05-001 (32) GENERAL NOTES
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A8 � 131 s. .SOIL? =) SOILPq W-D-17 W-D-15 W-D-13 W-D-11 96sq.ft. W -S-3 W_RN JAN. m m 102sq. W-D-2 W-D-1 187 sq.R. 192 sq.ft. 192 sq,ft. 192 sq.R. 2164 sq.ft. 4 sq. 192 sq.ft. 192 sq.ft,68 sq.ft.
8sq.ft 8sq.ft ALC 16 sq.ft
WEST CORRIDOR CORRIDOR
8 sq.ft. 8 sq.ft. 8 sq.ft. 8 sq,ft. 8 8 sq.ft. ,
q.ft. ��
VEST -
W-D-18 W-D-16[;W-D-14 W-D-12 W-D-10 W-D-9 W-S-5 W S 4 W-S-2 W-S-1 V W-D-4 ussa ft 192 sq.ft. 2 sq.ft 192 s ft. 153 ft. 153 sq R 160 sq.R sq•ft. 188 s ft187 sq.ft. q• 192 sq.R 153 sq,ft. sq sq.ft 158 sq.ft. q
w
Scale: 't'-G ' x
Graphic Scale
i
Robinson Design Inc.
Architects&Engineers
_ 405 Douglas Pike
Smithfield,Rl 02917
COMMON AREA PROVIDED Phone(401)231-0101,Fax(401)231-236C
-r .robinsondesignlnccom
r. mss.
TOTAL BEDS=40 @ 27 FT'/BED TOTAL email:rdi@rnbinsondeaigninc.cnm Lj
AREA=1080 FT REQUIRED.
TOTAL PROVIDED 430+388+188+244= 1,250 FTZ HIGHVIEW
OF
"= NORTHAMPTON
- MDAOCT frA7Yf
MEMORY IMPAIRMENT
NURSING WING
t AREA REVIEW
r
MEMORY IMPAIRMENT WING �° = sHEBr TBE
WEST WING f Floor Plan
Drawn By: SHEET NO.
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D,Ogn d)Chen«By:
Jahn Rabnson
Dare: Assess
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Srak: As Naled –
SHEET_OF
X6`��" S City of Northampton
tsuinng Department GENERAL NOTES
Plan Review
212 Main Street P°
Northampton, MA 01060
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HARDWARE / ATEACMR51DENTNOORTYRK AQUARIUMS.ETC.I —
BW.R. EW P.. 9w.M1 9w.1 aw.1, 6'.2. MEWwA &DOOR
y.rt. p 5 W:DELAYED YANK
DINING VEST LOUNGE/ y m �FSS MARDwwE
W-D-18 W-D-16 W-D-14 W-D-12 W-D-10 W-D-9 WS-5 W=S-4 WS-2 W-S-1 W-D-7 W-D-5 W-D-4 :1s . Q- +'vwGMNwROR
. ,. ACTIVITY
111nl .E9'1 IS3v.Y w h G'C O ABOVE MANCAAIE i
199'.1
NEW GWR
SOLARIUM O�Q- �. MFILL WN1 OPENW4
k MATE RWS TO
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Arckitecn&Engi-
I WEST WING MEMORY IMPAIRMENT FLOOR PLAN
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`� mtll:ra9RyrNlwaa�dmlNMxwv
HIGHVIEW
OF
NORTHAMPTON
MEMORY IMPAIRMENT
NURSING WING
AREA REVIEW
33 MIN, 15 30 1 15 1
smKSasE FLOOR PLAN
VERIFY IN FIELD
2 NEW NOURISHMENT STATION ELEVATION
- A1.2
KEY PLAN
Massachusetts -Department of Pubic S-311et,)
Board of Build'.ng Regulations and Standards
r
ConstructitinSupenis(ir
License:
I
F D.
E(piration
Commissioner
Massachusetts - Department of Public Safety,
x .
Board of Buildi" tt:!g Regulations and Standards
SLIpe.msor
), 96672 Vita ' � Y��. �� �5
Licen
dOMMMMOMP
STIEVIEM A
20 WIGWAM molt,
WIEST ROOKFIEL0�1"kMA
f Jr
Expiry tion
02/1712016
Commissioner
3/3/2015 1 : 01 : 18 PM 8618 02/02
1' DATE(MMIDDA YYY)
A) rRL� CERTIFICATE OF LIABILITY INSURANCE 03/03/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). CCApN�,�TT
PRODUCER 05012-001 NAHpMNEAE� p7(
George A Tetreault III NC.No.[ Et): (413)245-7600 FAIC.No.:
PO Box 467 MASS:
Brimfield,MA 01010-0467
INSURER A: A.I.M.Mutual Insurance Company
INSURED INSURERS:
Carroll Custom Contracting Inc
20 Wigwam Road INSURE D:
West Brookfield, MA 01585
INSU RE:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE POLICY NUMBER MMADA•`!1'Y POLICY_Jr]CP. LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
PREMISES(Ea
CLAIMS-MADE [:]OCCUR MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
EN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $
OLICY RO- OC
AUTOMOBILE LIABILITY COMBINED SINGL LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
HIAUTOS AUTOS ED AUTOS NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLA LIAR HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMSMADE AGGREGATE $
DED F RETENTION $ C U TH $
WORKER P V111 TIOI tJ X TORY LIMITS OER
AFF PERPFIET�RIPAL�lFDREI (ECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000.00
A OM !MEMBER E NIA VWC-100-6012619-2015A 4/3/2015 4/3/2016
�(((Maaanddatory��In NH) E L.DISEASE-EA EMPLOYEE $ 1,000,000.00
D�SSCF2IJ'��ONMF PERATIONSbelow EL.DISEASE-POLICY LIMIT $ 1,000,000.00
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SimpleGrinneil/Cisco Pump House
16 Brooks St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Worcester,MA 01606 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1111988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
9959
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8t'edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: I cm i teuw (NAr?4 Wl. MW-A4-.*WV X WWL Date: 5 2"'7 floi,T'
Property Address: Z22 K W VC YU%010 �, >$ XIA
Project: Check one or both as applicable: ❑New construction ❑ Existing Construction
Project description: 1!�f[�iL!ate_ 115 N- l W4��iu�1"�* 5�-T["S3 Gca4ttYAYL QdyC
t o LA�4a t S -ate/ S T•a C
fiWI-E &*t C4VZ,fr.. -J1?1 S V2,Wt. L,^LA-- 14.r++/ fJt'..�ye P W
I �04�N �ZtYt„tN Suc�l MA Registration Number: 1 52- Expiration date: 015 am a
registered design professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
[�'A rchitectural [ ] Structural [ J Mechanical
[ ] Fire Protection [ J Electrical [ ] Other
for the above named project and that to the best of my knowledge,information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts 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.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a`Final Construction Control tll
R
Enter in the space to the right a"wet"or
electronic signature and seal:
Jo►a+� a� 62�3cnrsw�t'h1s,+�u/r�t.•Gawi
401-231 -0161 1T
Phone number: Email: �N OF
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
20 Wigwam Road I Office-508-867-3600
West Brookfield,MA 01585 Mobile- 508-243-7735
Fax-508-867-9257
www.carrollcustomcontracting.com
RE: High view Nursing 6/2/15
222 River Rd.
Leeds MA.
As requested the day we spoke in your office I had the architect of record provide you with a Construction
Control Document for the proposed cross corridor doors.
The purpose of proposed doors is to stop wandering dementia residents from getting out of building.
The new door will be 3'8"x 6'8" out swing to main exit with 5x20 safety glass vision panel.
The new doors will be hollow metal door and frame as specified.
The new doors will be self closing and have push/pull hardware as specified.
The new doors will have delayed egress security magnets tied into building fire alarm system as required.
Any questions please call 508-243-7735
Sincerely,
Steven A. Carroll
President
GENERAL NOTES
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'B1-1 192sµR. 192 p,R :9i x-1 N P lal,D ._txi INS tt.- 19i swR 192 s4 R. LOUNGE N
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WEST CORRIDOR CORRIDOR U �'�'" GO��
.enn, Zll
DINING I VEST LOUNGE/
W-D-16 W-D-16 W-D-14 W-D-12 W-D-10 W-D-9 W=S-5 WS-4 W W-D-7 W06 W=D-5 W=D-4 tstt.s. ACTIVITY q Fes` PO .r
tl]p.R 1925p.9. t92tt.R s9islk 192p.ft !SIU.R ISJU.R. ISIU.R IbOWR u.P IiASµfl. :91u.R 19ip,R 193gP. :M2:n, 188q.R OX"
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HIGHVIEW
e�7 h OF
�o y/l NORTHAMPTON
/ O�
n
MEMORY IMPAIRMENT
t WEST WING MEMORY IMPAIRMENT)ORIENTATION PLAN NURSING WING
1 A1.1 Scale:3/32'.r-a^ AREA REVIEW
COMMON AREA PROVIDED ORIENTATION PLAN
TOTAL BEDS=40 @ 27 S.F./BED TOTAL
AREA=1080 S.F.REQUIRED
AM
KEY PLAN TOTAL PROVIDED(430+388+188+244)=1250 S.F. 5
�°
' Tire Commonwealth of Massachusetts
m=m Department of Industrial Accidents
:— Office of Investigations
"=fi4 600 Washington Sheet
r
-, Boston, MA 02111 -
_- www.mass.a ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le6ibly
Name (Business/Organizadon/Individual): at 1VG e ayc,4- 1 e oer• _
Address:
,�.0 c.c> r �, W�,�
City/State/Zip: W V7J iR Phone#: a ^ Z '����
Are you an employer? Check the appropriate box: Type of project(required):
1.g I am a employer to er with 4. ❑ I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7: �Zemodeling
sub-contractors have
ship and have no employees These 8. E]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.F-1 Electrical repairs or additions
officers have exercised their 11.❑Plumbing re airs or additions
3.❑ I am a homeowner doing all work p•
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' li.❑ Other
comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
r 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 thepolicy and job site
information. q
Insurance Company Name: I Y1^ UT.!?, 1
Policy#or Self-ins.Lic.#: V(k)C"WV 601 7_6 l I " 20 (expiration Date: Li
Job Site Address: 722 1 I Q viz- Carpd r— 6 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature �,� C,/�s��L Date:
Phone
Of use only. Do not write in this area, to be completed by city or town officiaL
--
—City or Town: _.__ _. -_ _ _- -_ Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Version 1.7 Commercial Building Permit May 15,2000
a
SECTION 10—STRUCTURAL:PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes r No
SECTION 11 -OWNER AUTHORIZATION-:TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _ _ ........ __..._.:_
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner _Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of penury
Print Name �m._ _._...... __._...:.
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder.'.._ .l-' �.✓� ,: ._ �_ __0.._...
License Number
Address Expiration Date
Signature Telephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L.c:15 §25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No Q
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR,1,16(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
.
Name(Registrant):
Registration Number
Address .�_.✓_ .__, W.„., .....,..._ .. ..,._..,....
Expiration Date
Signature _ Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
............_ _ 1-11-1-__.......... .1-111.__.
Address Registration Number
Signature Telephone Expiration Date
_.... .........._._... . ._................ ..
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
_ 1111:: ,._....w.__ ,._,._.,.� ._..w..__....__,___. ,.._..,__. , ....�_.,_.....,.___..._......_,_...___�......,_....___..__._...,..._., �.....__. 1111._. __....__ _ _.........
Address Registration Number
Signature Telephone Expiration Date
1-11..........._. .._._...._......._.,_ y 1111 1-111-_. _m_ ..w _. r _ _v _,_._._.
__....._ _. _........._ .
Name Area of Responsibility
f
......:. 1111..:..........1111 ....,_,....... ,....,.,,...._.. -......................�.�..:........._:..._.... ..,»............�_....«.....,..,,...,,._........sm._.,_...._......_..........,.._.... ..........._...... ..., ...,,.._..........,.. ... ,.....,...,..._..................
Address Registration Number
Signature Telephone I Expiration Date
9.3 General Contractor
_._
Not Applicable ❑
Company Name:
..
Responsible In Charge of Construction
_M.. _..
Address
Signattife Telephone
i
Versionl.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column tote filled in by
Building Department
Lot Size
Frontage .......... ...:_:_ ._ ......._.... . .,.� .�_ .w.,:_ _ .w.... _._.._..._.....__ _.____.
Setbacks Front
Side L. _.. _ R.'_._._ L t_..,,_._. R _.
Rear
Building Height
Bldg. Square Footage ""'" % "-
Open Space Footage __ _ % .
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO fvr� DONT KNOW Q YES 0
IF,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book `: Page: and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued
C. Do any signs exist on the property? YES 619 NO
IF YES, describe size, type and location:
...........
._._._... .... ._. _._..
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
s
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN.35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief description here.
Of Proposed Work:r / j
SECTION 5-USE GROUP AND CONSTRUCTION TYPE`
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
❑ A-4 ❑ A-5 ❑ le ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - h ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ _. _ ._. =- _. 3A ❑
Institutional ❑ 1-1 ❑ 1-2 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify: _
S Special Use El Specify:
COMPLETETHIS SECTION IF EXISTING BUILDING:UNDERGOINGRENOVATIONS ADDITIONS AND/OR CHANGE IN USE
Existing Use Group __ ,._...._._ _. _.___.._,__ ____ _._ Proposed Use Group:
Existing Hazard Index 780 CMR 34). _,_:..- _._ ._ Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1st_.
1 sl .._.....,. ...�., ......__..._....,......._ .,.. __,..,,o. _
_....,..-: _ _. 2nd
2nd
rd 3rd
m
4th 4
Total Area(so Total Proposed New Construction(sf) _.,_..
_.,.._
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal systemE]
Versionl.7 Commercial Buildin Permit May 15,2000
De aft use,only
_ ty of Northampton
Status of Perm�f
wIilding Department Curt;Cut/Driveway Permd:
r 212 Main Street Room 100 Wate�/W&1I Availability UN $ � I`� Northampton, MA 01060 Two Sets of Structdral Plans phone 413- 87-1240 Fax 413-587-1272 Plot(Site Plans u , ciions Other Specify:
ION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
_. _ ....:. _ _... ............_... _ ._, ..... ._.... _.._._.w_
Map Lot Unit
(� 1� Zone Overlay District
; Elm 5t:District' CS District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
k__............. .. .... .......
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3'-ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)'Building Permit Fee
2. Electrical (b) Estimated TotaI.Cost of
Construction from 6 __...._.
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) Check Number
This.Section For'Official Use Only
Building Permit Number Date
Issued
_Signature:_
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1301
APPLICANT/CONTACT PERSON CARROLL CUSTOM CONTRACTING INC
ADDRESS/PHONE 20 WIGWAM RD WEST BROOKFIELD01585 (413) 536-9454
PROPERTY LOCATION 222 RIVER RD
MAP 05 PARCEL 001 001 ZONE RR(101)/WP(7)/
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: INSTALL CROSS CORRIDOR DOORS
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included: —
Owner/Statement or License 096672
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
proved 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
ay
Si o uil ' g f icial 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.
222 RIVER RD BP-2015-1301
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05-001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-1301
Project# JS-2015-002392
Est.Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CARROLL CUSTOM CONTRACTING INC 096672
Lot Size(sq.ft.): Owner: Athena Health Care Systems
Zoning: RR(101)/WP(7)/ Applicant: CARROLL CUSTOM CONTRACTING INC
AT: 222 RIVER RD
Applicant Address: Phone: Insurance:
20 WIGWAM RD (413) 536-9454 WC
WEST BROOKFIELDMA01585 ISSUED ON:612912015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL CROSS CORRIDOR DOORS
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 6/29/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner