31B-004 (18) Initial Construction Control Document
To be submitted with the building permit application by a
F d Registered Design Professional
t
for work per the 81h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Restoraton&Renovations—Hubbard Hall Date: 6.4.2015
Property Address: 47 Round Hill Road,Northampton, MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Restoraton&Renovations
I Matthew D. Wittmer MA Registration Number: 31926 Expiration date: 8.22.2015, am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans, computations and specifications
concerning':
X Architectural Structural Mechanical
Fire Protection 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 Document'.
Q Al
Enter in the space to the right a"wet"or `'�.
electronic signature and seal:
�f 1�
o�r Sw, LU r .4
Phone number: (860) 264-1624 Email: mwittmer @phasezerodesign.com '- �a . ...
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.
Version 06 11 2013
City of Nol-thaznpton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the 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 111, S 150A.
Address of the work: 1-/3 ?z .
The debris will be transported by: nA�k=
The debris will be received by:
Building permit number:
Blame of Permit Applicant 0-M&OX
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
R. f Department of Industrial Accidents
'a
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual):Crocker Building Company Inc
Address: 186 Stafford St
City/State/Zip:Springfield MA Phone #:(413)737-7803
Are you an employer?Check the appropriate box: Type of project(required):
1.[Z]I am a employer with 15 employees(full and/or part-time).* 7. [:]New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ✓❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.[2]Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.FRoof repairs
These sub-contractors have employees and have workers'comp.insurance.*
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required,]
*Any applicant that checks box#1 must also till 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:Hartford Fire Insurance Company
Policy#or Self-ins.Lic.#:08 WE QT9438 Expiration Date:04/01/15
Job Site Address:47 Round Hill Rd City/State/Zip:Northampton MA, 0106
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer fy under the pains and na ' s of perjury that the information provided above is true and correct.
Si nature: Date: 64V,��?
Phone#• l(/ � 7�7. 2PQ3
Official 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#:
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
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
as Owner/Authorized
Agen ereby decl a 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 f Owner! ent Date
SECTION 12-C NSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: William Crocker Jr CS-067805
License Number
186 Stafford St. Springfield Ma, 01104 04/19/2016
oe
Addre Expiration Date
(413) 737-7803
Signature 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 � 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:
Matthew D. Wittmer Not Applicable ❑
Name(Registrant):
31926
Phase Zero Design, Inc. 8 Wilcox St, Simsbury, CT 06070 Registration Number
Address 08/22/2015 .
(860)264-1624 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
Crocker Building Company Inc.
Not Applicable ❑
Company Name:
'William Crocker Jr.
Responsible In Charge of Construction
186 Stafford St Springfield>,, 01104
Addre
(413) 737-7803
Signature Telephone
8. NORTHAMPTON ZONING
Versionl.7 Commercial Building Permit May 15,2000
-
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/Findi ever been issued for/on the site_?1\
NO 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded t the Regist of Deeds?
NO 0 DON'T NOW 0 YES 0
IF YES: enter Book Pa and/or Document#'
B. Does the site contain a br ok, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit een or need to be obtained from the onservation Commission?
Needs to be obtai ed 0 Obtained 0 , Date Issued:
C. Do any signs exi on the property? YES NO
IF YES, des The size, type and location:
D. Are there y proposed changes to or additions of signs intended for the property? YES NO 0
IF YES describe size, type and location:
E. Will t e construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
tha will disturb over 1 acre? YES Q NO
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 0 Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs El RoofingEl Change of Use Q Other❑
Brief Description Convert Hubbard Hall into 21 apartment units.
Of Proposed Work:
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 Hi h Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B 2
M Mercantile ❑ 4 ❑
R Residential El R-1 ❑ R-2 21 R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 56 ❑
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: (E),(B) A-3, S-1, (R) Proposed Use Group: R-2
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)
1 St 3,9031 1 St
2nd 12,988 2nd
3rd 12,988 3rd
4th 6,634; 4th
Total Area(sf) 36,513 Total Proposed New Construction(sf)
Total Height(ft) 51'
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 77.1FIo'o d Zon e Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ Outside Flood ZoneE] Municipal l] On site disposal system[]
Versionl.7 Commercial Building Permit MaX 15,2000
Department use only
ad
C� � � �►
of Northampton Status of Permit:
ing Department uOtAtlDnverway F'ermrt�� 2 Main Street SewerlSeptic Ayallatilit Room 100 Water/Well Availability
Lmpton, MA 01060 Two Sets of Structural Plans
Electric. -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:
47 Round Hill Rd. Map, Lot Unit
Northampton, MA 01060 Zone overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Historic Round Hill Summit LLC 33 Elm St West Springfield MA 01089
Name(Print) _ Current Mailing Address:
(413) 734-1351 _
Signature Telephone
2.2 Authorized Agent:
Max Hebert _ (413) 896-3019
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 2- TIMATE C NSTR CTI N COST
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
At 04too3. $
4. Mechanical(HVAC) '30.0 C13-T; oc�
5. Fire Protection
6. Total=(1 +2+3+4+5) (S ObG. Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1255
APPLICANT/CONTACT PERSON CROCKER BUILDING CO INC
ADDRESS/PHONE 186 STAFFORD ST SPRINGFIELD01104(413)737-7803
PROPERTY LOCATION 47 ROUND HILL RD-HUBBARD HALL
MAP 3 1 B PARCEL 004 001 ZONE URC000)/
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: CONVERT HUBBARDHALL TO 21 APARTMENT UNITS
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 067805
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
k_"4,J -
!Jr
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.
47 ROUND HILL RD-HUBBARD HALL BP-2015-1255
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-004 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-2015-1255
Proiect# JS-2015-002314
Est. Cost: $5155000.00
Fee: $30935.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CROCKER BUILDING CO INC 067805
Lot Size(sq. ft.): 311018.40 Owner: HISTORIC ROUND HILL SUMMITT
Zoning:URC(100)/ Applicant: CROCKER BUILDING CO INC
AT. 47 ROUND HILL RD - HUBBARD HALL
Applicant Address: Phone: Insurance:
186 STAFFORD ST (413) 737-7803 Workers Compensation
SPRINGFIELDMA01104 ISSUED ON.711412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT HUBBARDHALL TO 21 APARTMENT
UNITS
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 7/14/2015 0:00:00 $30935.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner