31D-142 Initial Construction Control Document
To be submitted with the building permit application by a
UT*
Registered Design Professional
for work per the 8'h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title:NEW FACES CAFE Date: JULY 10, 2015
Property Address: 175 Main Street,Northampton, MA
Project: Check(x)one or both as applicable: New construction XX Existing Construction
Project description: Modifications to existing space to include new kitchen, serving area and dining area for new Cafe.
Modifications to existing toilets to provide HC accessibility.
I, John Strandberg,MA Registration Number: 4010 Expiration date: Aug. 31,2015,am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans,computations and specifications
concerning':
XX 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'.
ARCy�T
Enter in the space to the right a"wet"or ��o sTR atio °A
electronic signature and seal: i No.4010 mA N
o
WILBRAHAM 0
MASSACHUSETTS
P
Phone number: 413-949-0353 Email: jls_arch@charter.net TM of
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,
The Commonwealth of Massachusetts
r- Department of Industrial Accidents
t"li,sir
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information ^ Please Print Leaibly
Name (Business/Organization/Individual): ChrIS AtjdfEL,.� y .hJC
Address: 1 7 s A &l ^ St
City/State/Zip: 1Vv('tkeAw, 10n o(,O Phone #: x113 " 59Y ° c/0 8�
F 1Are you an employer?Check the appropriate box: Type of project(required):
.1,9 I am a.employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
These sub-contractors have
ship and have no employees 8. ❑Demolition
working for me in any capacity. employees and have workers'
insurance. 9. Building addition
comp.[No workers' comp.insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 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
employees. [No workers' 13.0 Other
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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. r
Insurance Company Name: Am Trjs� �r�5-��ct�►c E Co.�+pplr�y 0 T eA035 A S "X-14c.
Policy#or Self-ins.Lic.#: Q(2, 10 4 1 025 Expiration Date: 5 f ro
Job Site Address: N`Panl St City/State/Zip: A look j-L-46,x , Ak t)i6w
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 thepains andpenalties ofperjury that the information provided above is true and correct.
Si nature:
Date: 3 /
Phone#: q S-q2 7 -W7q-7
Of use only. Do not write in this area, to be completed by city or town offzciaL
—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#:
y i
Version 1.7 Commercial Building Permit May 15,2000
.y
4
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR:110.11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER -TO'BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I, ___._ .... _.__ _.._ __...._.._ ., as Owner of the subject property
hereby authorize . ..__._.. _.,._n.. ..... _... ._ to
act on my behalf, in all matters relative to work authorized by this building permit application.
f
Signature of Owner _Date
I, l� _► �T.Q ._...__ _._......._.__: 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.
g .r the pain sand penalties ofpeffury, �:� ,�.
... .
Print t
_ 13�,r=._._ w_ ....._..
J
ignature of w r/A ent Date
SECTION 12-CONSTRUCTION:SERVICES
1 .1 Licensed Construction Supervisor, Not Applicable ❑
Name of License Holder.'..__..,.._ . _..„. .._.._.... r..,..:... _,., _. .... ._..... .
License Number
I
Address Expiration Date
Signature Telephone
SAVIT
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will suit
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
Version l.7 Commercial Building Permit May 15,2000
[SECTION 9-PROFESSIONAL DESIGN AND CONSTRlJCTION;'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):
rC-Y�A inn Registration Number
Address 4/Q�(�
l j4�0�v,'G" 40-7-11 m .
�3s3 Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
I
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
_,...._: ,. ...... _......: __...... _._...... _ _,.__.,._ _,.._ Not Applicable El Company Name.
Responsible In Charge of Construction
i
Address
ignature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON;:ZONING
Existing Proposed Required by Zoning
This colunm to.e filled in by
Building Department
LotSize _,.__...._.. _., .. _____ __.! `:. ._ . ....._ ..__. _ ,,., ;..:..—__.....m. ------------
Frontage
Setbacks Front __...
Side L _ .. J R:i_ ILL—1 R:__...___
_
Rear _.. ..
Building Height 1 -
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 0 DONT KNOW YES 0
IF.YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book m' Page'= and/or Document#.
B. Does the site contain a brook, body of water or wetlands? NO U DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:Wrr MYYy`
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location: _ fro.,'r o� .;��,,.5 Iz{kr,�S
_..._..
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN.35,600
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 1� Existing Wall Signs Demolition❑ Repairs d Additions L] Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing C Change of Use❑ Other❑
Brief Description lEnier a brief description here. l c�:n��n9 , wakt -+ Ck A'/C r re eta"rAt
Of Proposed Work:i f
NFactory -USE GROUP AND:CONSTRUCTION TYPE.
USE GROUP(Check as applicable) rl STRUCTION TYPE
A-1 ❑ A-2 ❑ A-3
❑ ❑A-4 ❑ A-5 ❑ ❑
❑ 213 ❑
❑ F-1 ❑ F-2 ❑ 2C ❑i h Hazard ❑ 3A ❑
Inst itutional ❑ 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: 1
_., _ _ _w..... _._....._ ...._ _
S Special Use ❑ Specify: .m.-.__-.___�__�._._..�.,.�...,�.__. .,�..�.,....___._,._�.,._..�._.._,..._......._._..
COMPLETE THIS SECTION IF EXISTING BUILDING INDERGOING.RENOVATIONS;ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: _` �s,M��. _ _- Proposed Use Group: — ,$�
Existing Hazard Index 780 CMR 34 _:,w„ ..
......:,_ _... _.,.,..... 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(st)
15f
1
St
2nd . _.,,._,._ _.,, w, 2nd
rd
3 rd
4�" ' 4m
Total Area (st7 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 system❑
Version l.7 Commercial Building Permit May 15,2000
�� l� �� ��
Departure t use,onfy
DD = -_ - City of Northampton status of'Permtt
J `� i t
! Building Department Curb Gut/Dnyeway Perm�G; ._
�i
tl Q 205 212 Main Street Sewer/SepftcAvatlabtit}c
Room 100 Wate6MI Avaffab`ilitjp
Electri Plumbing&Gas tr;speclio s Northampton, MA 01060 Two Sets ofkStructuraf Plans
orthampton, MA 07060
ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans K
en
Other`;Speetfy
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
_ _..... .. .._......_ __..... ______... .._w._._. __.__-_. ___
175 MAz+Q 5,N. } Map Lot Unit
/Vcartl�n«+�}�, /h� biC`bc3 1 Zone Overlay District
--- - Elm St'District`` CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) ��{�,� G �� Current Mailing Address:j f
S' nature Telephone
.2 Authorized Agent:
Name(Print) Current Mailing Address
w ,. _... _ ...,
,o ogqp
Signature Telephone
SECTION 3-ES T D ONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use,Only
completed by permit applicant
1. Building S�Q (a)Building'Permit Fee
2. Electrical l (b)Estimated Total,Cost of
i Construction from 6 —•_ ------
3. Plumbing coo Buildirig Permit Fee /�
4. Mechanical(HVAC)
U0
5. Fire Protection _.... ..
6. Total=0 +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-2016-0044 64
APPLICANT/CONTACT PERSON JOHN STRANDBERG
ADDRESS/PHONE 7 RICE DR WILBRAHAM01095(413)949-0353
PROPERTY LOCATION 175 MAIN ST-FACES CAFE
MAP 3 1 D PARCEL 142 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 42 4
Building Permit Filled out
Fee Paid
Typeof Construction: BUILD OUT FOR CAFE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure _
Building Plans Included:
Owner/Statement or License _
3 sets of Plans/Plot Plan �t°Gw6(/l G EL'r
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
L.<A"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
Demolition Delay
re 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.
175 MAIN ST-FACES CAFE BP-2016-0044
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D- 142 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-2016-0044
Project# JS-2016-000088
Est. Cost: $39000.00
Fee: $203.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 22389.84 Owner: HANNOUSH TIFFANY
Zoning: CB(100)/ Applicant: JOHN STRANDBERG
AT. 175 MAIN ST - FACES CAFE
Applicant Address: Phone: Insurance:
7 RICE DR (413) 949-0353
WILBRAHAMMA01095 ISSUED ON.711712015 0:00:00
TO PERFORM THE FOLLOWING WORK.BUILD OUT FOR CAFE
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 7/17/2015 0:00:00 $203.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner