31B-272 (11) Construction Control Affidavit
THE COMMONWEALTH OF MASSACHUSETTS
Department of Public Safety
Date: April 2, 2015
To: Inspectional Services Commissioner-City of Northampton, MA
Project:
Hampshire County Courthouse
Gothic Street Entrance Stairs & Repairs, Historic Preservation
99 Main Street
Northampton, MA 01060
In accordance with the Eighth edition Massachusetts State Building Code, 780 CMR Section 116.2:
I, Ronald J. Alex, Registered Architect, MASS Registration Number 5494
being a registered professional architect, hereby CERTFY that I have prepared or directly supervised the
preparation of all architectural design plans, computations, and specifications for the above named project and
that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of
the Massachusetts State Building Code, 8th Edition, all acceptable architectural practices and all applicable laws
for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that
the above mentioned design of the work proceed in accordance with the documents approved for this building
permit.
Upon completion of the work, I shall submit a final repo AN tory completion of the above mentioned
project. ��� !�v 3oH,yye�f
r
REGISTERED ARCHITECT No.5494 N
p BOSTON E,
Boston Bay Architects, Inc. 3�o Mw c�J
Ronald J. Alex, AIA y�FgITHOF *yS�'
S�Oe9
Name S' ure Mass Reg. No. Date
Projects/Northampton-Gothic St CA Construction Control Affidavit
Cgqmmmonwealth o N 4assachusetts
Cduntyof
On this day of tq kA 2015 before me,the undersigned notary public,personally appeared,Ronald J.Alex,
proved,to me through satisfactory evidence of identification,to be the person whose name is signed on this document in my presence and
who swore or affirmed_ to me that the contents of the document are truthful and accurate to the best of(his)(her)knowledge and belief.
NOTARYPUBLIC ANDREA HERZOG
Negry Public
Massachusetts
My Commission Expires: JQ L SFAi
Commission Expires Sep 24.-Z02T"
1
The Coi'nnlonwealth of Massachusetts
Department of Industrial Accidents
Office of lm)estigations
600 Washington Street
Boston,MA 02111
www.mass.g ovIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leo_ibly
Name(Business/Organization/In di vi dual):
Address: ?, n PAX 2-'1 Z_
City/State/Zip: Y Vk t V' S I G[A 4 3 tom° hone q 13 " 8-6
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with�_ 4. I am a genera]contractor and e hired the sub-contractors 1 6. ❑New construction
employees(full and/or part-time).'" have
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
have workers'
working for me in any capacity. employees and 9. ❑Building addition
[No workers' comp.insurance Comp. insurance.
required.]
5. ❑ 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 n o 12.[]Roof repairs
insurance required.]t c.152, §1(4), and we havve e n r, �^
employees.[No workers' 13. Other P1(F—OX
comp. insurance required.] S
*Any applicant that checks box#I mast 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 boa:must attached an additional sheet sbowing the name of the sub-contractors and state whether w not those entities have
employees. If the sub-contractors have employees,they must provide their workers'romp.policy number.
I am an employer that is providing workers'compensation insurance far any employees. Below is t1te policy and job site
information.
Insurance Company Name: tASI)Y"cc- Co
Policy#or Self-ins.Lic.#: W M-7z-_ �0d 400 613-7 S 201 Expiration Date: 1C0
Jab 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.
1 do hereby certi :der the paiizs and penalties of perjury :a ie information provided above is true and correct
Signature: Date: e2 l
Phone rr: `-f 1 0311, 9_6 3 ' 3
I
Official use only. Do not write in this area, to be completed by city or toxin official
I
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.
her
Contact Person: Phone�:
AFFIDAVIT FOR DISPOSAL OF DEMOLITION DEBRIS
Supplement to Permit Application
As a result of the provisions of MGL c. 40, s54, I acknowledge that as a condition of the
issuance of a Building Permit, all debris resulting from the construction activity governed
by this Building Permit shall be disposed of in a properly licensed solid waste disposal
facility, as defined by MGL c. l 11, s15OA.
I certify that debris resulting from this demolition will be disposed of as listed below:
Job Site Location: 99 Main St.,Northampton MA
Name of Permit Applicant: Renaissance Builders
Disposal Facility: F & G Recycling
Address of Facility: 15 Mullen Rd., Enfield Ct 06082
IF SAID FACILITY IS OTHER THAN WHAT I HAVE LISTED, I CERTIFY THAT
I WILL NOTIFY THE BUILDING OFFICIAL OF THE CORRECT LOCATION OF
THE SOLID WASTE DISPOSAL FACILITY WITHIN TWO MONTHS OF THE
DATE OF THIS APPLICATION.
5/6/2015
Sig turd of Applica Date
Number Date Pages
Portions of Addenda relating to bidding requirements are not part of the Contract Documents unless the bidding requirements
are also enumerated in this Article 8.
Attached and included as part of this Agreement:
Project Addendum Number One dated January 20, 2015
Project Addendum Number Two dated January 26, 2015
8.1.7 Other documents,if any,forming part of the Contract Documents are as follows:
(List here any additional documents that are intended to form part of the Contract Documents.AIA Document A201-1997 provides that bidding requirements
such as advertisement or invitation to bid, Instructions to Bidders, sample forms and the Contractor's bid are not part of the Contract Documents unless
enumerated in this Agreement. They should be listed here only if intended to be part of the Contract Documents.)
This Agreement is entered into as of the day and year first written above and is executed in at least three original copies, of
which one is to be delivered to the Contractor, one to the Architect r use in the administration of the Contract, and the
remainder to the Owner.
OWNER(Eignatwie) ��� CW ignature)
i`
Todd Ford, council Executive Director Stephen Greenwald, President
Hampshir Council of Governments dbal Renaissance Builders General Contractors, Inc.,
(Printed name and title) (Printed name and title)
AIA DOCUMENT A101 -OWNER - CONTRACTOR AGREEMENT - 1997 EDITION - AIA - COPYRIGHT 1997 - THE AMERICAN INSTITUTE OF
ARCHITECTS,1735 NEW YORK AVENUE N.W.,WASHINGTON,D.C.20006-5792• WARINING:Unlice.aed photocopying violates U.S.copyright laws and will
subject the vi-tor to legal prosecution.This document was electronically produced with permission of the AIA and can be reproduced without violation until the date of
expiration as noted below.
Electronic Format A101-1997
User Document: 97A10LCON-- 10/16/1999. AIA License Number 112717,which expires on 4/30/2000--Page#5
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
boe- M" �, as Owner of the subject property
hereby authorize to
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 perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: J n Not Applicable C1 Name of License Holder: � vV ` e-ev�wzk.4 — 4 1 -3130
License Number
` 2� �
Address Q Expiration Date
�(
? V4
Signatur, Telephone
SECTION 13-WORK S'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
now
'MAY-21-2015(THU) I0: 419 F. UC2/CC2
Vcrsionl.7 Camrn=ial Suilding Pcrrnic May 1S,2000
SECTION '9.PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TQ
C0NSTRUMN CONTROL PURSUANT TO 780 CMRdi6 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSER$PACT
9.1 RoglUtemd Architect:
Not Applicable El �EDARc '
Nome(Roptctrant); -- L
RaulctrAtlan Number ,
No.5494 '�
Addt*ss �
., • •�� Expltatlan Dalo ''.+ MA y z
� sJ
9.2 o t Prorcvslonal Encinror(sl, rN Of A
Name — Arra of Raoponstblilty
Addroso r -- — ( � Reghttation Number
r »
S anaturo Te!ephang Ex lrktlon Date
NaMo Nnn atRasponsIblilty
AddtOss .._._..o._w. �.w_..e. Rg4lmllonNumber -
v nature 7eirr=notta Expltzrt{on Maio
Nam* - Area or Pwipdnsibllily
Address Rapiatratlon Number
Slandtur* Tee hune &xr htlgn Out*
Name Area of Ra.ponsibltity
Atldm a Reglatradan Number
St nature — Mapnon* to#Ian Dato
9.3 Gap oral Contrador
f � JW �✓ ri t: + - NotApplimble 0
Company Name;
RaMpana i*Irl"alp tit Construe#tan �
Address
t3tonatur* Tohyphbne
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING 'j,v t D C
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOW U YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained o , Date Issued:
C. Do any signs exist on the property? YES ® NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
so
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Bu mg El
Alteration El Existing Ground Sign❑ New Signs El Roofing Change of Use❑ Other
Brief Description Enter a brief description here. 3uil d t�noJ i Prd f- ve�p�r Qv%'
Of Proposed Work: "
C. S • 51 df, ow ht y L�'i tAr SPtGS-j- IaMS oLff�arlv-aQ�-..'�p�
SECTION 5-USE GROUP AND CONSTRUCTION TYPE p 1C�1� 1A
r v _�
USE GROUP(Check as applicable) NC) CONSTRUCTION TYPE
A Assembly
A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
❑ A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 213 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A Cl
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,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
OFFICE USE ONLY
BUILDING AREA EXISTING PROP SED NEW CONSTRUCTION
Floor Area per Floor(sf)
1st
1 St
2nd 2nd
3rd 3rd
4th
4m
Total Area(sf) Total Pro osed 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 E] Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
Department use only
` City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
a ?ai5 J
JAN 212 Main Street Sewer/SepticAvailabiliry
Ele tric,Plumb cinc&G� insp'
ions Room 100 Water/Well Availability
Northampton.MA 0106(3 orthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: j
C, Mlk,1J gT, e ouvT� c 4_ Map 6 Lot (q"7 C Unit
w VVW""_ 1 1 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Tockck- R R MO-ZA
Name(Print) Current Mailing Address:
Signature JCp- Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 4, 1 40 (a) Building Permit Fee
2. Electrical V (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) Q Q Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Renaissance
Builders
PO Box 272, Turners Falls,MA 01376
Phone(413)863-8316; Fax(413)863-9712
www.renbuild.net
June 3, 2015
Louis Hasbrouck
Building Commissioner
212 Main Street
Northampton,MA 01060
Louis,
Enclosed is a permit application to make improvements to and repair the Gothic St. entry at the
Hampshire County Courthouse. Ronald Alex of Boston Bay Architects provided plans and
specifications; Stephen Greenwald is the project manager.
Also enclosed:
❑ A set of plans provided by Boston Bay Architects
❑ 2 sets of Specifications provided by Boston Bay Architects
❑ The Contract Signature Page
❑ A Workers Compensation Affidavit
❑ A Demolition Debris Affidavit
❑ The Construction Control Affidavit provided by Ron Alex of Boston Bay Architects
❑ A check for$1,056.00 for the permit fee
Please call Stephen if you have any questions regarding the project,cell number 413-772-9430.
Please send the permit to our office.
Thank you,
cax'c�a 4't"
Carolyn sbury
Renaissance Builders
S , 0 ZAA-C- dLt c`C /au g d'V 5( ee-S PYLV, !� / US
so calf c,�rt--���.� C wp'`e S 81 r.z-/;; .
enclosures
File#BP-2015-1217
APPLICANT/CONTACT PERSON RENAISSANCE BUILDERS
ADDRESS/PHONE P O Box 277,2 TURNERS FALLS01376(413)863-8316
1
PROPERTY LOCATION 99)�n"- ST-COURTHOUSE
MAP 31B PARCEL 272 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Iypeof Construction: BUILDING IMPROVEMENTS&REPAIRS TO STEPS ON GOTHIC ST SIDE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 013302
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
o ' ' n Delay
Signature of uil ing 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.
99 MAIN ST-COURTHOUSE BP-2015-1217
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-272 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-1217
Project# JS-2015-002300
Est. Cost: $175971.00
Fee: $1056.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENAISSANCE BUILDERS 013302
Lot Size(sq ft.): 15812.28 Owner: THE COMMONWEALTH OF MASSACHUSETTS
Zoning: CB(100)/ Applicant: RENAISSANCE BUILDERS
AT. 99 MAIN ST - COURTHOUSE
Applicant Address: Phone: Insurance:
P O Box 272 (413) 863-8316 Workers Compensation
TURNERS FALLSMA01376 ISSUED ON:612912015 0:00:00
TO PERFORM THE FOLLOWING WORK.-BUILDING IMPROVEMENTS & REPAIRS TO
STEPS ON GOTHIC ST SIDE
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 6/29/2015 0:00:00 $1056.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
99 MAIN ST-COURTHOUSE BP-2015-1217
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-272 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-2015-1217
Project# JS-2015-002300
Est. Cost:$175971.00
Fee: $1056.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin: RENAISSANCE BUILDERS 013302
Lot Size(sq.ft.): 15812.28 Owner: THE COMMONWEALTH OF MASSACHUSETTS
Zoning: CB(100)/ Applicant. RENAISSANCE BUILDERS
AT: 99 MAIN ST - COURTHOUSE
Applicant Address: Phone: Insurance:
P O Box 272 (413)863-8316 Workers Compensation
TURNERS FALLSMA01376 ISSUED ON:612912015 0:00:00
TO PERFORM THE FOLLOWING WORK.-BUILDING IMPROVEMENTS & REPAIRS TO
STEPS ON GOTHIC ST SIDE
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 6/29/2015 0:00:00 $1056.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner