Please downloading from www.touch-n-seal.com. damages beyond the description herein, refer to the Touch'n Seal website for the however,certain states have specific laws latest information. 6.AVAILABILITY&COST regarding limitation on incidental or Availability consequential damages, in which case,and Touch 'n Seale polyurethane foams are you may have other legal rights. available throughout the U.S., Canada, Mexico and the world.Contact 8. MAINTENANCE Convenience Products Customer Service None TYPICAL PROPERTIES OF TOUCH `N SEAL GUN FOAM II POLYURETHANE FOAM SEALANT Shelf Life 1 year;unopened container Dry time/Tack Free Time Approx. 10 min. @ 50%R.H. Fully Cured Approx. 1 hour Cuttable Approx.30 minutes ASTM C-273 Shear Strength 18 PSI(1.27 kg/cm ) ASTM C-273 Shear Strain 38 PSI (2.67 kg/cm ) ASTM C-518-4 R-Value 5.48/in.(25 mm) ASTM C-1536 Yield 24 ounce (680 gm)gun foam 2096 linear feet(639m)@ 1/4" (6.4 mm)dia. bead 30.5 ounce(865 gm)gun foam 3196(974m)linear feet @ 1/4"(6.4 mm)dia. bead ASTM D-1621 Compressive Strength 11 PSI (0.77 kg/cm ) ASTM D-1622 Density 1.3—1.8 PCF(20.8—28.8 kg/m ) ASTM D-1623 Tensile Strength 26 PSI (1.83 kg/Cm2) UL 1715 Fire Test Flame Spread 15 Smoke Development 25 ASTM D-2856 Closed Cell Content 77% International Building Code Conforms International Residential Code Conforms BOCA National Building Conforms 1999 Standard Building Code Conforms 1997 Standard Building Code Conforms ICC-ES Listed ESR-1926 California Bureau of Home Furnishings and Insulation Listed Underwriters Laboratories Classified Caulking&Sealants BLIS.R14175, BLiS7.R14175 USA&Canada @Convenience Products 866 Horan Drive,Fenton,MO 63026 USA Tel.(800)325-6180,(636)349-5855 54014-013111-TNS ` Thermal Protection 07 21 19 Foamed In Place Insulation I . TEON DATA SNEET i 1. PRODUCT NAME Touch 'n Seal®Gun Foam II Polyurethane Features/Benefits rr Foam Sealant • Approved Type V Residential Fireblock 4 24 ounce(680 g), Item#4004528712 Penetration Sealant(ASTM-814) 30.5 ounce(865 g), Item#4004529830 • Bright orange color;easily identifiable ,,. • Provides a permanent seal against air, 2.MANUFACTURER moisture and insect infiltration Convenience Products • Easier to use than caulk fireblock 866 Horan Dr., Fenton, MO 63026 USA penetration sealants (636)349-5855 • Bonds to common building materials (800)325-6180 including wood,concrete,insulating foam . 1999 Standard Building Code FAX(636)349-5335 boards,metal,plastics and sheetrock 1997 Standard Building Code E-mail support @touch-n-seal.com • Reduces energy loss • California Bureau of Home Furnishings Website:www.touch-n-seal.com • No ozone depleting chemicals and Insulation • Does not shrink • Underwriters Laboratories Classified 3.PRODUCT DESCRIPTION • Does not trap moisture,dust and Caulking&Sealants Touch `n Seal Gun Foam 11 polyurethane allergens like fiberglass insulation foam is a,high-performance,one • Expands to fill gaps up to 1/2" (12.5mm) PhysicaYChemical Properties component, approved Type V Residential wide reducing air exchanges See Table.Test data available upon Fireblock penetration sealant for use • Reduces use of fossil fuels and improves request. around pipes and conduits. Use bright air quality orange Gun Foam II to fill annular spaces • Helps to reduce Green House Gas Shelf Life around penetrations for approved fire Emissions 12 months in unopened container when blocking performance as an important part • Closed cell structure. stored between 60°-90°F(16°-32°C),in a of residential fire safety. Limitations dry,well ventilated area. Gun Foam II permanently air seals and • Not a firestop. Storage&Disposal insulates gaps and cracks up to 112"(12.5 • Do not expose to temperatures above Keep containers tightly closed in a cool, mm)wide blocking drafts, moisture, 240°F (116°C),open flames or sparks. well-ventilated area. Ideal storage insects while improving comfort and • Not for exposure to ultraviolet light. temperature is 600-90°F(16°-32°C). reducing energy usage in commercial, • Chemicals must be 50°-100°F(10°-38°C) Storage above 90°F(32°C)will reduce industrial,agricultural and residential prior to application. shelf life. Do not store at temperatures applications. • Do not store in temperatures above ° ° above 120*F(490C).Do not expose 120°F(49°C). Basic Use • Always refer to local building code containers to conditions that may damage, puncture, or burst the containers. Dispose Use Gun Foam Il as an approved regulations. of leftover material/containers in Fireblock penetration sealant in Type V • 1 component foams are not suitable for accordance with Federal,state and local residential construction. Gun Foam II may covering large areas or voids such as sill regulations.See Material Safety Data be used to seal cracks and gaps up to 1/2" plates, headers or in stud wall cavities. (12.5 mm)wide. Refer to ICC-ESR for Fireblock Sheet for more information. applications.Refer to local building codes 5.INSTALLATION/APPLICATION Gun Foam II foam provides a permanent for details specific to your area. Always refer to local building codes prior insulating and air seating solution to • Propellant is flammable. Read MSDS to application of Touch 'n Seal foam building component materials including and do not use near high heat,sparks or sealants. wood, masonry, insulating foam boards, open flame. metal, plastics and sheetrock. 4.TECHNICAL DATA The Touch `n Seal Gun Foam II one- Use Touch'n Seal Poly-Clean foam Applicable Standard component expanding foam sealant can cleaner to clean wet Gun Foam II foam ICC-Evaluation Services be applied to,and will adhere to,almost from hands,tools and foam applicator (ICC-ESR-1926) any traditional construction surface guns. • ASTM-814 Fireblocking including wood,masonry, insulating foam • ASTM C-273 Shear Strength boards,metal, plastics and sheetrock. Composition&Materials • ASTM C-273 Shear Strain Surface to receive Touch'n Seal foam Touch `n Seal Gun Foam 11 polyurethane • ASTM C-518 R-Value sealants must be dry,clean and free of one-component expanding foam sealant is • ASTM C-1536 Yield dust,dirt,grease and other substances permanent,bright orange in color, • ASTM D-1621 Compressive Strength that may inhibit proper adhesion. For best hypoallergenic and dries within minutes • ASTM D-1622 Density results apply Touch'n Sea!Gun Foam II of application.Gun Foam li is non-toxic • ASTM D-1623 Tensile Strength expanding foam sealant when surface and • UL 1715 Fire Test and will not decompose with age. • ASTM D-2856 Closed Cell Content ambient temperatures are between ce 60*-a Item#4004528712,24 ounce(680 gm) 100°F(16°-38°C). Item#4004529830,30.5 ounce(865 gm) Approvals/Certifications Temperature of chemical contents must be • International Building Code between 50°-100°F(10°-38°C)before Convenience Products • International Residential Code dispensing. 866 Horan Drive,Fenton,MO 63026 USA • BOCA National Building Code Tel.(800)325-6180,(636)349-5855 54014-013111-TNS w Technical Bulletin 2400 Boston Street,Suite 200,Baltimore,Maryland 21224 Phone: 410.675-2100 or 800-543-3840 Revised: 9/8/11 DAP® ALEX PLUS° Acrylic Latex Caulk Plus Silicone • Waterproof Seal • Paintable • Cured Caulk is Mold &Mildew Resistant • Excellent Flexibility • Easy Water Clean-Up • Indoor/Outdoor Use • Exceeds ASTM C834 Packaging: 10.1 fl. oz. (300 mL)cartridge, 5.5 fl. oz. (162 mL) squeeze tube* Color: White, Antique White, Brown, Cedar Tan, Dark Bronze, Slate Gray, Almond, Black UPC Number: 7079818103, 70798 1 8 1 1 8, 7079818120, 7079818122, 7079818124, 7079818126, 7079818128, 7079818129, 7079818130, 7079818152, 7079818172, 7079818656, 7079874225, 7079874230, 7079874250, 7079874254, 7079874256, 7079874258, 7079874260, 7079811530, 7079811532 * Available in white only Company Identification: Manufacturer: DAP Products Inc., 2400 Boston St., Ste. 200, Baltimore, Maryland 21224 Usage Information: Call 1-888-DAP-TIPS or visit dap.com&click on "Ask the Expert" Order Information: 800-327-3339 Fax Number: 410-534-2650 Product Description: ALEX PLUS Acrylic Latex Caulk Plus Silicone is a professional quality caulking product formulated to last. It is an all-purpose adhesive caulk ideal for a wide variety of applications for interior and exterior use. ALEX PLUS®contains silicone, which allows for excellent adhesion and flexibility to resist expansion and contraction without cracking. It provides a waterproof seal and prevents air and moisture from passing through cracks and joints thereby improving energy efficiency. Cured caulk is mildew resistant. ALEX PLUS°is paintable with latex and oil-based paints. It is easy to use, easy to tool, low in odor, cleans up easily with soap and water and has a low VOC content. Suggested Uses: Ideal for caulking and sealing: • Windows and doorframes • Vents • Eaves • Siding and trim • Baseboards • Corner Joints • Pipes • Ducts • Molding Raft-R-Mate Use Without an Ignition Barrier Flame Spread and Smoke Developed Building codes also often limit the "surface burning characteristics" of foam plastic to a maximum 75 flame spread, and 450 smoke developed. Larger numbers indicate a greater rapidity of flame spread, and a greater volume of smoke developed. See section 317.1.1 Underwriters Laboratories project report 95NK28694 details the results of ASTM E84 (UL 723) testing on Raft-R-Mate. The results are flame spread 5 and smoke developed 25. These values are under the maximum of 75 and 450 allowed by the code. These numerical flame spread and smoke ratings are not intended to reflect hazards presented by this material under actual fire conditions. Experience This report summarizes the Owens Corning position regarding Raft-R-Mate used in attics without covering, however, the user must always verify local building code requirements with the authority having jurisdiction, as theirs is the controlling rule. An example building department position letter concerning Raft-R-Mate is reproduced below. • # ' Department of Trade and Development ,t *G.tagar nrs;ary 6.Lashvtka Geomr,J.kn6d,Direr to ��Cldikl;�`F MEMORANDUM TO, ALL FIELD INSPECTORS AND PL4NS O(AMINERS I&II`S FROM: Joe Busch,Chief Building Offirial 1 DATE.- oc wber 30, 1998 SUBJECT: PRODUCT APPROVAL Ater a considerable amount of investigation and witneseing a video tape of the laboratory burn test on this product,be advised that effective immediately "RAFT-R-MATE",manufactured by Owan Corning,will be acoeptabts for attic rafter vents in residential application for both CABO and OBBC withai4t being covered with gypsurn board. CABO R-216.1 requires loam plastics to have a maximum flame spread index of 75 and smoke development of 250. This product has a flame spread of6'and a smoke Index of 25. it has been tested under UL report SSNK28694 ar*rneets the alranderds.of ASTM E84(UL 7231. NOTE_ The toxicity data listAT_6r this product is based on Nft-TOX 42.1 and is equal to wand. -Thus,this 'gFOduet or any stnliiar product meeting these criteria arc ccaptable in Ccldrribus without the ignition barrier. Installation shalf bop nufg�aurar's p lnted instruction and all products shall be labeled ue\nerye.:.^p\rser-v\reftr tc•Sb; November 1998 Page 3 Raft-R-Mate Use Without an Ignition Barrier Alternative "Performance" Test Data Owens Corning sponsored testing by, model code accredited, Omega Point Laboratories in San Antonio, Texas, to evaluate the performance of Raft-R-Mate, exposed in an attic configuration. The objective of the testing was to assess the behavior of Raft-R-Mate when exposed to a standard fire ignition source, and estimate it's likely contribution to fire growth in an attic. The full test report entitled, "Test Procedure Comparing Roof Vent Materials; Project No. 10950-99375; February 26, 1996, is available for examination. A brief summary follows. The test method utilized a mock-up of a rafter cavity, and a standard burner fire source. It compared traditionally accepted cardboard vents to Raft-R-Mate. Cardboard vents are routinely accepted, exposed to the attic, without covering. The report stated in conclusion, on page 4, that: "...........Raft-R-Mate foam plastic vents "melted quickly and removed itself as a fuel source," The cardboard vent system, 'when exposed to the same conditions, rapidly spread flames along the entire length of the deck, generated a greater amount of heat energy, and induced higher under deck cavity temperatures, than the (Raft-R-Mate)test decks............." See the comparison photos below. c> P.y Raft-R-Mate t r t r P r^ d Y t Cardboard November 1998 Page 2 Raft-R-Mate Use Without an Ignition Barrier Extruded Polystyrene Insulation c� a L o November 1998 Raft-R-Mate, Attic Rafter Vent, Used Without an Ignition Barrier Introduction Owens Corning Raft-R-Mate is an extruded polystyrene foam plastic product intended to preserve an airway through the ceiling insulation layer, and enable air movement, as required by most codes, between soffit and attic air spaces. Sometimes, uncertainty exists regarding the building code requirement that foam plastic be covered, in attics, with an ignition barrier. This report explains that Raft-R-Mate can remain uncovered, and the building code justification. This report summarizes the Owens Corning position, however, the user must always verify local building code requirements with the authority having jurisdiction, as theirs is the controlling rule. Raft-R-Mate is stapled in place, under the roof deck, between rafters or the upper chord of roof trusses, in the area between attic and soffit vents, where the ceiling insulation intersects the underside of the roof deck. Building Code Requirements Building code sections referenced below are from the 1995 CABO 1 and 2 Family Dwelling Code, a model code often adopted across the U.S. to govern the construction of single family homes. Ignition Barrier Covering Building codes often require that foam plastic insulation be separated from attic spaces by an ignition barrier. Common ignition barriers include glass fiber insulation batts, 1/4" plywood, and 3/8" gypsum board, as well as others. See section 317.2.3. Raft-R-Mate is not an insulation, and as such, could be considered exempt from the ignition barrier requirement. The ignition barrier requirement is primarily intended to govern foam plastic insulation used as sheathing. Code officials often interpret the code in that manner. See section 317.1. Other code officials have ruled that Raft-R-Mate, a foam plastic, must be covered by an ignition barrier. Given the manner in which Raft-R-Mate is installed, covering it is a significant hardship. This is particularly true considering that, to function properly, the foam plastic baffle surface must remain in the air flow to the attic space. To resolve such hardships when they arise, most building codes permit testing that demonstrates end use "performance" as an alternative to the "prescription" in the code. If the end use "performance" is judged acceptable by the authority having jurisdiction, then the proven "performance" installation can be substituted for the "prescriptive" installation. See section 317.3. November 1998 Page 1 INSTALLATION ra ft R-mate Attic Rafter Vent BEFORE ATTIC INSULATION INSTALLED USING AIR STOP FINISHED ATTICS with optional air stop/insulation block Installing the optional air stop/ Upon completing steps 1-3,proceed insulation block �� " to steps 4&5.Working toward the YEAR ROUND PERFORMANCE AND DURABILITY Center raft-R-mate between rafters. peak of the roof,continue to place Bend down at accordion hinge.Fold and staple subsequent raft-R-mate IN A QUALITY ATTIC RAFTER VENT. bottom at crease and fit tightly over the vents between rafters.If a full length top plate.Staple to plate. vent will not fit,overlap or cut one to fit remaining space.raft-R-mate attic FINISHED AND UNFINISHED ATTICS vents cut easily with a utility knife or scissors. Disregarding optional air stop/insulation block for use Note:Peak of the attic must be properly ventilated raft-R-mate attic vents assist in the constant flow as straight vent before installing raft-R-mate attic vents. of fresh air from the soffit to your home's attic... Remove any loose debris from soffit \ When all vents are in place from soffit ,t all year round. vent to assure fresh air flow.Center to peak,appropriate thickness of batt raft-R-mate attic rafter vent between insulation may be placed in space Why is that important?Without effective cross- rafters.Position raft-R-mate attic vent remaining between the rafters.Note: ventilation, summertime attic heat buildup can result through fibrous insulation making certain Owens Corning kraft faced insulation li , in a wasteful and costly strain on your home's cooling that product has unobstructed access with vapor barrier is recommended. system..,and your family's comfort. to soffit vent. When kraft faced insulation is used, Staple top left and right flanges,and an approved ceiling or wall material must be installed In the cold months of winter,raft-R-mate attic center valley(if applicable)to underside immediately.Unfaced insulation can be used with a 4-to vents significantly help achieve a well ventilated attic of roof sheathing.Working downward, 6-mil polyethylene vapor barrier.Finished ceiling(gypsum that helps prevent harmful ice dams by removing continue to staple both flanges and board,etc.) may then be applied. trapped moisture that can quickly cause roof damage. center valley every 10 inches.Use coated roof staples('/a max.). Rigidly durable, Owens Corning raft R-mate attic Note:For unfinished attics,stop here. vents will not rot or decay overtime.So years from now the product will be performing as effectively as USAGE the day it was installed. It is simple to apply and easily UNFINISHED ATTIC For 24"on center 24" On Center: held in place with coated roof staples. Perforation Install one raft-R-mate A�I—n rafters,install one attic R-FO�kSh-111 permits use of full or half width, depending on F,orafter vent between Fresh T P P $ attic vent between each rafters. "',F'° spacing of rafters. rafter.A typical attic Rime „RR ,e T requires approximately n•— A (22 k.) Whether you're getting ready to insulate your home's 40 pieces of raft-R-mate °^^° St'a:attic or your insulation is already in place,think of attic vents. raft-R-mate attic vents as an important part of an efficient insulation/ventilation system.When you do, r—A,F R°°`�Re1 you'll be thinking problem-fi-ee savings and comfort. ' FINISHED ATTIC The optional air stop/insulation block prevents loose fill insulation from filling the eave space during Atypical attic rafter will use approximately 16" On Center: installation of cathedral ceiling or attic floors by f four raft-R-mate attic :tee I lil I R°°FOeaSh°E� closing off the opening below the raft-R-mate attic A-- vents installed end to � vent to the soffit. It also helps to prevent'wind end to reach from the oR^e ' F, - Air Fbw wash"which can cause attic insulation to be blown soffit to ventilated peak - back off of the to late causing unwanted heat loss ride vent or common GYGsumBord For 16"on center - P P $ g FbivuslnsWrt° around the perimeter of the attic. air space area. Note: m A.Fbw rafters,snap along s,Pie Attic must be properly perforation and install hb- ventilated before installing each half between raft-R-mate attic vents. rafters. %.f RA- ® r INNOVATIONS FOR LIVING" FEATURES AND BENEFITS OWENS CORNING FAMILY OF PRODUCTS ra it R-mate° Attic Rafter Vent with optional air stop/insulation block Ventilation channel and air stop/ For more information on the Owens Corning insulation block in one easy to family of home building solutions: install product. Call Owens Corning at 1-800-GET-PINKT' • PINK FIBERGLAS' Insulation products Assists in the constant flow of are factory engineered to ensure the best fresh air from soffit vent to attic. thermal and sound-control performance available. Aids in reducing energy loss, PINK FOAMULAR®Insulation Board offers moisture build-up and summertime long-lasting efficiency and ease of installation. • PINKWRAPO Housewrap helps maximize cooling needs. your home's energy performance, • FIBERGLAS° Roofing Products offer lasting Extruded polystyrene construction good looks as well as excellent protection means Owens Corning raft-R-mate from the elements. attic vents are moisture resistant and will not rot or deteriorate over time. A SIMPLE, ECONOMICAL WAY Use full size for 24" on center rafters, or snap in half at perforation TO REDUCE ENERGY WASTE for 16" on-center rafter spacing. AND PREVENT ROOF DAMAGE. INNOVATIONS PoR LIVING • •;'i, / OWENS CORNING FOAM INSULATION,LLC / ONE OWENS CORNING PARKWAY TOLEDO,OHIO 43659 1-800-GET-PINK" www.ovvenscorning.com Pub. No. 20314-F. Printed in U.S.A. November 2007. THE PINK PANTHERT" & ©1964-2007 Metro-Goldwyn i Mayer Studios Inc. All Rights Reserved. The color PINK is a registered trademark of Owens Corning.'y 02007 Owens Corning. Y r N F NATIONAL FIBER Professional Cellulose for Cellulose-Professionals 3.1.2 In open cavity applications that will later be covered with drywall (wall /roof/floor/ ceiling), Insulweb is stapled to the face of the interior framing prior to cellulose installation. Install cellulose insulation using the tube insertion or'dense pack' method in accordance with the manufacturer's instructions to provide a minimum installed density of 3.5 pcf(ibs/cult). After cellulose injection, the Insulweb is rolled flat to allow for drywall application. For durability, drywall shall be installed as soon as possible over the Insulweb in any inhabited areas or where the possibility for damage exists from poking or tearing. In overhead areas, Insulweb should always be covered with drywall as soon as possible,to prevent the fabric from stretching over time. 3.2 Certification and Equipment. Installations will be made only by National Fiber Cel-Pak certified contractors using approved application methods and equipment capable of blower pressures of 3.5 psi or greater at the outlet of the blowing machine, with the agitator running. If you have any questions, please contact our Technical Manager, Bill Hulstrunk at technical,(d,)natlonalfiber.com. 50 Denot Street • Belchertown_ MA 01007 • 800-282-7711 • vrvrw.naUonalfiber.+cor r✓ r NF NATIONAL FIBER Professional Cellulose for Cellulose Professionals 2.3.3 Flammability Characteristics. Critical Radiant Flux: greater than or equal to 0.12 watts/cm2. Smoldering Combustion: less than or equal to 15%. 2.3.4 Moisture Vapor Sorption. This requirement assures that normal variations in relative humidity will not adversely affect thermal resistance. Cel-Pak cellulose insulation meets the requirements of less than 15%for maximum weight gain under the specified test conditions. 2.3.5 Environmental Characteristics. When in contact with steel, copper, aluminum, or galvanized materials, Cel-Pak cellulose insulation is non-corrosive. Cel-Pak cellulose insulation passes all required tests demonstrating that it does not support fungal growth. 2.3.6 Surface Burning Characteristics. Cel-Pak insulation was tested by Underwriters Laboratories (R-13173)for the following properties: 2.3.6.1 Flame Spread: 20 2.3.6.2 Smoke Developed: 0 2.4 Sound Transmission Classification. Numerous wood and steel stud wall assemblies insulated with Cel-Pak insulation, including firewall assemblies, have been tested according to ASTM E-90 and E-413 by Riverbank Acoustical Laboratories for STC ratings. Results are available upon request. 2.5 Building Codes. Properly installed Cel-Pak cellulose insulation meets the requirements for thermal insulating materials set forth in the IBC, CABO, BOCA, ICBO, SBCCI and the Model Energy Code. 3. Execution 3.1 Installation. Cel-Pak Insulation is pneumatically blown, dry, into attic, wall and floor assemblies after all mechanical, plumbing and electrical and other utility installations have been completed. Coverage charts are available upon request. 3.1.1 For loose fill cellulose applications, air seal all penetrations through the ceiling including plumbing, wiring, seams between top plate and drywall and all other gaps or holes,with the appropriate air sealing materials. Chimney and flue penetrations shall be air sealed with metal flashing and high temperature silicone sealants and anon-combustible insulation dam installed of sufficient distance and height to meet the code clearance to combustibles requirements. Install loose fill cellulose insulation in accordance with the manufacturer's instructions to settled thickness, or settled R-value, as indicated on the drawings. 50 Denot Street • Belchertown. MA 01007 • 800-282-7711 • 4f��v�.r�afir�slfit� r.ca � NF NATIONAL FIBER Professional Cellulose-for Cellulose Professionals National Fiber's Cel-Pak° Cellulose Insulation Specifications 1. General 1.1 This specification provides information regarding the pneumatic application of Cel-Pak cellulose insulation in floors, walls, ceilings and attics. Cel-Pak cellulose insulation provides superior R-Value (resistance to heat flow) for thermal applications, sound control for acoustical treatments, and fire control in floors, walls, ceilings and attics of residential and commercial construction. 2. Materials 2.1 Cellulose Insulation. Cel-Pak cellulose insulation is manufactured from recycled paper. Each pound of Cel-Pak insulation contains at least 83% paper fiber content. The fibers are treated with boric acid to create permanent flame resistance. The additives are mold-resistant, non-toxic, non-corrosive, will not irritate skin, will not outgas harmful chemicals, will not attract vermin or insects and will not adversely affect other building materials. 2.1.1 Thermal Performance. Cel-Pak cellulose insulation resists the flow of heat. Conductive heat transfer is limited as indicated by its R-Value of 3.8 per inch. Air infiltration through the material is limited because of the density of the material and methods used to install it. 2.1.2 Sound Control. These same characteristics, particularly the density of the material when installed in walls and floors, also provide significant airborne noise reduction in walls and between floors. 2.1.3 Fire Resistance. Cel-Pak cellulose insulation adds fire resistance to building assemblies, is a code approved ignition barrier over spray foam, and a code recognized fire block. 2.2 Standards. Cel-Pak conforms to the CPSC standard 16 CFR Parts 1209 and 1404. In addition, Cel-Pak cellulose insulation meets all of the testing requirements of ASTM C-739, E-84 and E-119, and UL-723. 2.3. Material Characteristics. The following properties were tested by Underwriters Laboratories (R-8078): 2.3.1 Settled Density. The maximum density after long-term settling in a loose filled, dry attic application: 1.6 Ibs/cult. 2.3.2 Thermal Resistance. The average thermal resistance per inch: 3.8 (R-Value/in). 50 Denot Street • Belchertown_ MA 01007 • 800-282-7711 atio[ualf€her.corn 5. The Big Burn" Insulators Guide, September(1978) 6. National Research Council Canada, Results of Fire Resistance Tests on Small-Scale Insulated and Non-Insulated Gypsum Board Protected Wall Assemblies(July 1994) 7. National Research Council Canada, Fire Resistance of Floor Assemblies in Multi-Family Buildings(Sept 1998) 8. Omega Point Laboratories, Project 16094-105450(1999) 9. Omega Point Laboratories, Project 16094-105449 (1999) For further information, please contact our Technical Manager, Bill Hulstrunk at .echnica!Qnatio faifiber.com. 50 Depot Street• Belchertown,NIA 01007 •800-282-7711 •WVAW naltC rE fiber.com 14iF NATIONAL FIBER Professional Cellulose for Cellulose Professionals Cellulose Insulation and Fire Safety Studies of both actual demonstration fires have shown that the dense fiber structure and fire retardants in cellulose insulation slows the spread of fire through a building, giving occupants more time to escape and firefighters more time to save the structure. During the manufacturing process, cellulose fibers are permanently impregnated with a boric acid fire retardant. Cellulose insulation achieves a Class-A noncombustible rating and passes a strict battery of Federal 16 CFR Part 1209, ASTM E-84 smoldering, ASTM E-970 flame spread and ASTM E-119 fire endurance testing. Testing by Oak Ridge National Labs (1990)1, US Testing Company (1991)2, UL (1993)3 and US Borax (1994)4 all established that the fire retardant chemicals do not degrade over time and are permanently bound to the cellulose fibers. 1978 "Big Burn Demonstration"5 • Fiberglass insulated building — Ceiling failed at 20 minutes — Building burned to the ground in less than 2 hours • Cellulose insulated building — Ceiling failed at 70 minutes — All four walls left standing, fire burned itself out after 3 hours 1994 NRCC National Fire Laboratories6 • Fire resistance of wall insulated with fiberglass is slightly worse than a non-insulated wall • Fire resistance of wall insulated with cellulose is 11% to 55% better than a non-insulated wall 1998 NRCC National Fire Laboratories' • Cellulose increases the fire resistance twice as well as fiberglass in a floor/ceiling assembly 1999 Omega Point Laboratories • Cellulose insulated wall performed 77% better than uninsulated wa118 o E-119 testing (1 hr, 2hr firewalls)on Electrical box placements — 24" Minimum Spacing for Fiberglass — 3.5" Minimum Spacing for Cellulose References 1. Chiou, N., and Yarbrough, D., "Permanency of Boric Acid Used as a Fire Retardant in Cellulosic Insulation", Energy and Buildings, 14 (1999) 2. United States Testing Company, Study for Suncoast Insulation (1991) 3. England &Assoc. and Underwriters Laboratories, study for Suncoast Insulation (1993) 4. Perm, Donald J., and Shen, Kelvin K., US Borax, Study on the Permanence of Borates in Cellulosic Insulation," Proceedings of the Tenth International Conference on Thermal Insulation (1994) 50 Depot Street• Beichertown, MA 01007 • 800-282-7711 •vevy w.natl�rtt��f�G��re��t?B NF NATIONAL FIBER Professional Cellulose for Cellulose Professionals Cellulose Fire Blocking and Ignition Barrier Capabilities Numerous US and Canadian studies have confirmed cellulose insulation's superior capabilities in terms of fire resistance, sound attenuation, and thermal performance. The permanently impregnated, borate-based fire retardants, along with its high installed densities, allow our cellulose insulation to retard the propagation of fire and hot gases by resisting flame spread and remaining in place much more effectively than other types of insulation and non-fire retardant treated building materials. National Fiber's Cel-Pak cellulose insulation achieves the highest and most fire resistant material rating of Class A/ Class 1 under ASTM E 84 and passes the strict Federal 16 CFR Part 1209, ASTM C 739 and ASTM E 970 requirements, having a flame spread index of 20 and a smoke developed of zero. National Fiber's cellulose insulation has been approved as a fire blocking material under Section 708.2.1, Item 1, of the UBC, Section 716.2.1 of the IBC, and is permitted as an alternate to the fire blocking in Section R602.8, Item 1, when installed in a dry or spray application to a depth of 14.5 inches, cellulose outperforms conventional wood fire blocking in fire blocking tests. One and a half inches of cellulose has also been approved as an ignition barrier in the 2009 ICC under section R316.S.3. This is useful in attics over foam products that have been used for air sealing. Adding cellulose insulation to wood frame walls increases their fire resistance rating by 15 minutes. Our cellulose insulation is ASTM E 119 tested and UL approved for use in a variety of wall and floor/ceiling fire rated assemblies. For example, Southwest Research Institute Project#01-5920-611 tested and approved a one hour fire-rated load-bearing wall assembly, consisting of a single layer of 1/2" type X sheetrock on each side of a 2 x 4 stud wall filled with cellulose insulation. The International Building Code (IBC) 2000 &2001 Amendments also allow electrical outlet boxes to be installed on opposite sides of a one-hour firewall, if they are offset by 3.5 inches of cellulose insulation. This offers greater design flexibility over fiberglass, which requires a minimum of 24 inches separation between outlets. In 1994 the Research Council of Canada (NRCC) reported that fiberglass decreased the fire resistance of insulated walls, while cellulose produced a 22% to 55% increase in fire resistance. In 1995 the NRCC tested floor/ceiling assemblies and found that cellulose increased the fire resistance more than twice that of fiberglass and 40% over that from rock wool. Even though cellulose improves fire safety, it is important to remember that cellulose insulation is not a non-combustible material and minimum clearance to hot surfaces such as chimneys and non-IC rated light fixtures must be maintained. For further information, please contact our Technical Manager, Bill Hulstrunk, at 50 Depot Street• Beichertown, NIA 01007 •800-282-7711 •��F ��t��'�� Initial Construction Control Documen To be submitted with the building permit application by Registered Design Professional fV�P°pi '7 Ulf for work per the 8t"edition of the a°,eJwS Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: Weatherization of Meadowbrook Apartments Date: 8/12/14 Property Address: 491 Bridge Rd,Florence,MA Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Air seal attic spaces, install rafter vents,and insulate attic spaces with additional R-20 of blown cellulose over existing insulation for an approximate insulation value of R-49. I, David Vreeland,MA Registration Number: 46317, Expiration date: 6/30/16,am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Entire Project Architectural Structural Mechanical Fire Protection Electrical X Other: Construction Control for the above named project and that such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I (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. 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'. S"OF Enter in the space to the right a"wet"or }� DAVID A. cic electronic signature and seal: VREELAND CIVIL No.46317 ISTEA O� Phone number: 413-624-0126 Email: dreeland @verizon.net st L Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description. Trial Version 10092012 :t tae commionweC,itin ui 1i�f6S5Lee rere.secru r -- Department of Industrial Accidents ^ , E4 Office of Investigations ,z{ l 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AUplicant Information Please Print Legibly Name (Business/Organization/Individual): � �unc Address: Q City/State/Zip: `(�f��(l C \ � yhone#: 7j— 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 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.F1 I am a sole proprietor or partner- listed on the attached sheet. 7. E)Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working or me in,an capacity. employees and have workers' g Y P tY• 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 1 L❑Plumbing repairs or additions myself. [No workers' comp. ri ght of exemption per MGL 12❑Roof repairs insurance required.]t c. 152, §1(4), and we have no ,f q ] 13.( Other Il� is�t' fz,Y1 employees. [No workers' �` comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance•for my employees. Below is the policy rand job site information. Insurance Company Name: ,r� �t� Policy#or Self-ins. Lie.#: �JS C3 ©� P cv Expiration Date: 0 ' Job Site Address: .q $ (��rp�g`�.� e j� i r i�l i�P_r ,�g City/State/Zip: RD c e'.ti e AA C,tC', 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 DU for insurance coverage v/eHfication. Z do hereby certify a taae pains a j�d penalti perjury that the informadon provided above is trace-and correct Sim afore: �' /a' ,4 f'°� Date: "� Phone-747: Official use only. Do n®t u.wite in this cares,to be ear Dletecl by ccty or to w n d�ccia City or Town: 1�er��lk Pcert�e# Issuing Authority (circle one): I.Board of Health 2.13u-11ding Department y. City/Town Oerk 4.Electrical Inspector S.Plumbing Ingpector 6. Other i Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location ) No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire AIarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other(Specify) v C- 21 Other(Specify 22 Other(Sp ecif *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information qll� - �'1 C ,cN.1t1 . ��.Ct7i1.11 Name(Registrant) Telephone No. e-mail ad ess Registration Number r� s lye�r RJ beuit-U k �` A �i 337 Cleo�r ;� J I l l " Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Proppe Owner '� wlsll�iI"J�C�t�"T'1 r-'. �Gfm' .~? Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-mail address` If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13, Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin g document submittals) ^oa d V r araj 14 t?-(�,A— 012)1;0 �� t:�s'��: b�?Cat 1 z l.11� '�� 7 Name(Re ids/tr {ant){ /y( Teleph ne No. e-mail ald�dr ss / ¢ Re stria/t)ion Number i7} `9 1 I C.Sa' (L!'�.'1�Y ll:^.• Yom ' r�jY� /"y ls�l .�7 C_d_» (x ,J6' f Street Address y/Town State Zip Discipline Expirat<on Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if AppIicable Street Address City/Town State Zip Telephone No. usiness Telephone No. cell e-mail address SECTION 11:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.9 25C 6 A Workers'Compensation Insurance Affidavit from the ALA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? YesjK 13 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ mc o,c)o Building Permit Fee=Total Construction Cost x`(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 7S CO, (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of myy know,d nd understanding. Please print and sign name Tide Telephone No. Date .- "€►c. d'4 F ��'a�_��. 6�� j�►.,��:....-- ��- �,;i�,,�,<�° ...,�"�`i� ,� ��,t,��x))j�r?.e,�r:�l�:��; e..��t' : ��`r� Street Address City/Town State Zip Entail address Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts Department of Public Safety v Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) ^ Assessors Map# _ Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing BuildingX I Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ 1 Change of Occupancy ❑ Other Specify: 1415120-41Cn — Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:rJ/"S <,-lases G_x4e-k vropex i _5 ' C G' . "1 a CeflVIDS� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 4S<� Total Area(sq.ft.)and Total Height(ft.) 1 Pq SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑j B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ I R: Residential R-10 R-A R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ 111 [3 ❑ IIB C3 IIIA ❑ IIIB E3 TV ❑ VA E3 VB SECTION 7.SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit. Debris Removal: Water Su pl : Flood Zone Information: Sewage Disposal: Licensed Disposal Site Public Check if outside Flood Zone Indicate municipa , e trench w' not be P require or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-real=: Hazards to Air Navigation: N!A Historic Commission RevieNy Pro ess: Net Applicable is Structure within airport ap roael1 are is their review c �np��ted? or Consent to Build enclosed❑ Yes❑ or NoA Yes❑ �T SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: — File#BP-2015-1251 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP 28/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid V- Buildiniz Permit Filled out Fee Paid Typeof Construction: INSULATE ATTIC,HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing_ Accesso1y Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1251 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) CateQory: INSULATION BUILDING PERMIT Permit# BP-2015-1251 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.•61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 28 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ine (.ErdEbt'riiJr'¢F'a%euttot vJ 1GBtCa.7Nl.ecssuv�� Department of Industrial Accidents Office of Investigations ►'' 600 Washington Street —� Boston,MA 02411 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetrleians/Plumbers A-Pplieant Information Please Print Legibly Name (Business/Organization/Individual): k �Oftrvc Im,picmYnn C' 4- City/State/Zip: A, `Ol E't�11« ,%one##: Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 19 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in.any ca P aci tY• employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑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 ` ( Other employees. [No workers' 13. '1lSlL��✓Ji>>� 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 ornottbose 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 rand job site information. Insurance Company Name: ,�b�'.lt� r-- Policy#or Self-ins.Lie.#: G�J�C °j "Z S Expiration Date: S Job Site Address: =�`%1 1 rr r a�+,,r;� �tt i�t��1�i ,� I City/State/Zip: r-110 Q4,1C AA 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 i v tine pains a.d penald perjury that the inform,at!on provided above is traae and correct Sianature: / tl / ��' f'°i Date: =7 Lx Off vial use only. Do not write in this eaveaa,to be completed by city or town of cciaL City or Town: Permit[Lleense# Issuing Authority(circle one): 1.Board of Health 2.Baaifl na Depzrtrnent 3. Cfty/Town Clerk 4.Electrical Inspector S.Plaimhing Inspector b. Other �� Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location t ,err No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No M Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist-for Construction Documents' Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Su ression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas atural,Pro ane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifica tions 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Surve /Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMIZ 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) ty vC. _ 21 Other S eci 22 Other(Specify 'Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information 4+(e3i Name(Registrant) Telephone No. e-mail ad ress Registration Number .i(. � Pct. L_eijAc,_x) KA Gt337 ct\14 l Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Property Owner 14 Name(Print) �— No.and Street City/Town Zip Property Owner Contact Information-.-. VC J Cite- J If X19 -��l - Title` — Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not wider Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin document submittals) D-AyLa V relelGll f _G ` , C G �V� et�tt'i�; 1itetE�i«l,l�e �v� l` Name(Re is Teleph ne No. e-mail adds ss Re.' b•ation Number Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name C'S - 6)t'D- Name of Person Responsible for Construction License No. and Type if Applicable 3*1, Ru, List& -Ly• Floience_ Street Address City/Town State Zip 413 - = '7524- SYe- yaiiir lbaneiMrovelr r+ : c Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WOP.KERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Ye!JK No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 00 O Building Permit Fee=Total Construction Cost x`(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to _ 6.Total Cost $ 75DO, 07C) (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know�d d understanding. Please print and sign name ` Title Telephone No. Date pe Ir�"":;'v°e"�?'9bc'Y Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: RA r SECTION 1:LpOCATION d L\ `•__ .l NO No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # ' '" SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other 9 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes ❑p�� No 6� p Brief Description of Proposed Work:Ct r 5 e l GZ-i1C S e-x4ee Ck pr-pl>ec 14 errs th k�e- otee- j -S^ leJ- r-- '6 t `'(d. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 14897 —^ -- Total Area(sq.ft.)and Total Height(ft.) W4 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-10 R-3g R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility 07 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IlB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB SECTION 7.SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information Sewage Disposal: Trench Permit Debris Removal: Publi Check if outside Flood Zone Indicate municipa A trench w;l not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-`waa Hazards to Air Navigation: MA Historic Commission Review Process: Not Aprlicab-ef is Structure within airport approach area? Is their review c mpl ted? or Consent to Build enclosed 11 Yes❑ or No Yes 13 NoX SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1249 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid ;2= Building Permit Filled out Fee Paid Typeof Construction: BLDG 27-INSULATE ATTIC,HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan TH OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I ORMATION 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 sPermit DPW Storm Water Management Demolition Delay A) 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1249 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.-Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1249 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner., MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zonine' URB(100)/WPl28Z Applicant: VALLEY HOME IMPROVEMENT INC AT.• 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.•61512015 0:00.00 TO PERFORM THE FOLLOWING WORK.BLDG 27 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1tie uommonweatin o iriassucriuseus -_ Department of Industrial Accidents Office of Investigations 600 Washington Street a Boston, MA 02111 AV dia www.mass.govl Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1,� Please Print Legibly Name (Business/Organization/Individual): QA lftl, k_n')K Address: �� y��j�C;t� t�;`-� City/State/Zip: `Q,(-P_ bf, \ r PhZ one:#: Are you an employer? Check the appropriate box: Type of project(required): . a g 1. I am a employer with �9 4 � I m a eneral contractor and I [� 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 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, F�Demolition working for me in.any capacity. employees and have workers' g E]Building addition [No workers' comp.insurance comp.insurance.1 required.] 5. E] We are a corporation and its 10.0 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 12,0 Roof repairs insurance required.]t c. 152, §1(4), and we have no ` x employees. [No workers' 13. Other (ll5 4L� t Z�y1 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 nay employees. below is the policy and joh site information. Insurance Company Name: f�ylpf �o C VII Ai�L1 `°e Ga rC)J" — Policy#or Self-ins.Lic.#: 00(G )cE)Q`Je2 0_S Expiration Date: a I(, Job Site Address +- i -� City/State/Zip: k lC- 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 DLA for insurance.coverage verification. I do hereby ceryof. the pains a fed penalti perjury that the information prodded above is true and correct Signature: 4 �,�/ f�,-�i Date: �" I l IJ Phone_ O f f i c i a l apse o n l y. Do not write in t iz i s area,to be completed b y city or town of ccga City or Town: hermft[License# 1&iuing Authority (circle one): 1.Board of Health 2.Build- mg Department 3. 0ty/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other I Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location 0/060 t� �` IU n1 No. and treet City/Town Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) ry & G E 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad ress Registration Number RA &037 Street Address City"/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address f Pro r»er(y Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not wider Construction Control then check here E3. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible i for C_onstru:ction Control(the professional coordinin g document submittals) Day+ Vr-eejLnA �� l c{ d \ iZ 1 ^ fj C re1a , , J 7 Name(Re istrant) eleph ne No. e-mail adds ss Re istration Number Street Address (-*/Town State Zip Discipline Expiration Date 10.2 General Contractor c ue; Rome- _' nv! eA-y -Xi` Company—Name .41 07D-72 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413 _ 751.E _ - - y ) V jjj:::Ah6MeivWiTVe3ren-1: C Telephone No.(business) Telephone No. cell —�� e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 13 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ -75-00,DO Building Permit Fee=Total Construction Cost x,(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 75W, (;7(' (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to th#bs of my know and understanding. P f J e EM•�1 [ f & �i/!>�,`�/ 4€J _5FY- 752 L Please pr�nt and sign name Title Telephone No. Date c t N J1 xw-� I,N Street Address y City/Town State Zip Email address Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts Department of Public Safety ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official:- SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # F�7i( " SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: i'I Sl - t u�'1 Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: r 5e ) .-S e-X4ca•c� n er vet l'S . e- fc �. t 4e1 +0 _ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 W17 17 -- Total Area(sq.ft.)and Total Height(ft.) NUT 30 - — SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA (3 IB 13 IIA C3 IIB ❑ IIIA ❑ IIIB E3 IV ❑ 1 VA ❑ V SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site Public./ Check if outside Flood Zone Indicate municipa A trench will not be p Private 13 or indentify Zone: or on site system required, or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable is Structure within airport ap roach area? Is their review c _ plated? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1248 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 26-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing - Accessory Structure Buildituz Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1248 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1248 Project# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 26 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I he commonweatm of jriussaacnuseaas Department of Industrial Accidents ®ffice of Investigations =r A. 600 Washington Street t=om' Boston,MA 02111 - - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly_ Name (Business/Organization/lndividual): VVIe,,t' 4- , Address: �� tY `C�f�t�C \ 1) Phone 4:_ LI, ��`�X22, Ci 1State/Zip: � Are you an employer?Check the appropriate bog: Type of project(required): 1.M 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling slip and have no employees These sub-contractors have S. ❑Demolition working for me in.any capacity. employees and have workers' insurance. 9 ❑Building addition con [No workers' comp,insurance p• 10. Electrical repairs or additions required.] 5. We are a corporation and its ❑ p 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 [1'17 t)i��4 t y 1 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 ornot 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 gray employees. Below is the policy and joh site information. Insurance Company Name: �iZ i} � G roue Policy#or Self-ins. Lic.#: �J�J �`Z 0_S Expiration Date: Job Site Address:_ ` l~),r 0JI t�l 1'1l - City/State/Zip: F-Io c it 1 J�'-- 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 forth 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 rrification. I do hereby certify r the pains a°j?d penalti perjury that the information provided above is true and correct Signature: t� lai i (/ .4 �.,��, f-�i Date: "0 Phone#• Official use only. Do not write in this area,to he completed by c!V or town of acieal City or Town: permit/License# Rguitng Authority(circle due): Z.Board of Health 2.BuRdinm Departments y. City/Town Clerk 4.Electrical Inspector S.Flumbing Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location 54 01U6o MA lAje6joj�l No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program _ 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' end C 21 Other(Specify 22 Other(Specify "Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information �y� Vi G' ZC '@��_ � 1; f1i >` 7tivE''- 7 1 l � C 7 Name(Registrant) Telephone No. e-mail ad ess Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Please follow this link for construction control_forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address f Property Owner p } �t�C�aw°��C k- iESCt'Jca dc"`•T1• - . 3 -,, c-", .�:a�"�Llti' �-' _ ,1 , Name(Print) and Street City/Town Zip Property Owner Contact Information: Ztkj Title Telephone No.(business) Telephone No. (cell) e-mail address` If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide constwction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinlatin document submittals) ff Name(R strant) elgli ne No. e-mail addr ss Number 01 Street Address /Town State Zip Discipline Exptratron Date 10+x.2¶General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable 340 R E 4(_),C5ae ty• _ F(oi-e4-ice— Nth CSCo& Street Address City/Town State Zip 413- '7524- Telephone No.(business) Telephone No, cell a-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this applica tion? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 7529, 00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under,the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d d understanding. `�✓ 0...41,* F �.Ft C i/�, �.f� jr tF �' / ./j�11 '/ Y12 5FY- ,�52"" Please print and naine� ✓{ �/ �{Title Telephone No.� Date 5�q tG� (E �R M1' ✓m of ... SA C t�@"`� Ci..'".!' }"V'` .�i 4 -� C �+F(C �+E.eC l,C,,,�6}}�'�`l riei �,.Wi�l�PC't•z Street Address City/Town State Zip `Email address t a Municipal Inspector to fill out this section upon application approval: Name Date ~ The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION i' art doe- M. No�q y) 010410 intend tombrmk'. t 'cw Finer No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used 50, If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other X Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:ajr St"Ck/ Z ° e.7C t"ck rorper verAs . • e n 11,7-2/U 1pA &4E5 66 D26W 9 C L L. LLQ rt �� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 qeq 7 Total Area(sq.ft.)and Total Height(ft.) It{0 ?)p r SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 0 A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 RA R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ ILA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VBX` SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply. Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Publi Check if outside Flood Zone Indicate municipa A trench w' not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of' Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable is Struct--re within airport ap road:are a? is heir review c -npl ted? or Consent to Build enclosed 11 Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1246 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid �J Typeof Construction: BLDG 25-INSULATE ATTIC,HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I ORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1247 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1247 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning URB(100)/WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 he Con€monweatin of niussucritasetta ` Department of Industrial Accidents Office of Investigations P= 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information i1 Please Print Legibly Name (Business/Organization/Individual): Address: �-�At; \CA �,X k`, City/State/Zip: aC [ h e##: Are you an employer?Check the appropriate box: Type of project(required): LM I am a employer with I S 4. [] I 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 S. []Demolition working for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.t 9. Building addition required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑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 13 Plother 1 ` t��1 employees. [No workers' 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number, lam an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. Insurance Company Name: &bf'.. o, G rc�jP r Policy#or Self-ins. Lic.#: (,� E� Q J 0"- 1 Expiration Date: Job Site Address: E)rl dru_ Rv . V U,-1 t l t� City/State/Zip: 1:_10 Ce4lt�e A 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 ILIA for insurance,coverage iification. l do hereby certify r tlae pains a fed penalti per, ry that the inform. ation provided shove is true and correc� Si afore: 1 ` : i ,4 ?i ;'f�,-�� Date: I-) ! �J Phon° UVim^sl�q--"�C�� ' O frciaPl use on11: Do not write in tHs areay to be come-leted by city or fowra of ciaal City or Town: Permit/License# �� Issuing Authority(circle one): 1.Board of Health 2.BuMna Department 3. City/Town Clerk 4.electrical Inspector S.Pla�mbkg Inspector 6.Dtber 11 Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. liqt Property Location 540 lqec 12 Bndcle- No. and treet City/Town Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation.Documentation 20 Other(Specify) w v C- 21 Other(Specify 22 Other(Specffvl *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad ess Registration Number f6)1v KA 337 Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Dace Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Addressyf ProEper Owner 14 ec��t�R ice, 1 s�.I Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Id's Title Telephone No.(business) Telephone No. (cell) a mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin document submittals) David �� yf�_C�'�_ �'i..�t� (��I��tu8'1�: ��i?vf1��t.17�! q63 17 Na pmFe�ft istratnt) /q{ eleph ne No. e-mail adds ss / t } Re/qp"—�s�tr/a�tion Number Street Address C' /Town State Zip Discipline Expiration Date 10.2 General Contractor \ t� Rcme— jmpfj),s& -A-f " Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c 152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accident;must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Ye!X No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ -7,500, G O Building Permit Fee=Total Construction Cost x,(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ "75001 O 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know nd understanding. Please prtt and sign name . Title Telephone No. Bate ��,� 5r, � ,-. .k ,�. a,-P ��-r,✓� �,}'� �h',- � �,,.. d.�C.yn�, ,r a� ��, tr re rr r �'y`"� _I eC,; 6 1�,.�t��`��_ ."y i.�' o ' �•,• ` __ �„��:,c —� ----� v��ei�� ,f.Yi�"'. 'tl�- '�;"6N.Ft'fr` Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts Department of Public Safety ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # 6-o f do 4 SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration ❑ Addition❑ Demolition 13 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other JK Specify: �50ia ltd'''► Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No, Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:Coo Sea) LA / •S �x-E .� _rack je `Gfs :,o)l-e-re- r�F� _�l2�I SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) It H7 — — Total Area(sq.ft.)and Total Height(ft.) jq(eq 30, ..� SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4 Cl H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-113 R- R-3❑ R-4❑ S: Storage S-1 13 c_ 2❑ U. Utility❑ Special Use❑and please describe below: Special Use Description: SECTION&:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su pi Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipa A trench w' not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ _ Railroad right-of-way: Hazards to Air Navigation: MA Hstoric Commission Review Process: Not Applicable,, is Structure within airport approach area? is their review c n I ted? or Consent to Build enclosed❑ Yes❑ or Nox Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1245 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB000)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT la Fee Paid_ Building Permit Filled out Fee Paid Typeof Construction: BLDG 24-INSULATE ATTIC.HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN�RMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1245 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2015-1245 Project# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)/WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 24 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Siiinature: FeeType: Date Paid: Amount: Building 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Y4 1 die C©mmionwvealith of iwassacaiuseeas =: Department of Industrial Accidents a= , Office of Investigations _ i 600 Washington Street —' �if?;: Boston CIA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name (Business/Organization/Individual): R 1,-n Address: City/State/Zip: `C7f��1C� \ `(� Q�(�Phone##: Are you an employer? Check the appropriate box: Type of project(required): 1.[� I am a employer with 19 4. E] I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, EJ Demolition working for me in.any capacity. employees and have workers' 9 [:]Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.( Oth er try 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 nay employees. Below is the policy and job site Mformation. Insurance Company Name: Policy#or Self-ins. Lic.#: G�J�J 0 d02— P.v Expiration Date: a � t 1� 5 Job Site Address: ` 6'"1 6 fit'a t�1 :k ae, —City/State/Zip: rlo L-ence iqA C)1C� �- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration slate). 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 v/erification. I do hereby certify i the pains a 1�d penalti perjury that the information provided above is true and correct W, n 9 ! Si afore: 7�• �� ,'fv�-. Date: ( �: Official uEe only. Do not write in this area,to he coinpleted by city or towns of ccial City or Town: Permit/LEceme# �� lgsuing Authority (circle Gne): 1.Boars of Health 2.Buffding Department 3. City/Town 0erk 4.Electrical Inspector S.Plullab nu In Pector b.0 ..-er Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Locations llqt r- No.and treet City/Town Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified. and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression _ 5 Fire Alarm(Lnay require repeaters) 6 HVAC _ 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' et v C-' , 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information _ .1 Name(Registrant) Telephone No. e-mail ad less Registration Number Street Address City"/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zip Discipline Expiration Date Please follow this link for construction control.cn s to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Property Owner �j 1�(`�c v'c'4 y O1 � r' fG�"' ] 4 �`t 4iU !fir _1S1, �'lfe do's Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-mail address'✓ If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Reigstered Professional Responsible for[[Construction Control(the rofessional coordinatin document submittals) a`yLd yneeiG�i 413_�'.A C'f<aq(ti �.1Vredtti'lr: 017 Name(Re istrant)� eleph ne No. e-mail adds ss Registration Number Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Mme l x evyw � Company Name —7 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 4)3 - = c? e� �9E dd � l a�ei ► °��r -1 cam, Telephone No. business Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? YesX No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 00. 00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $_ __ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ _ Enclose check payable to 6.Total Cost $ '7500,©6 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to 71,41,ZA"S"of my know r/ d understanding. i} Fc '7 ``ua"1 /e� / Oi` /! d f -/ `e 1.�1 `��` - F/5 Z� , Please pr' t and sign name `" a Title Telephone No Bate E�a Street Address City/Town State Zip Email Xddress Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION ►fit Brtc oe. R& No rzt»,w)a,n CIO(0 a ken&L No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # V��6!�� a3 SECTION 2:PROPOSED WORK Edition of MA State Code used ' If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: �41SOia- [0—n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:Cdir 5`e z) 6&&2_S S ex-4e"'Ck ViMpec ve+"Th'. wKere0, I'm-sa x1a:4"1�-_ .t f +0 - SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) �j y 0 7 — Total Area(sq.ft.)and Total Height(ft.) Iq(A( 30 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ TSpecial Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 113 E3 IIA ❑ 1115 IIIA ❑ IIIB ❑ IV C3 VA ❑ VBr SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench w' not be Licensed Disposal Site PublicX Check if outside Flood ZoneV Indicate municipa require or french or specify: Private 13 or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right of Hazards to Air Navigation: MA Hisao.is Commission Review Process: No±Applicable Is Structure within airport ap roach area? Is their review c mpl.-ted? or Consent to Build enclosed❑ Yes❑ or NOX Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1244 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 23 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Delay 4�Xa" /�/�x,-, (/?, 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1244 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-1244 Project# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning URB(100 /�28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 23 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 tae Commonwealth of ltiassacnuseas Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'i t. 1'�-•may ls! www.mass.gov/dia Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: j�C, ��`,`-�Vr��CtV"� City/State/Zip: ! i( ,(_e ce, \ `(�_ C)1 Ph e#: Are you an employer? Check the appropriate box: Type of project(required): 1.M I am a employer with 19 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 S. ❑Demolition working for mein.any capacity. employees and have workers' [No workers' comp,insurance comp.insurance.: 9. 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.E]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 Ix , V�tct+Pc)y 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 indicati ng 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 nay employees. Below is the policy and job site information. Insurance Company Name: �Ybeyt(k,_ LI M E? G Policy#or Self-ins. Lic.#: U�J�J Q"'j "Z 0. Expiration Date: a t tv Job Site Address: -`Yl 1ar� ;2fL �t�lt" i City/State/Zip: rlsCetU Gq P c GEF '=s-- 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 foam 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 ILIA for insurance.coverage verification. I do hereby cert€�y r face pairs a d penalti perjury that the informadon provided move is trace and correct Si attire: r' ( 1 y ^.��n.'f�� Date: _5 Phone!I. Offacial use aril. Do not write in this area,to be completer)by c107 or town of M I City or 'own: Permft/LPeense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. C ty/'rown Cterk 4.Electrical Inspector 5.Plambfng Inspector 6. Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. lipProperty Location BI J 4JqJ gr-c h� - -� /U � _ MA No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No C' Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections)_ 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Pro am 14 Fire Protection Narrative Report _ 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Com ensation Insurance _ 19 Hazardous Material Mitigation Documentation 20 Other(Specify) ty,� v C (,YJ 21 Other(Specify 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information b.yt V i G' -la qj l _ Di: lrs�'�. El�� t ,L, �l 1.1� — 'T.G t Name(Registrant) Telephone No. e-mail ad ress Registration Number Street Address Ci /Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Nance(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Proffer Owner 1 e( b t7 i1 E S(7 iC 6 ( 1 �� ) Name(Print) No.and Street City/Town Zip Property Owner Contact Information: . C; r ---_- Vic ., w� _ lob 3tt �� = �tea� ,,. �� s, L:_.h C', Title Telephone No.(business) Telephone No. (cell) a mall address' If applicable,the property owner hereby authorizes: Name Street Address i City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin document submittals) yi-d yi' f _ I__ �; C�Vi` tWB'1s; 1'2(E: l.Nly� �17 Name(Re istrant) eleph ne No. e-mail adds, ss Registration Number - I� d\fe:``�C '1 � tit � 7 civEi _ Street Address /Town State Zip Discipline Expiration Date' 10.2 General Contractor Company Name S+e.Ven Sr l re ,4-+ 0,71-2-72 - Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town E State Zip ` 13 -,.'v C3_ '7524- _ e.,en VLLl)f z11)�idB�'► �1�V"c"IY!'tr►� CC r+"1 Telephone No.(business) Telephone No. cell — — e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 66• C3 0 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ _ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ _ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains,and penalties of perjury that all of the information contained in this application is true and accurate to the 4ws",sit of my know d d understanding. "en g } 2a- Please pr' t and sign name Tide Telephone No. Date Street Address `City/Town �State Zip^� Email��w�p��er��a`�pieEtie'�' Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LO,CyATION No.and Street City/Town Zip Code Name of Building(if applicable) o� Assessors Map# Block#and/or Lot # "�`--- SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin& Repair❑ 1 Alteration ❑ 1 Addition❑ Demoli tion ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: St t 1 _ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: j1 e_x-lack vrapec v erfl'S neerjLrl. =_ . t ' 1<2f65 AD _ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) `'3 8q7 -- Total Area(sq.ft.)and Total Height(ft.) (Q 30 '- ---- — SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 13 A-4❑ A-5❑ B: Business ❑ E: Educational 13 F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R--;g R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ I1 ❑ IIA ❑ IIB ❑ IIIA ❑ IHB ❑ IV ❑ 1 VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PublicX Check if outside Flood Zone Indicate municipa A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-FVa Hazards to Air Navigation: n?Aistaric Com:nissioa Review Process: Not Applicable is Structure with:*:airport ap roach urea? Is their review c p , lated? or Consent to Build enclosed 11 Yes El or Noe Yes❑ No A SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System:':_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1243 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Bu Permit Filled out / Fee Paid Typeof Construction: BLDG 22-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building-Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan TFA LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IATION PRESENTED: roved 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 Q It? Signature G � 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1243 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1243 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413)584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.•6 1512015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 22 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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: FeeTyne: Date Paid: Amount: Building 6/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner the Lommonweatin o iriassuctiusetes Department of Industrial Accidents -L k, Office of Investigations ( 600 Washington Street Y' Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f Please Print Legibly Name (Business/Organization/Individual): Act Address: Qb Z City/State/Zip: (�re�1(� 1 [ � Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.[ I am a employer with- �9 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in.any capacity. employees and have workers' 9 E] Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions �.❑ 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 1 �✓�V)-) 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 ornot 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 joh site information. Insurance Company Name: Ga t'c p Policy#or Self-ins. Lic.#: 10(J�b J 0.S Expiration Date: a 1 � f Job Site Address: '`9Y i ht1`r t i a City/State/Zip: d ea c' kN P G Er - 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 ILIA for insurance.coverage r ification. I do hereby certify the pains a!Id penalld perjury that the information provided move is trace and correct Si afore: Date: �:) �a� �J Ph o �v e Official use only. Do not uYrite in this area,to be completed by c v or town of MaL City or own: FermitUceflrse# I Igiul ng Authority(circle one): 1.board of Health 2.Building Department 3.Cfty/Town Clerk 4.Electrical Inspector 5.Plu-mbfng Inspector 6.Other Contact Person: Phone rr: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location 3(4j,-,t 0106U No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No 11 Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 1 Gas Natural,Propane,Medical or other 10 Survey ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) tt v C _ 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad ress Registration Number 1(n. RNt'`, )V. �eackcx) MA Cif aW Dis r! patio f j Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address f Property Owner w s k �fE SI f j! Name(Print) No.and Street City/Town Zip Property Owner Contact Information: r Gb� 4 'tV�-i _ - Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered,Pr,,oifessional Responsible for Construction Control(the professional coordinatin document submittals) "�N.t axyLd VG q1-3U,)q_ �,'�._+� C��%I'L� ��11r; `?2i @ H�,P q&3i 7 Name(Re }strant eleph ne No. e-mail addr ss y Relish ation Number Street Address C /Town State Zip Discipline Expiration Date 10.2 General Contractor j Company Name S�efen 51,1 077 '74L` Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip j_ - - .5'J yen .'Vc?j!&jbtmeyic7 r0 eiw_.'i-': Cc Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ '75001 00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ -7500, 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know ed nd understanding. Please pr t and sign nam^e� v Tr ide R Telephone No Date �p ��1R aYC.t �55Y%iEC,,�L EPoI :E} � °C Street Address City/Town State Zip Email t}}ddress Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety y Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# _ Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used ° If New Construction check here❑or check all that apply in the two rows below Existing Buildin&Xl Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: i Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No, Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:&r"Sic/ t4jc s ex4e"Ck rJ!25a9k 4 s t a-,)le-re- nee,�l��- r� i 5 f cc _w. 7r CPfleg� 5 sal 'fd '10 _ SECTION 3:COMPLETE THIS SECTION I17 EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 ', --� Total Area(sq.ft.)and Total Height(ft.) (�� '30 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-i❑ RA R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA E3 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA E3 VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Publi Check if outside Flood Zone Indicate municipa A trench 'w not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of--way: Hazards to Air Navigation: M A Historic Commission Review Process: Not Applicabl- is 5truct=e w;thin airport approach area is their review c ;Tplpted? or Consent to Build enclosed❑ Yes❑ or No Yes❑ N SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1242 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 21 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFRAMATION 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 Delay A4x, Lc-e- , 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1242 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1242 Project# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 21 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 ne uodEBFDmnIW%euttaz Uf r��ea��ree reas5err� Department of Industrial Accidents 4.J;2t -r office of Investigations =•` :i=, 600 Washington Street X47 Boston,M4 02111 -;�- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibIy Name (Business/Organization/Individual): y Q(k,lick�;MK Address: �(� City/State/Zip: Ph e##: Are you an employer?Check the appropriate box: Type of project(required): 1.M 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. 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 g, ❑Demolition working for mein.any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. 1 ❑ 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.EJ 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 (i"1 �?1 "1 �1 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for nay employees. Below is the policy rind joh site information. Insurance Company Name: �Y be•� a_ D�moir�r_.f'_ G r C�j Policy#or Self-ins. Lic.#: �J 0 J 02 1 S Expiration Date: a Job Site Address:_ t :f2 ( U'a [l Y' ` '` �� Ci /State/Zi �� : �. U iC-1€%1 -- ty p: �� .� 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 v/e ification. I do hereby certify r"IY1110 tfaepams a��d penalti prjaEry that the information provided above is true and correct,Si afore: 't ( .d , f� -0i Date: 7 phone Qfjacial use only. Do not tivrite in this area,to be completed by city or Pawn cf=ecial I City or Town: PermitrlLieense 4 6 Issuing Authority(circle acne): 1.Board of Health 2.130ding Department 3. Cfty/Town Clerk 4.Electrical Inspector S.Pta robing Inspector 6. Other I Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location ( No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) �Wv c 21 Other(Specify 22 Other S ecif "Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information �2�� '��p_.�tn:��C� `��_ �� _ ty:i�t� ��'�e l�.rt��V"`` ..� •1 � �-i-tc3l°7 Name(Registrant) Telephone No. e-mail ad t ess i 7 Registration Number i l�f':r t• 1 � l 7 Discipline Expiration Date Street Address Ci /Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/Town State Zi Discipline Expiration Date Registration Number Name(Registrant) Telephone No. e-mail address d Discipline Expiration Date Street Address City/Town State zip Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name 14 and,Addressgf Prope Owner vw �sC� �Sc'tviceicYt p. ;br ""rjJ" oe`3-tZ`t"1 14i C: EC CO Name(Print) No.and Street City/Town Zip Property Owner Contact Information: . ti`J P Cr z.h C—t"3L Title Telephone No.(business) Telephone No. (cell) a-mail address'--J If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coord' ting document submittals) Name(Re istrant)r eleph ne No. e-mail add r ss Registration Number HL, iyeA Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor \I,al' � Company Name S+em CJs l Y �' �'y-1 (' 0"7'� `` Name of Person Responsible for Construction License No. and Type if Applicable Roc),cSide, Florence- IAA- Street Address City/Town State Zip Telephone No. usiness Telephone No.(cell) e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesX No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 00� 0 0 Building Permit Fee=Total Construction Cost x-(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to -_ 6.Total Cost $ '7,5 00. 0 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to th4bbst of my know e,)4-- d understanding. ¢J {e [�.( / �� — b�- ,75-` L Title Telephone No Date Please pr t and sign name .- � �Street Address City/Town State �. Zip Emai1�G2djd�reYst�s Municipal Inspector to fill out this section upon application approval: - Name Date The Commonwealth of Massachusetts ! ._ Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION .14(41 j3 rtc O af0tl No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # xil SECTION 2:PROPOSED WORK PL Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other A Specify: �56a_ 10-n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes 13 No Brief Description of Proposed Work: r Sett) t e xr e-+ r-ts e t v erffS ` ` e mpajej, j,0-Sj,-44e_ x? 5 t S +0 A491 _ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) J 4917 -— Total Area(sq.ft.)and Total Height(ft.) N(091 1 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4 13 H-5 F3 I: Institutional I-1❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Debris Removal: Water Su pl : Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Dis osal Site Public Check if outside Flood Zone Indicate municipa A trench w' not be P requiredA Private❑ or indentify Zone: or on site system❑ or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: NIA Historic Commission Review Process: Not Applicable is Structure within airport approach urea? Is their review c pl ted? or Cop-sent to Build enclosed❑ Yes❑ or No Yes❑ Noo SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:. Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1241 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB000)/WP(28)/ 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: BLDG 20-INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existin Accessory Structure _Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 Delay 67�d" A4:"9 ('�,at�c 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1241 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1241 Project# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning URB(100 /)WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413)584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 20 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/5/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I ne C,OdE Monwetattra vJ It�tt��azc resc�eee� 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 usiness/Or anization/Individual : Address: �� Citystate/Zip: Al \of e�n�� (� 11�hone##: Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with_ 4. E] I 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 S. r-1 Demolition working for me in.any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. 1 � required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.F1 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers 13. Other 1nS',1A41yn 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 tray employees. Below is thepolicy and joh site information. Insurance Company Name: G r6J2 Policy#or Self-ins. Lic,#: G Expiration Date: Job Site Address: ` ) Brt ��. R-f U i ��€i"1 ) -! City/State/Zip: t='t'lt i' ►''�i. t t C Ear 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 DU for insurance.coverage vperification. I do hereby cerYo the palns a f td penalti- penury that the information provided above is trace and core ecL Si afore: Date: 7 Phone . Official rise only. Do not wvrite in this area,to be completed by city or town offpcial City or Town: Permit/License#� Iysubng Authofi ky- (circle one): F.Board of Realth 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i 6.Other IL Contact Person: Phone m: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location Mbr4 chCLM 1I4gg3oz,J6itioK r4 No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other(Specify) n of 21 Other(Specify 22 Other(Specify "Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information (3_U _ 'i�� gtL-3i7 Number Regi stration Numm er Name(Registrant) Telephone No. e-mail a&6 �.-i .a i, o037 Ji(p Leo I RA Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zipDiscipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/ Town State zip Discipline Expiration Date Please follow this link for construction control ferns to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address, f Pro�erry Owner i�31 J<0(kl Name(Print) �- 61No.and Street City/Town Zip Property Owner Contact Information: , l 'r i- J Cle yG L`J % 0'-;y. I -_ �Ci`3 Title Telephone No.(business) Telephone No. (cell) a mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3. Otherwise p rovide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coor ting document submittals) Name(Re istrant) Teleph ne No. e-mail addr ss Registration Number cry,I Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 1413- = '7521 _ - - a c'd'en vas lajh6me-t ��►l�ve��r-�, cam, Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 _ A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result n1 the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesX No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Soo- o o Building Permit Fee=Total Construction Cost x`(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ ASV d . 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the st of my 1,now d�rf7ond understanding. P lease p�r�'1t and sr name p ,Tide Telephone No. Date �y`�'_ W�.ct�C`e Street Address City/Town State Zip Email t}.ddress Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: I Building Official• SECTION 1:LOCATION Men y� p 8`l G.i C!'�'' T,- v �( (`��f39(,8 �sw" I�r"Tr`i-- `.'4iiA s No.and Street City/Town Zip Code Name of Building(if applicable)q Assessors Ma # Block#and/or Lot # �L i! dl SECTION 2:PROPOSED WORK PL Edition of MA State Code used Y If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration 13 Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: �141;133�+On Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No, Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: r 5 ea) _2 e_x-ael ck Vn pex- 4 erd-, ° e uC feL-5 - D SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) oZ Total Area(sq.ft.)and Total Height(ft.) 3150 SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ 7 R: Residential R-10 RA R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION b:CONSTRUCTION TYPE(Check as applicable) IA 13 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VBy1 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su pl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipa A bench 119 not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: N4 a Histo is Conintission.Review Process: Not Applicable is Stmic ure within airport approach area? is their review coInpl ted? or Consent to Build enclosed❑ Yes❑ or INTO Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations Design Occupant Load per Floor and Assembly space: File#BP-2015-1240 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid '� T eof Construction: INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing- Accessory Structure Building Plans Included• Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 Delay f • I/ �0-t�•CJrV 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1240 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-1240 Project# JS-2015-002306 Est.Cost: $55.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: U�RB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61512015 0:00:00 TO PERFORM THE FOLLOWING WORK:BLDG 19 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Sisnature: FeeType: Date Paid: Amount: Building 6/5/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 he t,'o rnionweaste$ of lriassacraat¢seeas Department of Industrial Accidents +— Office of Investigations . F._. M t 4-d 600 Washington Street r•-r ' Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affl<davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly_ Name (Business/Or anizationdndividual): ,� If l Address: City/State/Zip: '� `(�l{?tr1C \ '(J� I Vh O one#: L-tj— 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. ❑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 S. ❑Demolition working for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. t 9. 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. [No workers' comp. ri ght of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no ` employees. [No workers' 13. Other t n S O t,4 l y rl 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 indirating 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. lam an employer that is providing workers'compensation insurance for nay employees. Below is the policy and job site information. Insurance Company Name: 6be.AAe- —Dmc G rc j2 r— e Policy#or Self-ins. Lic.#: ( GGJ�J0502— P S Expiration Date: a Job Site Address: City/State/Zip: �Fi b� � d" 1 CS EC -- 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 Vrilication. 1 do hereby cer*ify r the prait:s 90 penalti perjury that the information provided above is trrae and correct, Si afore: �� f -bi Date: 7 �J Phone:L, �' Official use only. Do not write in This urea,to be comp--leted by city or town of=acical City or T avm: PermffJLicense# Issuing Authority (circle one): 1.Berard of Realth 2.Building Department 1 Cky[Fown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location W 0114 0 No. and Street City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other(if applicable) Appendix I Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where plicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) _ 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Surve /Investi ation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' 11,5 v C. G 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendrnent has been approved by the authority having jurisdiction. Registered Professional Contact Information yt',J VrePAV 'Irk_ ^, `C- f" � , ill ,V 4+Lc3i7 Name(Registrant) Telephone [N^o`. e-mail a;�d�f rrryj\ess /(� ^�� y a] Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address, f Propperl�yy Owner CfSC I`�/sC{i( Name(Print) No.and Street City/Town Zip Property Owner Contact Information: YY Title Telephone No.(business) Telephone No. (cell) a mail address' If applicable,the property owner hereby authorizes: Name Street Address i City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu,ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coor ' ting document submittals) Y&J' Name(Re istrant) T eleph ne No. e-mail address Registration Number 1 � (?A/_ - R�1 tIto Lie 3:37 ems_ Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413- = 7524- Vo ii6i btMej!Mj-0Ve1re_6-1: Ccm Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Ye!jK No El SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Suo, oc) Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ _ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ OD (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know� nd understanding. tEvs _5c%`P- 1.. 5 Please pr�ntt and sign name . , p T[i�tlle � Telephone No. Date �y DIE, �� Ems°'OCR E✓V` ��fa:i c� +�vL��L lP� E€ta Ylt�}AY�S Street Address City/Town State Zip Email Zdress Municipal Inspector to fill out this section upon application approval: -- Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION t-t(, thy' ' 010 I�+fF'£x(_.3L�ty" 1Z"ZpY- {-14?Ct.tiY14't'7 f No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# _ Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration 11 Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other pk Specify: 56 a-+M Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:Cu!"S 14z f/c5' �z '� n_rope.r 4 erd-5. Lo e '' & r 4he i 5 e? ce. . er l6�/ S t 'fel. _ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) X5'75 Total Area(sq.ft.)and Total Height(ft.) 3 i s SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R-2g R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility Cl Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA [3 VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Publi Check if outside Flood Zone Indicate municipaX A trench w' not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredX or trench or specify: permit is enclosed❑ Railroad right-of-wa : Hazards to Air Navigation: MA Historic Commission,Review Process: ?Tot Applicable is St:ct-ire within airport ap roach urea? Is their review c m I ted7 or Consent to Build enclosed❑ Yes❑ or Nox Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does die building contain an Sprinkler System?:_ Special Stipulations Design Occupant Load per Floor and Assembly space: File#BP-2015-1239 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ; Fee Paid Tyueof Construction: BLDG 18-INSULATE ATTIC,HATCHES, WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Delay ,�" A�tm (j?,a'itie-4 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1239 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1239 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 18 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner i he commionweatin of-=ussucetuYu,e,s =- == 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 i1 Please Print Legibly Name (Business/Organization/Individual):�a k� if t 3� 16(w Address:_ City/State/Zip: �hone Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with 19 4. ❑ I 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 S. ❑Demolition working for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. $ 9. 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 1 L 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 [i- S t LC`A l Z.l r1 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 nay employees. Below is the policy andjoh site information. Insurance Company Name: Nrbe Ao, Ll l }( rlt G cnjp � z Policy#or Self-ins. Lic.#: G�J� �J�� S Expiration Date: ! d to Job Site Address:_ tt1 On 6 Z J- ,t, Hl1-b'l 5&17 City/State/Zip: ��o cen%�' wl t�� o 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 rification. I do hereby certify e the pains a rid penald perjury that the information prodded above is true and correct Si afore: ,Ii,' / ,4 ^��f, f�� Date: ^l c Phone QfrciaPl use only. Do not write in this area,to be co,,rnpfeted by city or town off4ciaal City or Town: PermitUcense# Issuing Authority (cf7cle dne): F.Board of Mealth 2.Build-mg.Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location �L No. and Street City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No 11 Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surve ed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Ins ections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Cam ensation Insurance 19 1 Hazardous Material Mitigation Documentation 20 Other(Specify) n- tyawn CrgiAnt 21 Other S eci 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until tivs application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information y71.` V l GC.-e.s�L(� CEJ- �,��- 4..l lc7ti� G..&�E a�.✓E�.� .�Lt`{t;^l 1L+.�6.1�.�� qV+'3r 7 Name(Registrant) Telephone No. e-mail ad less Registration Number &03 J i .el '�� 1f� ' 1 7 Discipline Expiration Date Street Address City/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/Town State Zip Discipline Expiration Date Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address City/Town State Zip Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AU'T'HORIZATION Name and,Address f Proper Owner ,4'E( � fr v C' ) ` �r G, `/0 �!�r,'�..��f. Jif'�� r2Q��ZFl�1 t�lr� Name(Print) TfT No.and Street City/Town Zip Property Owner Contact Information: trxip �'� ` urr _L- 71 _- Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coor * ting document submittals) Name(Registrant) eleph ne No. e-mail addr ss Registration Number kkfl CIO , G136 Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor _ Company Name S'�eY n S,1 y-e r S 77 r?�! Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413_�58Y- '7521 - - lea°t?s� �1cI1ticrnwy '�tr �: Telephone No. usiness Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? YesX No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $_ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ J`b{J� � (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d and understanding.Please pr at and sign name Tide Telephone No. Date 121- r 1i i11a- ¢} , r'� s '' e*V�• 6t Street Address f City/Town State Zip Email`Address Municipal Inspector to fill out this section upon application approval: _ Name Data The Commonwealth of Massachusetts 1' Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 14150iCL41 bn Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes [I No Brief Description of Proposed Work:GZr S` and S ex-4e4,d, $2rojoer 4 erg j,, e tr- p� i d66C5 cell0laS SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1575, Total Area(sq.fL)and Total Height(ft.) 31-_z ap' I-- SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 13 A-2❑ Nightclub ❑ A-3 ❑ A-4[3 A-5❑ 1 B: Business 13 E: Educational ❑ R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-113 R-g R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ N ❑ 1 VA C3 VBX, SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Publi Check if outside Flood Zone Indicate municipax A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: MA Historic Coniniission Review Process: Not Applicable is Structure xvit_hin airport approach area? Is their review c plated? or Consent to Build enclosed 11 Yes❑ or No Yes 13 No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: _ File#BP-2015-1238 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 17-INSULATE ATTIC,HATCHES, WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MOTION 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 Delay r4a" �z 0�c &k�c 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1238 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1238 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(scl.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:_URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 17 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner �� l u C.ommionwealih of ll�assacnuseas �— Department of Industrial Accidents Office of Investigations Is+: �'? 600 Washington Street .: .,_ �. a Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,�-etk VV1e,n - , Z� Address: �C, ��+`f'Vr� � l`,� tY p: 'r �ofe�nce OMPR e##: Ci IState/Zi Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with, i S 4. R I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.$ 9 E] Building addition required.] 5. F� We are a corporation and its 101-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no ` r employees. [No workers' 13. Other I nS L 1CC A 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 gray employees. below is the policy and job site informadon. Insurance Company Name: Policy#or Self-ins. Lic.#: G�JS � O S Expiration Date: a t k �o Job Site Address: vl= f Ali i�i8 a- l �p City/State/Zip: �E �`M, i' t i >iEO` 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 vjerification. I do hereby certify r the pains a°1d penalti� perjury that the irforination provided above is true and correct Si mature: t �� , f��i Date: / c 1z) Phone Official mEe only: Do not wvrite in this area,to be completed by city or town of rclaI City or Tawas: Permft/Lf cen se# Issuing Authority (circle one): I.Board of Health 2.yarding Department 1 Cfty[Fewn.Clerk 4.Electrical Inspector S.Flurnb ng Inspector i 6.Other I Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location No. and eet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No I I Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No 11 Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that-must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may re uire re eaters 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Ins ections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 1 Workers Compensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other (Spec' o n-A v C 21 Other(Specify 22 Other S ecif *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until thus application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad Tess Registration Number Lei i.(_A�x) KA b 3 7 Discipline Expiration Date Street Address City"/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/Town State Zi Discipline Expiration Date Name Telephone No. e-mail address Registration Number Dame(Registrant} p- Discipline Expiration Date Street Address City/Town State Zip Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Pr erty Owner �-("$i,�'wtffcc"?7'1`'7�® ��►r:�_S�. �,:.'t�L7�jy ' t✓��CI�I �� C%�-EC�� C��> Name(Print) No.and Street City/Town Zip Property Owner Contact Information: p 'Fl Dvr &. art ` .�` - C 1 _-- - �6�i�i ` . � .0 Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the roe owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu,ft.of enclosed space and/or not wider Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Re 'stered Professional Responsible for Construction Control(the professional coor ting document submittals) Name(Re istrant� eleph ne No. e-mail add ss y Registration Number I d (ts �`'roc . j �� c yt7 - Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413 _ '75 � _ Telephone No.(business) Telephone No, cell e-mail address SECTION 11:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YeNo SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ d 5-D®. Oa (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains.and penalties of perjury that all of the information contained in this application is true and accurate to the best of my/Jkno Jw e,� d d understanding. ,ry ✓��Or d F t i /^� �U _2Y � �,.�!-1 --` Title Telephone No Date Please � prnt and sign name! pti�, Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # ��f I t, SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin&l< Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ 1 Other Specify: 14'150 On Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes 13 No Brief Description of Proposed Work:,air S I 2 ex4e,,o-, , m c veor ` ' e t' �- r i 'S a �f `62t SECTION 3:COMPLETE THIS SECTION Ill EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Kd= Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(iticlude basement levels)&Area Per Floor(sq.ft.) �2 Total Area(sq.ft.)and Total Height(ft.) 3:5D ao, SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Publi Check if outside Flood Zone Indicate municip A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-way: hazards to Air Navigation: NIA Historic Commission Review Process: Not Applicable-A lv Structure within a;port ap roach zrez? is their review c plpted? or Consent to Build enclosed 13 Yes El or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System:':_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1237 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out n e Fee Paid Typeof Construction: BLDG 16-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1237 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1237 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON:61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 16 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ine uommonweatin of-mussac-nusuits Department of Industrial Accidents Office of Investigations 4�� ' ► 600 Washington Street Boston,MA 02111 3 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information t Please Print Legibly Name (Business/Organization/Individual): �Q b1 P -J" Zln Address: City/State/Zip: �" 1C7f��1C� 11 o Ph ne#: Are you an employer? Check the appropriate box: Type of project(required): 1. I am a em to er with 19 4. � I am a general contractor and I p y employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. EJ Demolition working for mein,any capacity. employees and have workers' 9 R Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no ` employees. [No workers' 13. Other i�11�€`T 1y11 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 joh site information. Insurance Company Name: 1/�C}f' 1G.. c, 15��i -e 61 r6jp Policy#or Self-ins. Lic.#: oo��Jo 50,Z Expiration Date: a M1 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. do hereby certify r the pains a�{�d penalti� perjury that the irf ormation prodded oho Jve is trace a d correc,N Siana fore: y, ! ,4 �. ' %/e� Date: Thou:L1.- Official use only. Do not rcYrite in thlE area,to he caarnpleled by city or town offilciaal City or Tom: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.C ty/Town Clerk 4.Electrical Inspector S.Plumbing Inspector { 6. Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location ,� s� Ul UCQC> q C ,r c C lUbr-�h 6L �? � `vcC�G(G�QL�7r�Y`�v r r {fis�Eri m No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ Noffl Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Su ression 5 Fire AIarm(may require repeaters) 6 HVAC 7 Electrical 8 Plun nulude local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) h'3 C `-9 21 Other S ecif 22 Other S ecif *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad Tress Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Registration Number Telephone No. e-mail address Street Address City/Town State Zip Discipline Expiration Date Nance(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control fcrnns to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Pro erly Owner 2 p f '"fir �C"SC3'u�1 iC`�7► cam, ,C�,. �7 `iQ ,0r S�j, �� -�_ �� i1. (� Utica Name(Print) No.and Street City/Town Zip Property Owner Contact Informa tion: l Nv Gne t . J 7�. l k —C m IQP Title Telephone No.(business) Telephone No. (cell) a mail address'If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the pmfessional coordinatin document submittals) DavAvreda� Name(Re istrant eleph ne No. e-mail addr ss Registration Number I1fr !y{i1fe',k' 1KRIJ. �_e 0 lit( ( 1 .3 7 Civil. . Street Address /Town State Zip Discipline Expirarion Date 10.2 General Contractor L Romer jmen),fevww�� Company Name —p Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip tl3_ _ - *% a yad ep-1bbmeiMf` ye1'Yk-.6i— coyn Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes K No El SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 500,00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ j OO,0 Ci (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b 5t of my know,�ddr d understanding. f_ / Please pr, t and sign name Tide Telephone No. Date _ pt ' .k .?i..! 1 C G'N.::j4" Yh.-� ;"' t..ri :G LC+l li�..�€ICGf ,}"C "Gyl("`t Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Y Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Buiilding(if applicable) _ Assessors Ma # Block#and/or Lot # �t`�`! � /5 SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify:_'T415th On Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:Corr S ze GZ-TICS z'f ora9aec v rGa"t"pS t a hie t 0e if' e- roed1d, In AIC _ 7 V,C gA 1: "CY e f I L"f n SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1,57S ' Total Area(sq.ft.)and Total Height(ft.) '315D ac ' s SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ 5-2❑ U: Utility❑ I Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal. Water Su pl : Flood Zone Information: Sewage Disposal: Licensed Disposal Site Publi c Check if outside Flood Zone Indicate municipa A trench w;h not be p Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of.- a� Hazards to Air Navigation: NIA Historic Commission Review Process: Not Applicable A -roach zrez? Fs ffieir review c �npI ted? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1236 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB000)/WP(28V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: BLDG 15 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existinia Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF,QRMATION 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 Delay (� 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1236 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1236 Project# JS-2015-002306 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT.• 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.•61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 15 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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: FeeTyne: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 2�1 ine 4�U :GEQlP6PYCfE��.i VJ lriwu�ww.v.. ... Department of Industrial Accidents Office of Investigations 600 Washington Street , Boston MA 02111 :;,x •��,,^., Fps` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electilelans/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); Address: X1Q- �nn City/State/Zip: �ot ?Vl�� \ 1 Ph Z ne##: Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with_ 19 4. E] I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 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.T 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. [No workers' comp. ri ght of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. Other �� 1y�1 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 stay employees. Below is the policy rand joh site information. ` Insurance Company Name: ak Policy#or Self-ins.Lic.#: a �J�0 02— S Expiration Date: l Job Site Address: ` 1v tY (. � � . >jl a to .li` City/State/Zip: LCtt ' - 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 DU for insurance.coverage verification. I do hereby certify a the pains a �d penalti perjury that the inforn. ation provided above is true and correct Si afore: (�° 1 •1.,,� 'f—11 Date: 7 f p Official use only. Do not ivriie in 6WE area,to be completer)by city or town of lciaL City or Town: herr�tILieense# �� Is§uiug Authority(circle acne): r.Roars)of Realth 2.BuRal;"g Department 3. City/Town Clerk 4.Electrical Inspector 5.PlumP�;ng Inspector 6.Other I Contact Person: Phone#: __� Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location olo6o er dne- NbMVLMP�n )JA No.and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Ener gy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) n v&t(,,A Cpl,-hl 21 Other(SpecifV - 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until thus application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information V � ZC P'3_ '�- ! ► dry t i n �; 'r r,,� 1 44(e3i 7 Name(Registrant) Telephone No. e-mail adaress Registration Number tJ t�,AG,i 337 Street Address �City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date PIease follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUPTHORIZATION Name and Address ff P roperty Owner / C-c�' LW L�6�t�- 1� 1 i/''.'cl�I..[• (E✓j" Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ( �_ �0s4 ."�? Title–, Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to a l for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application, SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin g document submittals) Name(Re istrant L eleph ne No. e-mail apd�dr ss 7 Registration Number Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor geov jMen Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. cell mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesX No E3 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ bQ• 00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ - Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ ,.-;t j Qo r 0c) (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my lai �3 d 0 nd understanding. A,('(./ V r�Yi',ePP E �,.J 1 I T'f✓'i Jd�Cf.f i /./f{,tF (�_ �l f�! Please print and sign name 6� Title Telephone No. Date~ r {�Ure 4 j� '. r� 'i "E^ '. kj r �EC�}F Street Address City/Town State Zip Email Address Municipal Inspector to fiII out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION ` ^� ` r i i?S° c' C to 4n 0 1�L�'E`r^d b c-o brm-k: �t?a;:-Y1'1 -err S No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # 3uiI d� SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin&l< Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 41502.- t 'l _ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes 13 No Brief Description of Proposed Work:&r S' l Z - m eC v wrds wKerc t linfe15 SECTION 3:COMPLETE THIS SECTION IF DQSTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) [6'76- — — Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub 13 A-3 13 A-4❑ A-5❑ B: Business 13 E: Educational 13 F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-113 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1II11 ❑ IV ❑ VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Su pl : Flood Zone Information Sewage Disposal: Licensed Disposal Site Public Check if outside Flood Zone Indicate municipa A trench w' not be P require or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-wa c Hazards to Air Navigation: NIA Histo-ic Commission Review Process: Not Applicable Is Stnactt re ivithin airport approach urea? Is their review c pl ted? or Consent to Build enclosed n Yes El or No Yes 11 No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: — File#BP-2015-1235 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T eof Construction: BLDG 14-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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 Delay tl�-LC�to 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1235 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1235 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(scl. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 14 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Sisnature: FeeType: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner :—�-�� Department of Industrial Accidents • �iii t" r if' Office of Investigations ,f 600 Washington Street -:-,_K. � Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ( ,�,`�t� Address:, "OX City/State/Zip: ,C `Q/,P_V ,C C \ `UL 0 4bone##: Are you an employer? Check the appropriate box: Type of project(required): 1.M 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. ❑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 S. ❑Demolition working for me in.any capacity. employees and have workers' [No workers' comp.insurance comp.insurance. 9 r-1 Building addition required.] 5. ❑ We are a corporation and its 10.01 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,gOther 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 nay employees Below is the policy and joh site information. Insurance Company Name:_ �Y be� a_ r--- t Policy#or Self-ins. Lic.#: 00101:505012 Expiration Date: Job Site Address: lI �t 7Gi[t li "i 3 City/State/Zip: i?M C i0€;` -- 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 vlerification. I do Hereby certify s tlnepains a id peanalti perja�ry tkat the I,orma�tion provided above is trace and correct Si afore: /,rti ,4 ��,��,' ^i Date: `7 ,f Phone `: Official rase only. Do not write in this area,to be completed by city or town of cial, City or Town: Permft[Lieeanse# Igsuinng Authority(circle one): 1.Board of Health 2•Building Department 3. City/Town Clerk 4.Electrical Inspector S.PlumbIng Inspector Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location Ii c i --3-- IIILr4 m f`'�c'c�dov)/a voK r4 No. and beet City/Town Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incom lete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Surve /Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other(Specify) 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact In€ormation LF ''7 2y%C r3_ �.� _ Ao�el.�?11:� frrz �l.1� i Registration Number Name(Registrant) Telephone No. e-mail ad ress l V. r Street Address City/Town State Zip Discipline Expiration Date Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address City/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address City/Town State Zip__ Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Property Owner { r� C�t'CEGw�'1iZk (Z?5(7� tEEi�1• ' e S1 le ` fipt Name(Print) No and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin g document submittals) Da VL Vl' 411'>_(:�< 'Y&3'7 Name(Re istrant} eleph ne No. e-mail addr ss Registration Number tea (\fit=k'! �i3-] r (V' f Street Address /Town State Zip Discipline Expiration Date. 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 75)x- V.-t.j Telephone No. usiness Telephone No. cell e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is sane of the building permit. Is a signed Affidavit submitted with this application? Yes No SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ `� a Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ SQQ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true=77 he b st of my];now d d understanding. Please p r' t and si name T Telepho�No. �D�ate �{ t✓�PGf Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: -- Name Date The Commonwealth of Massachusetts Department of Public Safety ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # 'a-or1 dtj SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair 13 Alteration 13 Addition❑ Demolition 13 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other PL Specify: '�'1500 51 Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No, Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:air 64 exie^ck j+-,f PA rcen-,hs u-,k 4 h Si.s lte�� F '5 CIS p2ealxd 1n5L)kUV-e_' lC t I cal -tD SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) /57 Total Area(sq.ft.)and Total Height(ft.) 315D 20 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1❑ I-2❑ 1-3❑ I4❑ M: Mercantile❑ 1 R: Residential R-10 R- ` R-3❑ R-4❑ S: Storage S-1❑ 5-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111$ ❑ IV ❑ 1 VA ❑ VBXP SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su pl : Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipax A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: NIA Historic Commission Review Process: Not Applicable is Struct'vre within airport ap roach area? Is their review co*npl ted? or Consent to Build enclosed❑ Yes n or Noe Yes❑ No Ak SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: _ Design Occupant Load per Floor and Assembly space: _ File#BP-2015-1234 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: BLDG 13 -INSULATE ATTIC,HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessoa Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION 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 Delay t2o-w-IC4 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1234 GIS#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1234 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 13 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Siinature: FeeType: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 fie uommionweutin of le�ea�seee per��cce� Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ma=r- www.mass.gov/dia Workers' Compensation.Insurance Affldavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): a kG-Ctj,�6r\-,c 7n Address: City/State/Zip: �' of ern c \ I%one#: - Are you an employer?Check the appropriate box: Type of project(required): I.M I am a employer with 1�3 4- ❑ I 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 8, ❑Demolition working for me in.any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance. 1 ❑ required.] 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 LE]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 1 n 5 L .6'J)y)-) comp.insurance required.] *Any applicant that checks box#1 must also fin 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 ornot 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: �_Y be lAC`, 7 7 G ccu f� r-- p1 Policy#or Self-ins. Lic.#: 0G7-YE)0602- 1 Expiration Date: a ! ! I a - Job Site Address: `t [Fart �? 6 !r F i .l ) City/State/Zip: ��'"jC;Ce 11CC AA- O lCIV''- 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 DTA for insurance coverage verification. I do hereby cerfify i the pains a'd penald perjury that the information provided above is true and correct Siiyn ature: ,s ,'%�., Date: t D l Official age onbz . Do not write in this at-ea.,to be completed&y city or town of cial City or Town: Permit/License# Issuing Au'110 ity(circle onc): 1.Board of Health 2.Bafd9mg Department 3. Cfly/Towa Clerk 4.Electrical Inspector 5.Flambing InsTector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location B J ( `BF e_ . -- No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No I I Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No 9 Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Su ression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbin include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' y c- 21 Other S eci 22 Other S ecif *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information IviJ 'V r 16 r3_ - cii� v try ;� ' � tz �.�� (1,3i 7 Name(Registrant) Telephone No. e-mail ad ess Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date PIease follow this Iink for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address f Pro e Owner �� s�� n,�® �j�''i_ � Name(Prin - 11 t) No.and Street City/Town Zip Property Owner Contact Information: '� Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this uilding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not wider Construction Control then check here O. Otherwise provideconstruction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin document submittals) jir 4113, T F'id� Cl1l��t'�C11'lr: , ''tVZ nJ q&3 17 Name(Re istrant eleph ne No. e-mail ad& ss , Re stration Number 1i E�-> riVeu`�,"J � n =` 01 3.x'7 V __ t- &Z Town State Zip Discipline Ex Street Address / p iradon Date p P 10.2 General Contractor _ Rime- .1mpf?>Ievw � Company Name Name of Person Responsible for Construction License No. and Type if Applicable 71+0 RoeCS&. Ly, — F�Ioi-e 1t:e_ MA otoy.- Street Address City/Town State Zip � LV e � �er ►1 413 '753 Telephone No. usine s) Telephone No. cell e-mail address SECTION 11:WORKERS CON-4PENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is ance of the building permit. Is a signed Affidavit submitted with tlus application? YesjK 0 SECTION 12- COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 1500. 00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ OO- Go (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d d understanding. Please pr Title Telephone No. Date print and sign name k' t�,e(iCc��Rt�rr*'p�:��b�.'ite:'G. Street Address City/Town State Zip Email 2ddress Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts 1 Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official• SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # Vu d SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ 1 Change of Occupancy ❑ Other Specify: h15L�Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:&r -4er 4s wjiji e r-,ee . jhS.v/te Z xI fs "a ' lc SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Groups): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1975 Total Area(sq.ft.)and Total Height(ft.) �3(. Jo' SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit. Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site Publi Check if outside Flood Zone Indicate municip A trench w' not be P require or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-o€-wa : Hazards to Air Navigation. NIA H;Storic Commission Review Process: Not Applicable fs Stuct!wre within airport ap roach zrea? Is their review c mpI ted? or Consent to Build enclosed❑ Yes❑ or NoA Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Constriction: Does die building contain an Sprinkler System?:_ Special Stipulations: _ — Design Occupant Load per Floor and Assembly space: — File#BP-2015-1233 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 12 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing- Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I✓✓VORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1233 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1233 Project# JS-2015-002306 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P_O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 12 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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: FeeTvpe: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner the (,olnn$onweaun uJ 1i1Cf55EkLwEEfJeera 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): k�if kA Address: �nn lo City/State/Zip: `(�f�6'1(� \ j— Are you an employer? Check the appropriate box: Type of project(required): 1.EA I am a employer with 4• ❑ I am a general contractor and 1 6. ❑New construction employees (full and/orpart-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in.any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.msurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 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.[3 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 41 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 rand job site information. Insurance Company Name: LbO,\C`i�. Ga rbie Policy#or Self-ins. Lic.#: oy;� (D 1 Expiration Date: a Job Site Address: +. , , E*'`s �ti i City/State/Zip: �'4i � Attach a copy of the workers' coampensation 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 foram 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 rl,11;0�i the paia.s a:�d penalti pperjury that tore informadon provided above is trace and correct. Si ature: 4i .' Date: Pho 17) Official rage only. Do not write in this area,to he completed by city or town of eceaal City or 'own: # Issuing Authority(circle one): I.Board of Health 2.Building Department 3. Ci¢y/Tawvn Clerk 4.Electrical Inspector S.Pluamblug Inspector 6. Other Contact Person: P hone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location 345_7#7 01060 i a-ooe - ---!1----- / iv--�ha-mPtn No. and Street City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No I I Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Ins ections Pro am 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 1 Other(Specify) vv c,. 21 1 Other(Specify 22 1 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Lf- . . /.bay� V i ee -0 Registration Nu mber Name(Registrant) Telephone No. e-mail ad ss A Street Address Ci /Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and�A6�ddr�sof Pr ery Owner 14 an fSifd 'y ►°� � E�7`c' cs_ t , E Name(Print) No.and Street City/Town Zip Property Owner Contact Information:`` /� yy iii c,fi �r Gne�t - ` 1 Title" Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required, 10.1 Registered Professional Responsible forr�Construction Con trol".(the rofessional coordinatin document submittals) D"wrii-d yreejf 1 _C`��`� c1`:QLv clV1'erlct9'j yVii"i zo, '1&317 Name(Registrant) eleph ne No. e-mail addr ss .,. Registration' r Number Street Address /Town State Zip Discipline Expiratton Date 10.2 General Contractor 'fie fee Kane- .1mpngevv_A_i� Company Name y Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413 . 7524 Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ cL S00, oo Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ �500, OD (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d� d understanding. Please print and sign name Title elephone No. Date e ` �fi�_at�,e*1�.:,d4',��d,at'Ctf Street Address City/Town State Zip Email_ ddress Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts aK Department of Public Safety t u Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION { E F No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # u I I d t � 11. SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 7515JAaz t 1 _ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: r S t e-xl4eh':�- n le.c v er4s ° ' a ltz4e_ s 9 t_ S ' lt= Yr rGa�Z?�i f d, +0 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) a S`� Total Area(sq.ft.)and Total Height(ft.) &50 a f) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IHA ❑ IIIB ❑ IV ❑ VA ❑ VB° SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Su PI Flood Zone Information: Sewage Disposal: Disposal Site Public Check if outside Flood Zone Indicate municipa A trench w' not be Licensed require Private❑ or indentify Zone: or on site system❑ or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: NIA Historic Commission Review Process: Not Applicable Is Structa:re within airport approach area? Is their review c pl ted? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: _ File#BP-2015-1232 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100 /)WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: BLDG 11 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON /Approved RMATION PRESENTED: 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 � � 'Ally 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1232 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1232 Project# JS-2015-002306 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sg.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 11 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 Sisnature: FeeType: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner •°.�'.�� 1 B1e C.OdEtnFOn�ec�acn v� liliQ55LG1.oasftoc+ow Department of Industrial Accidents Office of Investigations ' 600 Washington Street -- ^-y iV Boston,31A 02111 =«= =' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � �nc Address: �nn Q 2 City/State/Zip: `D,(�erlCe, Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with �S 4. E] I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g, F�Demolition working for me in.any capacity. employees and have workers' 9 Building addition [No workers' comp,insurance comp.insurance.$ required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no ., employees. [No workers' 13.( Other 1n'5Aax•-1"lU1il 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'camp.policy number, I am an employer that is providing workers'compensation insurance for nay employees. Below is the policy rand job site information. Insurance Company Name: <�}�'�� C,1 1`�}(Z` e Ga trbip Policy#or Self-ins.Lie.#: GGJ� 0 Expiration Date: a Job Site Address: ` "i i LYt� - 'i�� lj" i 1� City/State/Zip: Attach a copy of the workers' compensation policy declaration gage(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 aya thepaitas a jalpenaIt' perjury that the information provided above is trace and correct. Signature: 1; ;;! ,4 ^�� , f�i Date: mho,u®# k\�-SOW W" 0! ial:use only. Do not write in this area,to he completed by city or town o 4cl al City or Town: FermftUeeme# Issuing Authority (circle one): i I.Board of Health 2.Building Department 3.C'ity/Tmwn Clerk 4.Electrical Inspector 5.Plumbbpg Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location P 1 al UL9 NLr#6LMP125y-) MA No. and 5 ree� t — City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No I I Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No —Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other(if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or otlter 10 Surveyed Site PIan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existin Buildin Survey/Investigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) n-Aru c "'A 21 Other(Specify 22 Other(Spec!bj *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendinent has been approved by the authority having jurisdiction. Registered Professional Contact Information eel� l� L: lt .l 4$tc3i7 Registration Number Name(Registrant)��77 Telephone No. e-mail ad ress /3 Street Address Ci /Town State Zip Discipline Expiration Dabs Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Property Owner f A t��CRl~is'�c KiE?Si1�G cr`7ti 14 URIC a1 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: lap -' L Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here C3. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the r•o£essional coordinating document submittals) Name(Re istrant)� eleph ne No, e-mail addr, ss Registration Number �. I 1 u Clive. p j. �� I 01 3'.37 �p x s' Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor \Ia[N Company Name Name of Person Responsible for Construction License No. and Type if Applicable 40 Rtljc-X-Sdk� TY, Florence— Street Address City/Town State Zip 4i3 _ - '7 - ,der-gin � dlcaphta'�i'_gVilS'�,elreni, e Telephone No. usiness Telephone No.(cell) e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ ( ? 00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ -500, oO (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d Ind understanding. Please pr' t and sign name Title Telephone No. Date D1, Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety y ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION ,-acfhto7r i-t C t 0(4-10 JAI en& brmk 1242a-4merr S No.and Street — City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy 13 Othe rx Specify: �AACL:hOn Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:ear Sea) el Ac-S' e°z4e4%ck o co Fgx- e- �t gel -�0 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) v� S7J Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- ` R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use Cl and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ V ❑ VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site Public Check if outside Flood Zone Indicate municipa A trench w' not be P Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable is Su t ct' re within airport approach are a Is their review c npI ted? or Consent to Build enclosed 13 Yes❑ or NTO Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does dhe building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1231 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28) 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: BLDG 10-INSULATE ATTIC,HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RMATION 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 Delay ff � Iii ,a-t�: 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1231 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catego_ : INSULATION BUILDING PERMIT Permit# BP-2015-1231 Project# JS-2015-002306 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sa. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 10 -INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner I ne 1.0a nrunnweutta VJ lilG(w55GeG FrGY SGGGJ Department of Industrial Accidents Office of Investigations ,: 600 Washington Street it 11" F31 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 11^ Please Print Legibly Name (Business/Organization/Individual): Address: �j�b `'`f✓V�� ,✓ V� City/State/Zip: �' 1Cif E'V1C _ I%e#: �(� j--�rb'�`�IS2Z Are you an employer? Check the appropriate box: Type of project(required): I.M I am a employer with i S 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 S. F-1 Demolition working for mein.any capacity. employees and have workers' 9. Building addition [No workers' comp,insurance comp.insurance.: required.] 5. [] We are a corporation and its 10.0 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.[3 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.gOther I nS , 1.a 11a4h t-1}1 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. p am an employer that isproviding, woe leers'compensation insurance for nay employees. Below is the policy rand joh site information. Insurance Company Name: �31'-�l� c, �; e _ �'CAD e Policy#or Self-ins. Lic.#: oG,J�(0 f "Z 0 S Expiration Date: a 1 I Job Site Address: `' I �`'t �I ? P U'4 � 1 g q City/State/Zip: I ' � i'IkA C104;),— 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 vierification. Z do hereby certify a the pains a!1d penalti perjeaey that the nu ormation pr®sided above is trae and correct �M ! 1. Signature: ,�� I��,':�t (�• �. ��'.� � Date: t� ��1. ►::.� Phone 41. Qfjaciaal use only: Do not write in this arena,to be completed by city or town of°"acieal City or Town: Perm ltlLieens�e# Issuing Authority (circle one): I.Board of Health 2.BuffdAng Department y.C'fity/Tawn Clerk 4.Electrical Inspector S.Plumbing InFspectGr 6,Other Contact Person: P hone#: r 2, Footer Road -" a Ut on O 0 _ Office of Consumer and Business Peou ation �r 10 Park Plaza- Suite 5170 Boston, Massachusetts 02)116 Home Improvement C6ntractor.Registration Registration: 1053 Type: Private Corporation Expiration: 711712016 'Tr4 254029 VALLEY HOME IMPROVEMENT INC. STEVEN SILVERMAN ___..._ ..__.. P.O. Box 60027 FLORENCE, MA 0062 _._._...._ ._... _.. ---------: . ........ ... ._ _ ..__. Update address and return card.Mark reason for change. :address _._, Renew tl Employment ___. Lost Card Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Locations c qgF, h /11�,rh t' 1'I ea No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program_ 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' v C 'L 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information ,oavlj Lf- a3i7 Name(Registrant) Telephone No. e-mail ad ress Registration Number 1iC, SI\Je'�- ail. L:&A(kQ1,O RJR oi337 Ciao' 41/11 & Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Nam�e�an( d,Addryyess f Proper t�O�.wner /t 14(7(.E�(.c la j C I i! �V t r 1.t f �V l!� -1 t.5 alop Name(Print) �� No.and Street City/Town Zip Property Owner Contact Information. ( 't l I t Gi Title �J Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the proper owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin g document submittals Name(Re istrant) eleph ne No. e-mail addr ss Registration Number �� 4� �r cad 37 e 1 C e Street Address ' /Town State Zip Discipline Expiration Date 10.2 General Contractor \Jcd�� Romer jmpg>tew---w ri-� Company Name 'Fe��n Ss IYL, frk n C'S - 077R-7V Name of Person Responsible for Construction License No. and Type if Applicable 34o Rozvsde Dr, Street Address City/Town State Zip 4►3 _ '7594- _ _ crr no V,_IJ 64h6meiM✓VeMe�, Cam.-, Telephone No.(business) Telephone No.(cell) e-mail address SEC'T'ION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ a1501 00 Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ '),rj 0Q 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my l rrowl� d understanding. Please pr[* t and sign name ,g y �T`i[tlle Telephone No. Date bt.^c€ff,:l��:.�-id�'+�EZ�I�WI_tC?�L4''e' Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable Assessors Map# _ Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 5150 Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:CZr Spa l' x.4Z4%Ck 120V v eat ` e , l je- r9 [ 5 66 Plc /G3�L5 VN-It-k% 65 +0 - SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Kda= Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) a I S?S -- — Total Area(sq.ft.)and Total Height(ft.) 315D SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U. Utility❑ 1 Special Use_❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: . Sewage Disposal: Trench Permit: Debris Removal: Public) Check if outside Flood Zone Indicate municipaLK A trenchs wp not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: NIA Historic Commission Review Process: I�?ot Applicable ��St uefi�re tvitlti*t airport ap roach wren? is their review c npl�ted? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1230 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid Typeof Construction: BLDG 9-INSULATE ATTIC HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ORMATION 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 Delay 6�4e" gt, 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1230 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1230 Project# JS-2015-002306 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.-61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 9 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 tte uorEgmonliWeutta uJ 1F�(l�SLCLre�.�ecru - 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 Le0bly Name (Business/Organization/Individual): Address: aAu� City/State/Zip:_ �Of-'Vl(� \ V%one#: Are you an employer? Check the appropriate box: Type of project(required): 1.M 1 am a employer with 19 4. [] I 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 S. M Demolition working for me in.any ca p aci ty employees and have workers' 9. E]Building addition [No workers' comp.insurance comp. insurance.1 required.] 5. We are a corporation and its 10.0 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 I17Ic° iZ��°, 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 ornot 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 rand job site information. Insurance Company Name: be��o, _CM � Policy#or Self-ins. Lie.#: G�J�C%i J Z 0 Expiration Date: d Job Site Address: t i i ',:'t �� l:i t �iR : City/State/Zip: f}6 'it ice$ t E G" ' -- 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 vlerification. I do hereby certify f flag prairds a 1'd penaalti ��IQY2 erjury that the irforenQtion provided abo/ve is tree and corrects Sim afore: �; �4 f�'�' Date: Phan-±1. � ^S, qq ci�D Offcial use only. Do not write in this arena,to be completed by city or town of iaL City or Town: Permf ULicense# Isguing Autharity (circle one): I.Board of Health 2.Buil g Department 3. City/Town Clerk 4.Electrical Inspector 5.Pla robing Inspector 6.Other f Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location o �`Uw No. and treet City/Town Zip Name of Building(if applicable) Assessors Map # Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist;for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incom lete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) h v C- 21 Other(Specify 22 Other(Specify "Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information (e3i°7 Name(Registrant) Telephone No. e-mail ad ress Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION 6 Name and Address f Prope Owner r� A__�SQ C4 I 410 _�y,-4-��!— Name(Print) No.and Street City/Town Zip Property Owner Contact Information Title Telephone No.(business) Telephone No. (cell) a mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13. Otherwise provide construction control forms see section 107 in the code as required, 10.1 Registered Professional Responsible for Construction Control(the professional coordinatin g document submittals) Name(Re istrant) eleph ne No. e-mail add ss Re tration Number ,, 11 L, iyex PJ ��" , '1 IAN cat 3a7 _ ��I Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name S+emn CS Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip q 1-�_ 175,�l homeiMi' ref rc-n Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a sipned Affidavit submitted with this application? Ye!X No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 1Q5W100 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to _ 6.Total Cost $ ,5C)O, C?>°, (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st o '� f my kno/w /d / d understanding. r� ,! ' 'r�! Please pr' t and sign name V y Title Telephone No. Date 4LCe"tCc�� lt'dE� 'ieC: �i� Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION pp No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: �sytCt�Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No, Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: T 5e Z ' e_x`e'K� propex 'r ems Lo e 1")S"'2 1' t 'nt_e.5 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) j f Q0 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB E3 IIA ❑ IIB ❑ IIIA C3 IiiB ❑ IV c3 VA E3 VB SECTION 7.SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su pl : Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal Public Check if outside Flood Zone'( Indicate municipax A trench wjll not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ r equired X or trench or specify: permit is enclosed❑ Railroad night-of-way: Hazards to Air Navigation: N!A Historic Commission Review Process. Not Applicable is Structure within airport ap roach area? is their review c pl°ted? or Consent to Build enclosed❑ Yes❑ or NOX Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Constriction: Does the building contain an Sprinkler System?: Special Stipulations: — Design Occupant Load per Floor and Assembly space: — File#BP-2015-1229 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out -1 Fee Paid Typeof Construction: BLDG 8-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFpRMATION 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 Pen-nit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay CX" � �za-v 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1229 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1229 Project# JS-2015-002306 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK:BLDG 8 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner -Kk 1 sae 4,rvmmun weuun- vJ �c�etSSir�roaroGiGJ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 �t- www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ��; City/State/Zip: `('l�V�(� '�� 04h e##: Are you an employer?Check the appropriate box: Type of project(required): LM I am a employer with `B 4• ❑ I 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 S. ❑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 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.g0ther I �&A"ft>>, 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 ornot 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 joh site information. Insurance Company Name: b •�1� Lll` �i j -t;' �j �� Policy#or Self-ins. Lic.#: 001:�0, �"Z 0 S Expiration Date: Job Site Address: `7.i ��r�f'=" •<o j �u d cii yy C `t�e 1` 1 � ( City/State/Zip: ��fi � �A 0 lG l€•�— 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 r the pains a°1d penalti perjury that the information provided move is true and correct �M �•`<f f ,,i�,' �� Date: �"7 La Si afore: ( 1 d/, f J Offrcial use only. -Do not mrife in this area,to he completed by city or town off2cia l City or Town: PermitlLicensze# Issuing Authority(circle one): 1.Board of Health 2.Builaug Department 3.Cfty/Town Clerk _4e.Electrical Inspector 5.Pluunbing Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location � C 'en doe-2 i - --Z---- Mbrffi No. and�t City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a vvlicable No. Item Submitted Incom fete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Pro am 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance _ 19 Hazardous Material Mitigation Documentation 20 Other S ec' n-) J( Ini 21 Other(Specify 22 Other S ecif *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until thus application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information ��iC� `'��E.�r-��C� �!3_ _ t:i►�t� r��.�.tt :��►Z��I.1��' 4+cc3d'7 Name(Registrant) Telephone No. a-mail ad ress IVi Registration Number Discipline Expiration Date Street Address City/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address Ci /Town State Zip " Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address City/Town State Zip Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Property Owner K.. �((� �}�'r T✓ �,t6 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: -t.J � Title' Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu,ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coord' ting document submittals) aav� d I'1' A� Lf 11 6 A. t l td�� c::l'�6: �\aeriz�l.l2 463 f�j Najmpp Ye�(Re istrant){r, (f eleph ne No. e-mail adds ss / t y Re ti�3tion Number Civil Street Address ' /Town State Zip Discipline Expiration Date 10.2 General Contractor _ \WIN fie- JMPg>le,-n_.l ;� Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413_ 752J- _ e,, _f, c'c , Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION PENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesjK ❑ s SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ '75 0©. oG Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Nate:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ -750a 0a 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains,and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my kn �(i ow d d understanding. Please print and sign name r v Title Telephone No. Date 3 o 1.11,J&'5 Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts g `_ Department of Public Safety d Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION t-c( �r G O .0 It+(�'E;C.)&obrmi' � i?tr'�t�1�ti'f'z1S No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # FL2 d tl 7 SECTION 2:PROPOSED WORK Edition of MA State Code use If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition 13 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other JR Specify: 51 50,i t-- On _ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:ajr. -ea) a ex4e,,ck its et'14 C'crts i oh ere noeaia± SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Kd= Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 4R7 --- Total Area(sq.ft.)and Total Height(ft.) 140 1 3® SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ i Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su pl : Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Pubfic Check if outside Flood Zone Indicate municipa e french will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable is Stricture within airport approach urea? Is their review c pl ted? or Consent to Build enclosed❑ Yes❑ or No Yes 13 No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does die building contain an Sprinkler System:':_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1228 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB000)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out aLdh�1 Fee Paid Typeof Construction: BLDG 7-INSULATE ATTIC HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1228 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1228 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP zoning:URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 7 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Sisnature: FeeType• Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner !ne uommionweuttrt ui 1F1C455LC�.re€csccra ,. 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): �GA�fkl Address: `;-�- City/State/Zip:. A- `Q1,_r ke, \ 01 h e#: Are you an employer?Check the appropriate box: Type of project(required): 1.M 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. ❑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 S. ❑Demolition working for me in.any capacity. employees and have workers' 9 ❑Building addition [No workers' comp,insurance comp.msurance.t 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 1 L 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 inS0 Y) 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name: C CbJD s fl � �to Policy#or Self-ins. Lic.#: 001�0 J02— 0 S Expiration Date: a Job Site Address: "`ti t '€ l%°` t t City/State/Zip. ' ' F r,' 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 a thepaaiIts¢ ,d peaPaalti pperjaary that the inyormation prodded above is true and correc-t Sign ature: �; 1 / `4 ,�;.f'°, Date: ` / jJ Phone 4: Official icial rise only. Do not mrite hn this area,to he eo&Dleted 5y city or town of cia€L i City or Town: Fermtt[Lfcense# II Issuing Authority (circle one): Z.Board of Health 2.13u_ff ing Department y.City/'awa Clerk .Electrical Inspector S.FlumMug Inspector s 6. Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location "arc i fgeC dol No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) nkrV C-ft 21 Other(Specify 22 Other(Specify *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Y+� 1�s'� �C� `�I'�_ �';1' - Ui;�,t� C�v`f L%��.f� ;� �v��►Z��►.►?�� — '+(e3 �7 Name(Registrant) Telephone No. e-mail ad ess Registration Number i(r. �'1�#�',`" mil! ,�'n RA Gla37 �lV�� i�� r �(' —�-- Discipline Expiration Date Street Address City/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Street Address Ci /Town State Zip_ Discipline Expiration Date Registration Number Name(Registrant) Telephone No. e-mail address Street Address ..City/Town State Zi Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and AddressQf Pro Owner , qQ C J 114e' Name(Print) No.and Street City/Town Zip Property Owner Contact Information: � yy_ �: Y e 7 C / ——_- 4a, 0 L, Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address i City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this milding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here C3. Otherwise provideconstruction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) Name(Re istrant eleph ne No. e-mail address Registration Number P I Lo iy(?f R)IJ �L-c�; fl i,.6 (21 337 civil — p Street Address Ci y/Town State Zip Discipline Expiration Date 10.2 General Contractor \WLC':�.'i Rome- - Company Name efen CS - 07D Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 4r3 _� 7��- _ - - ��c�d��►�� ocp i�h�rvl�l �•�F�-1: cc,�, Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesX No SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1,Building $ 00• 00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ - 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ -7600. 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my kno7P11, d d understanding. 'if �r e� �J��- F�✓`a°� _� Title Telephone No Date Please pr t and sign name P 3'- l�t ° 'i' %' .LE� i ` t^cttt �ft _;rte°9RtZJ;_e apes E ELI+�. Street Address Cityy/Town State Zip Email ddress Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION - 0 C No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # ��EI��r SECTION 2:PROPOSED WORK Edition of MA State Code used F0, If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 141512 b_n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:for Sedx/` a e-x4 X31 2.0 4 erAS e l a7 i 5 a CC . 7 `r ld f Y RUA SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) q997 Total Area(sq.ft)and Total Height(ft.) q(O l 1 50° --- SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 13 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ 5-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA [3 IB ❑ IIA ❑ IIB El IIIA 13 IIIB ❑ IV ❑ 1 VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Su p1 . Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public Check if outside Flood Zone Indicate municipa A trench wW not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require permit is enccll trench or specify: osed❑ Railroad right-of-wa : Hazards to Air Navigation: MA Historic Commission Review-Process: Not Applicable Is St-uct::re within,airport approach are Is their review c npl'ted? or Consent to Build enclosed❑ Yes❑ or NoA Yes❑ N SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Constriction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1227 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 6-INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1227 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-1227 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 6 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1 he Golf moaET!'09eaun of 1Ciassactiuseai3 • ,-- -=� _ Department of Industrial Accidents Office of Investigations �= 600 Washington Street Boston MA 02111 - - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): a k lf.1k t6'w � 1 Address: City/State/Zip: f \ I 8hone Are you an employer? Check the appropriate box: Type of project(required): LM I am a employer with 19 4. ❑ I am a general contractor and T employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in.any capacity. employees and have workers' [No workers' comp,insurance comp.insurance.$ 9 Building addition 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 11❑Roof repairs insurance required.]t c. 152, §1(4),and we have no F employees. [No workers' 13. Other f nSU 6-Ali.i 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 nay employees. Below is the policy and job site information. Insurance Company Name: 6beMo- G rcu-p � � 1 Policy#or Self-ins. Lic.#: C ?D 02— 0 S Expiration Date: l 1 Job Site Address: ` t J City/State/Zip: locetict Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration mate). 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. do hereby certify r the pair's a'd penalti perja`ry that the€nyorma*ion provided above is true and correct 7 Signature: Date: `) / l r Phone:L,. Official use ow r- Do not write in this area,to he com Meted by city or town off clal �! City or Town: Fermftl fLrcense Issuing Authority (circle one): 1.Board of"ealth 2.Bu dtno,-Department 33. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 7 Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location c No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other(if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Pro ant 14 Fire Protection Narrative Report 15 Existing:Building Survey/Investigation 16 Energy Con,ervation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec' f G. 21 Other(Specify 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendinent has been approved by the authority having jurisdiction. Registered Professional Contact Information 'b�[ �pF,/ E g.^�(�,y� �6 ) (�g� Eery y��,y �,? t"� Y 1�i�ry CC.'a d- F. _ CJ'1. ., t.t 'e t. @�E.� �rf l'',t t 4�-+8 t.l�•�.: (.0 3t' Name(Registrant) Telephone No. e-mail ad ress Registration Number Rot. 537 Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State zip Discipline Expiration Date Nance(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION ' Name and Address f Pro e Owner 4- s7C �E s��C, 1 r E� € n`�0 1�y r� -Sl l J 'r '� � � 1"1 Name(Print) No.and Street City/Town Zip Property Owner Contact Information• 1. Title Telephone No.(business) Telephone No. (cell) e-mail addreaddres5 If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this buildin ermit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1.) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for(E Construction Control"(the professional coordinatin document submittals) -cokV L d y r—Ma ti q 1 j_ aq__ C,f��;r d y':erac..tl'd \a Cif E Ze;bl.g�!.r q&3 r 7 Name(Re istrant) eleph ne No. e-mail addr ss Registration Number� 37 Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Rome- Jmpro fev �'� Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 413 _ '752) Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Yes No SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 5 0 D Building Permit Fee=Total Construction Cost x`(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ -7506, 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b sit of my know d. and understanding. `'lam - p"Fr- '75 2�- Please pr' t and dssign €name u Title Telephone No. Date e�G€E.G, Street Address City/Town State Zip Email�ddress Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # ��t`!�t SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 1115ti�C� Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No; Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:&r Sam i cx4e."ek mrpex "WAS e IC' C6 n2aw ) C CL 6'clefivlase- At enf Zl -�D SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 y897 --- Total Area(sq.ft.)and Total Height(ft.) 14 611 30 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-113 R-2 R-3 13 R-4❑ S: Storage S-1❑ S-2❑ U: Utility 13 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 7 IV ❑ I VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Publi Check if outside Flood Zone Indicate municipa A trench wi}Jl not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredA or trench or specify: permit is enclosed❑ Railroad right-of-W Hazards to Air Navigation: ??Historic P ric Commission.Review Process: Not Applicable is Stri:cttire Tvithin airport approach area? is their review co pI ted? or Consent to Build enclosed❑ Yes❑ or NTo Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does die building contain an Sprinkler System?: Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1226 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 5 -INSULATE ATTIC HATCHES WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing AccessoKy Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1226 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catego : INSULATION BUILDING PERMIT Permit# BP-2015-1226 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sg.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413)584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 5 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 'y-N 1-he (10MMIonweUllra Uf �r[G635ikY.raeq�eee� -� .. Department of Industrial Accidents 1= _ 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/Organizatiomhdividual): k -n Address: �1G City/State/Zip: Rhone##: - 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. ❑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, E]Demolition working for mein,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 3.❑ I am a homeowner doing all work officers have exercised their 1 L Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 11❑Roof repairs insurance required.]t c. 152, §1(4),and we have no � employees. [No workers' 13.[Other Ii� l 1 lL��1 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 ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Z am an employer that is providing workers'compensation insurance for my employees. Below is the policy rand job site information. Insurance Company Name: �Vbt* y a_ Policy#or Self-ins. Lic.#: J�J C�j Expiration Date: a 10� Job Site Address: ` I t � ' f 6}tit 9 - - ! City/State/Zip: riO 14'16 ;4 A 0 E0V',�-- v 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 vierification. I do hereby certify r the paiarsa penury that tlse infbrmration pr®vided wave is true�^nd correct Si afore: ��i '°, Date: �°7 r� Offacical use ont. Do not write in this mi=ca,to be contpleted by city or fawn, City or Town: PermitUeeme# Issuing Authority(circle one): 1.Board of Health 2.BTTIMng Department y.City/Tawn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other �� Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location ( No. and treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ NoM Provider notified. and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where apphcabl e No. Item Submitted Incom lete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plum ocal connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existin Buiidin Surve /lnvesti ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 1 Hazardous Material Mid ation Documentation 20 Other(Specify) et v C 21 Other(Specify) 22 Other fSpecffy) *A as of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad ess Registration Number Street Address CiW/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. ray SECTION 9: PROPERTY OWNER AUTHORIZATION �{ CVc c1�lDC r-- rf xi-, a�oc�7►Owner 7�t J AZ,,- �., � I,- ? ; e- ��sj�,. . %tarp cam; tC C l Name(Print) No.and Street City/Town Zip !Property Owner Contact Information: lU�� t�C $ C1�' ( Ji" � e r _ - Ct ) ,nom t L�. c.rc Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals) DuxyL d y reelani 1413-621 C O(. CI$I 1'G dctt*)`:i \t of l Zt�).III q&3 f} Name(Re istrant) eleph ne No. e-mail addr ss Registration Number B f 9(y eV KCI. '' Af4t 1 (;fit ] Civil ' Street Address */Town State Zip Discipline Expiratton Date. 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable 51+0 C x u'l o S i�G ' L . _ Fl©a zrlc: M, CAL c '� Street Address City/Town State Zip 413 _158Y_ '7524-. Telephone No. business Telephone No.(cell) e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accident,must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this applica tion? YesX No 13 n SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ r1500•dd Building Permit Fee=Total Construction Cost x—(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ '1 ?, (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains.and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d d understanding. L p— Y 1s^t° Pleac,s�pe�pr t and sign namerr u- Title Telephone No. Date CtEii '. 6h �� rSf N.% eCejE9je% rr`e°� Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: - Name Date The Commonwealth of Massachusetts Department of Public Safety y ' Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Ma # Block#and/or Lot # f t 4 SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: �5QiCt: C>n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: /°S 1 ' e -+eftck Vn ex 4 e.rf lt'' z 9, e '5 t [c `' y 1��5 t d SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) gsq'7 -- Total Area(sq.ft.)and Total Height(ft.) A uqi 3o ' SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA E3 IB ❑ IIA C3 IIB E3 IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PublicX Check if outside Flood Zone Indicate municipa A trenckwp not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requiredX or trench or specify: permit is enclosed❑ _ Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable� is S±ructure ivithin airport approach area? is;heir review c . plated? or Consent to Build enclosed❑ Yes❑ or Noy Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: File#BP-2015-1225 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD-MEADOWBROOK APTS MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG-4 INSULATE ATTIC,HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1225 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: INSULATION BUILDING PERMIT Permit# BP-2015-1225 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)/WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 4 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ine d.omirnonweatin ofitiassacnu etas Department of Industrial Accidents 0,_ Office of Investigations '=' ' 600 Washington Street � a �- Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Am)Ucant Information 11 Please Print Legibly Name (Business/Organization/Individual): Address: j�� City/State/Zip: - AQf•C'abf, \ r 1 h e##: . Are you an employer? Check the appropriate box: Type of project(required): 1.[� I am a employer with I B 4. ❑ I am a general contractor and 1 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in.any capacity. employees and have workers' 9 E] Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. r-1 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑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 _P employees. [No workers' 13. Other 11�5i Zit 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: G_!.�j- r- 1 Policy#or Self-ins.Lic.#: (E)COO J 02— P S Expiration Date: Job Site Address: City/State/Zip: 10 6�C�6C, i'\ 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 rrifcation. I do hereby certify :t the pains a°d penalti perjury that the isaformadon provided above is trace and correct Signature: ► ,r;4 . n. iA,'��i Date: Phcm�11: ,� Official use only. Do not write in this area,to be coinvieted by city or town off ecial City or T oRm: Per=it/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location leN l U�� No. and Street City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified.and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required _ 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Pro am 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 119 Hazardous Material Mitigation Documentation 20 Other(Specify) h v C 21 Other(Specify 22 Other (Spec') *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information �;l�t 'V I'�a .p�C� `�I�_ ,::� - z:%i�.l� ��`a�F�l.�.t1 d`�v�'�►Z(t'1.l�ir>�'. �lsf�i'7 Name(Registrant) Telephone No. e-mail ad ress Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address� � f Prope Owner rg i E!SC�7'u`c:1tlGf�% �" n �► ��s r. ya ,te� v , 5 � ' tn. iif ca10 Name(Print) No.and Street City/Town Zip Property Owner Contact Information- . aI tip:,��Gn `f Y - - - t Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to applV for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professionadl coordinatin g document submittals) D,v1.d Vrmf. 1 dyr-edard YNerizo,P,J '/&317 Name(Re istrant) eleph ne No. e-mail add r ss y Registration Number ii f�a i16 VA��rC • �'' 1 Cst3�� _ci it Street Address /Town State Zip Discipline Expiratton Date 10.2 General Contractor Company Name &few) S"l re.rn'tt, C5 - 07'D 7 Name of Person Responsible for Construction License No. and Type if Applicable 3" Rtwlcst(le) -LY, Florence— MA Street Address City/Town State Zip Y13_ 75):x- vaila4 Telephone No.(business) Telephone No. cell —�e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? Ye!X No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ UG, 0 O Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ '7500, 00 1 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d nd understanding. Please pr'it and sign name Title Telephone No. Date Milt- vc�Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date ~ The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied Building Official: SECTION 1:LOCATION i'e f r ,. R& No r-krunp&O 0 0 C) !.4"i r" Pm K. No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ !1V Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ ^Specify:_�h'151AC010n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: r s. ea) et !S ex4e^ck enr>(?x 4 en, re n �1 -- � a n 'Yt7 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) 50 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ 1 R: Residential R-113 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U. Utiliij_07 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB SECTION 7:SITE INFORM_ATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Publi Check if outside Flood Zone Indicate municipax A trench wP not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ _ Railroad right-of-wa : Hazards to Air Navigation: MA Historic Commission Review Process. Not Applicable is Structure within airport approach area? Is their review c mpl ted? or Consent to Build enclosed❑ Yes❑ or NoA Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: _ Design Occupant Load per Floor and Assembly space: File#BP-2015-1224 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD MAP 17D PARCEL 012 001 ZONE URB(100)/WP(28)/ 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: BLDG 3 -INSULATE ATTIC HATCHES,WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN RMATION 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 Delay A i�0,-f,� 6AIl'-;— 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1224 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1224 Protect# JS-2015-002306 Est.Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)[WP(28)/ Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.6/4/2015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 3 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 Sisnature: FeeType: Date Paid: Amount: Building 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner i he commonweaun of ivassacnitseaas = = Department of Industrial Accidents Office of Investigations 600 Washington Street ; r774,1_ Boston, MA 02111 =,-r - ==tom www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Indi,,idual): k .�- U`v wen-]— , 7Tn L, Address: y bZ 'a �2Z City/State/Zip: '� �(�l•(��1.C.� \ � � � Phone#: �-��-� �" 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 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. Demolition working for mein.any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.t required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 I �� y�Z�� 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 nay employees. Below is the policy and job site information. Insurance Company Name: f kybe , , C, l` )i2` 'e L7 c U,> a r— Policy#or Self-ins. Lie.#: (1)0(�)<5060 Z o S Expiration Date: a I(, 4: G " City/State/Zip: t 1 a s� Job Site Address: "�,``�I L'-.!'r�9 kn.;z ��,°," c t; fl ;� �.(�' �E' `:� i 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 ILIA for insurance-coverage verification. cation. do hereby certify r the pains a fed penaslti. peerjury tkat tl�e iaforenatioaz pr ovided above is true and correct Sijzna fore: ai �, i-, f��i Date: Q ..r. e Official use only. Do not write in this area,to be completed by city or town df�ccic�l City or Town: permi{ILicens-e# iC Issuing Authority (circle one): P.Board of Health 2.Building Department y. City/Fown Clerk 4.Electrical Inspector S.Plumbing Inspector I 6. Other Contact Person: Phone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Locationl zigt 'arc d,e i No. and 5'treet City/Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other(if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm 'may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surve ed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review _ 13 Structural Tests&Inspections Program 14 1 Fire Protection Narrative Report 15 Existing Building Surve /Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other S ec' vy,54ry C- 21 Other(Specify 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail ad ress Registration Number LeTAL_('�k� MA of a07 Discipline Expiration Date Street Address City/Town State Zip Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State ZiE Discipline Expiration Dates Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/ Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and,Address f Propperty Owner qo coud j, t2 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address' If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here C3. Otherwise provide construction control forms see section 107 in the code as r uired. 10.1 Registered Professional Responsible for,,``Construction Control('the professional coordinatin document submittals) DayLd Vt-e, r2 r� �'�i_ld �_ �'&. �°< Qyael€dlf; l,l2f.' Name(Registrant eleph ne No. e-mail addr ss Re is anon Number Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name S+ Sr 1 Yt?'r ra,141 CS - 07D-7`- Name of Person Responsible for Construction License No. and Type if Applicable Florence— Street Address City/Town State Zip 413_ '1524- slovenavai t lbomomrovenw-ri-1: CCs Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6)). A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this application? YesX No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ DO• 00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ _y__ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ T500. ()Cj (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know]/e/dg/rnd understanding. d jry( `{r Please pr, t and sign name a Title Telephone No. Date : �?- 1,1 @�} ,•� j '1t i"v�",46,j I--- -r -tit : 0- t Street Address City/Town State Zip Email ddress Municipal Inspector to fill out this section upon application approval: _ Name Date The Commonwealth of Massachusetts u; Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ('This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION No.and Street City/Town Zip Code Name of Building(if applicable) r Assessors Ma # Block#and/or Lot # 3�.�t1 SECTION 2:PROPOSED WORK Edition of MA State Code used I If New Construction check here❑or check all that apply in the two rows below PL Existing Buildinvl< Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other X Specify: I 5_, y_Z__R_C_5n Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: r S l' ex4e,+.- , ro e c v e+^ e o, t �(eL, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1 R: Residential R-10 R- R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ I IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Sup pl : Flood Zone Information: Sewage Disposal: Licensed Disposal Site Publi Check if outside Flood Zone Indicate municipa A trench w' not be p Private❑ or indentify Zone: or on site system❑ require permit is enccll trench or specify: osed❑ Railroad right-of-wa,: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is St-ucture within airport approach area? Is their review c _ pl ted? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: _ File#BP-2015-1223 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD MAP 17D PARCEL 012 001 ZONE URB000)/WP(28)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out e�? Fee Paid Typeof Construction: BUILDING 2-INSULATE ATTIC,HATCHES, WEATHERSTRIP DOORS&AIR SEAL New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Delay 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1223 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1223 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sq. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning. URB(100)/WP(28)/ Applicant. VALLEY HOME IMPROVEMENT INC AT: 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.BLDG 2 - IINSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS & AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner The Commonwealth of Massachusetts Department of Industrial Accidents lzp ,,`r, Office of Investigations --- ry } 600 Washington Street Boston, MA 02111 fir_§ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ok'If1k � -, V'Yl�D��J`v�1�f1E'V' , 7-n L, Address: City/State/Zip: `01,e %one#:Are you an employer? Check the appropriate bog: Type of project(required): 1.M I am a employer with_ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in.any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing airs or additions 3.El f I am a homeowner doing all work ❑ big re p myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no t lyn employees. [No workers' 13.�Other �� ` comp.insurance required.] *Any applicant that checks box#1 must also fin 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 far nay employees Below is the policy and job site information. nn � Insurance Company Name: �Vb Mo, U r6j-P 1IPolicy#or Self-ins. Lic.#: GJ�JQ 'Z O Expiration Date: a Ito Job Site Address: qql 13ulldnL :4- City/State/Zip: ADCe M, ►AA C9lQ'V - 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 jerification. I do hereby certify the pains a��d penalti- perjury that the information provided above is true and correct. Siana fore: 1 ;: �� ''`� Date: 5 a 1 15 Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Peranit/Lieense# 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: P hone#: Appendix 2 (For total demolition only) For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for ;public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Locationd�� Imp ( No. and beet City /Town Zip Name of Building(if applicable) Assessors Map# Block#and/or Lot# For the above described property the following action was taken: Water Shut Off? Yes ❑ NoM Provider notified and Release obtained? Yes ❑ No Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No --Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Yes ❑ No Provider notified and Release obtained? Yes ❑ No Other (if applicable) Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a pplicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMK 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S eci t1 v c 21 Other(Specify 22 Other S eci *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information `Davin yree,Cand q13_L_ 0eat, dvreelal L2(,tzon.nU -- gw31 7 Name(Registrant) Telephone No. e-mail ad ress Registration Number 1v4elf +� . L n MA Di 33`7 CV,, 4��36 1" __ Street Address City/Town -State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addrgss f ProperV Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 17- �+�t�_C' nerc " �YY o _ +Ct_5 a Cyr Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3. Otherwise provide construction control forms see section 107 in the code as requ ired. 10.1 Registered Professional Responsible for Construction Control(the professional coor i ting document submittals) re&nd t Name(Re istrant eleph ne No. e-mail addr ss Registration Number Kier '�: µ� 01 33 mil c0 Street Address /Town State Zip Discipline Expiration Date 10.2 General Contractor \pa. IN 1��n�rtxte��-I- Company Name S+e.(w) sI 1 077J-71 _ Name of Person Responsible for Construction License No. and Type if Applicable ,34o Roi(x5lt e Ty. _ Florence— MA b�ri(oZ Street Address City/Town State Zip 4)3 - 752d _ - - 5'`feven4? Vajle4 omel+'v�provemer�-}: Cc Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is uance of the building permit. Is a signed Affidavit submitted with this applica tion? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ -7500, 4 O Building Permit Fee=Total Construction Cost x____(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ _ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to _ 6.Total Cost $ 750 0, 00 (contact municipality)and write check number here _ SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the b st of my know d nd understanding. l3 Sin �i _� - 75��- Please pr} t and sign name l Title Tele hone No. Date us0e vaC� ne,mpro reme �(by►-� Street Address City/Town State Zip Email ddress Municipal Inspector to fill out this section upon application approval: _ Name Date r Commonwealth of Massachusetts Electric, P urnn;r, -°�'� Department of Public Safety 9&uas Inspections Northam ton,AAA 01060 Massachusetts State Building Code(780 CMR) Building Permit pp ication for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: _ SECTION 1:LOCATION r U_ Noe - v o 0 Mend&'Trrcyk l +4;4me No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# _ Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other Specify: 714_ 15U QD Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No 1 Brief Description of Proposed Work:CU 5 e x4e -ok ru�e:� v e�5 e lt4e_ S is _ N l vllaS UA SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): KIL _ Proposed Use Group(s):_ SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) S L!691 Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ _ E: Educational [I F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2 11 H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-113 RA R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ t Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IlIB ❑ IV ❑ 1 VA ❑ VBX SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) - Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipa A trench w' not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ require or trench or specify: permit is enclosed❑ Railroad right-of-wa : Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport ap roach area? Is their review c pl ted? or Consent to Build enclosed❑ Yes❑ or No, Yes❑ Noo� SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ Type of Construction: Does the building contain an Sprinkler System?:_ Special Stipulations: Design Occupant Load per Floor and Assembly space: _ File#BP-2015-1222 APPLICANT/CONTACT PERSON VALLEY HOME IMPROVEMENT INC ADDRESS/PHONE P O BOX 60627 FLORENCE01062(413)584-7522 PROPERTY LOCATION 491 BRIDGE RD MAP 17D PARCEL 012 001 ZONE URB000)/WP(28) 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: INSULATE ATTIC,HATCHES, WEATHERSTRIP DOORS&AIR SEAL-BLDG 1 New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077279 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INPORMATION 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 Delay / �" /�i4 GZ cv-,e-4 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. 491 BRIDGE RD-MEADOWBROOK APTS BP-2015-1222 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-1222 Project# JS-2015-002306 Est. Cost: $7500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VALLEY HOME IMPROVEMENT INC 077279 Lot Size(sg.ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning:URB(100)/WP(28) Applicant: VALLEY HOME IMPROVEMENT INC AT. 491 BRIDGE RD - MEADOWBROOK APTS Applicant Address: Phone: Insurance: P O BOX 60627 (413) 584-7522 Workers Compensation FLORENCEMA01062 ISSUED ON.61412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLDG 1 - INSULATE ATTIC, HATCHES, WEATHERSTRIP DOORS &AIR SEAL 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 6/4/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner