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24B-067 (13) Forish Construction Company TRANSMITTAL No. 00027 PROJECT: Lia Kia of Northampton DATE: 7/13/2015 TO: NORTHAMPTON BUILDING DEPARTMENT REF: City of Northampton Building Department Northampton,MA 01060 ATTN: WE ARE SENDING: SUBMITTED FOR: ACTION TAKEN: ❑ Shop Drawings ❑ Approval ❑ Approved as Submitted ❑ Letter ❑ Your Use ❑ Approved as Noted ❑ Prints ❑ As Requested ❑ Returned After Loan ❑ Change Order ❑ Review and Comment ❑ Resubmit ❑ Plans ❑ Submit ❑ Samples SENT VIA: ❑ Returned ❑ Specifications ❑ Attached ❑ Returned for Corrections ❑ Other: ❑ Separate Cover Via: ❑ Due Date: ITEM PACKAGE SUBMITTAL DRAWING REV. ITEM NO. COPIES DATE DESCRIPTION STATUS 1 7/13/2015 Workers Compensation Insurance NEW Affidavit 1 7/13/2015 Check#68256 NEW 1 7/13/2015 Construction Control Letter NEW 1 7/13/2015 Building Permit Application NEW Remarks: CC: Signed: Dan Ryan Primavera rish CONSTRUCTION ESTABLISHED 1846 July 13,2015 Louis Hasbrouck Building Commissioner City of Northampton 212 Main St Northampton, MA 01060 RE: 263 King St Kia "de-branding"work Dear Mr. Hasbrouck, Per your email dated July 9th,2015,we respectfully request the requirement for construction control be waived for the Kia "de-branding"work for the property located at 263 King St(Lia Kia.) I can be reached at the number listed below should you need further clarification regarding the scope of work. Thank you, Dan Ryan Project Manager Forish Construction TEL: 413.568.8624 FAX: 413.562.7136 21 MAINLINE DRIVE PO BOX 358 WESTFIELD MA 01086 WWW.FORISHCONSTRUCTION.COM INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE I, Lisa O'Neil, of 123 Interstate Drive, West Springfield, MA, Underwriting Administrator, USI Insurance Services LLC, licensed resident broker of Midwest Employers' Casualty Company do hereby affirm that Forish Construction Company, Inc. is insured with said insurance company with Policy Number EWC005891 effective 1/1/15-1/1/16 for Self-Insurance Excess Workers' Compensation in accordance with Massachusetts General Laws Chapter 152 and Sub Section 7.05 of the Standard Specifications for Highways and Bridges of the Massachusetts Highway Department. (SIGNED) Subscribed and sworn to before me this 7t" day of January, 2015 at West Springfield, MA Notary Public Z MARIA C. SULLIVAN U�fl Notary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires August 20, 2021 The Commonwealth of Massachusetts Department of In dustrial Accidents Office of Investigations 6001flashington Street Boston,11L.4 02111 w}4'wanass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): FORISH CONSTRUCTION 'COMPANY ' INC. -Address: 21 MAINLINE DRIVE, PO BOX 358 City/State/Zip: WESTFIELD, MA 01086 Phone.#: 413-568-8624 Are you an employer?Check the appropriate bog: Type of project(required): �_ 4. J am a general contractor and I 1. I am a employer with 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a'soie proprietor or partner- listed on the attached sheet_. 7. ❑Remodeling ship nd have no employees These sub-contractors have P 8. E]Demolition working for me in any capacity. employees and have workers' comp.[No workers' comp.insurance co insurance.$ 9. E]Building addition required.] 5. F-1 We are a corporation and its 10.❑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.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 1351 Other Commercial employees. [No workers' comp.insurance required.] Construction , *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. xContractors 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 bave 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 and job site information. Insurance Company Name: Midwest Employers Cadiialty Company Policy#or Self-ins.Lic.M E WC 0 0 5 8 91 Expiration Date:_ 1/1/2016 Job Site Address:263 Kim Street City/State/Zip: Northampton, MA 01060 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 M GL c. 152 can lead to the imposition of criminal penalties of a fine lip 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 Investi eations 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 Si mature: Date: 7zz 3 " Lin d'& Day Phone 4: 413-568-8624 Official use only. Do not write in this area,16 be completed by city or town offciaL City or Town: Permit/License 4 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 4: 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 O No O SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , 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 I, Er Z. - 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 le alties f per' ry. �. Print Name r. J L. . j�,,;�.� 7//3 /5 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: r i G F°�' P License N tuber Address Expira i ate IV(3 -- � 4s - &,(-'�-)G/ Signature V Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, §25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 0 No 0 Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Co. Tvv Not Applicable ❑ Company Name: Responsible In Charge of Construction NI, v)vg6 Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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/Findin ever been issued for/on the site? NO 0 DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Re wry ry of Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES CJ NO O IF YES, describe size, type and location: �,�c J- f D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 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 Q NO 0 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 El Existing Wall Signs E Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other d Brief Description Enter a brief description here. 'Ri2roo".A (e�� I��.5 I�' �'r."oj Of Proposed Work: m,;'V-� Shew�c`z �l f�wtu��l� �T 'fhx+ en�rci.�e Ca✓ra�t/ . 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 ❑ 1B ❑ B Business 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 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 ❑ 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 BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so 1st 1st ( �+�t 2nd 2nd 3rd 3rd 4th 4th Total Area (so (C)/C, Total Proposed New Construction(so Total Height(ft) Total Height ft 7.Water Supply(M.G.L,c.40, §54) 7.1 Flood Zone Information: 7wage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ al ❑ On site disposal system❑ Versionl.7 Commercial Buildin Permit May 15,2000 Department use only , 3 ��� ..fit of Northampton Status of Permit: ��. �Bupi,� ing Department Curb Cut/Driveway Permit - (3a 1" , IDOL Main Street Sewer/Septic Availability, �'u"'g MAp1° Room 100 Water/Well Availability. Phu' ' � tcn, , vorth2R p Northampton, 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 1.1 Property Address: This section to be completed by office S� ,�`'o� `"' � /�}t ©��(,d Map Lot Unit r� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) c. ,1�.4M ��^ Current Mailing Address: /}IEwnj I Al Y 10Q65, ►s�- `�ss`1 - a �� i Signature Telephone 2.2 Authorized Aqent: ff 1& i�jc jC 333 0?', l o, 'a%� C)C, Name(Print) Current Mailing Address: 1-1 ) S— S-C S — �;-L`) Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building a`U0 0 (a) Building Permit Fee 2. Electrical (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) 00 6 Check Number my This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0045 APPLICANT/CONTACT PERSON FORISH CONSTRUCTION CO INC ADDRESS/PHONE P O BOX358 WESTFIELD01086(413)568-8624 PROPERTY LOCATION 263 KING ST-KIA MAP 24B PARCEL 067 001 ZONE HB(99)/GI(1)/ 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: REMOVE FRONT ENTRANUCANOPY&RED GLASS KIA 'BRAND WALL" IN SHOWROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 027190 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demp 'tion Delay S ature of Bui ding 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. 263 KING ST-KIA BP-2016-0045 GIS#: COMMONWEALTH OF MASSACHUSETTS MapBlock:24B-067 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-2016-0045 Project# JS-2016-000089 Est.Cost: $2000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FORISH CONSTRUCTION CO INC 027190 Lot Size(sq.ft.): 93218.40 Owner: 293 NORTHAMPTON REALTY LLC C/O WILLIAM LIA Zoning: HB(99)/GI(l) Applicant: FORISH CONSTRUCTION CO INC AT. 263 KING ST - KIA Applicant Address: Phone: Insurance: P O BOX358 (413) 568-8624 Workers Compensation WESTFIELDMA01086 ISSUED ON.712312015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE FRONT ENTRANCE CANOPY & RED GLASS KIA"BRAND WALL" IN SHOWROOM 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 7/23/2015 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner