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32A-123 (6) PANDOLFO COMPANY INC DESIGN / BUILD P.O. Box 1068 • Burlington,MA 01803 781.272.8896. 978.670-9100 •FAx: 978.667.6001 ,x-m.pandolfocompany.corn August 11, 2015 Commissioner Hasbrouck Subject: Request for Waiver I request that you grant a modification to waive the requirement for control construction for the "INTERIOR DEMOLITION "at 63 King Street in Northampton because the work is of a minor nature, will not affect health, accessibility, life and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work. All work will be completed within the prescriptive requirements of 780 CMR. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" ""Ra5vKtfully, f 'j eph Pa lo o Pandolfo Company, Inc. P.O. Box 1068 Burlington, MA 01803 GENERAL CONTRACTORS • DESIGN/BUILD • ASBESTOS �s- SAMPLING FORM C: E I LA. -35 COMPANY CONTACT INFORMATION Company:Ba state Contracting Services, Inc. Job Contact:James Beaudry Address:352 Albany St. Email/Tel: 413-781-0821 Springfield, MA 01105 Project Name: The Former Friendly's Project ID#63 King Street Northampton, Ma VOLUME/ SAMPLE ID# DESCRIPTION/LOCATION AREA TEST 1 12"x12"White Ceiling Tile PLM ® TEM 2 Sheetrock/Joint Compound PLM ® TEM 3 Clear Caulking On Chair Rail PLM ® TEM 0 4 SheetrocklJoint Compound PLM ® TEM �] 5 2'x4'White Ceiling Tile PLM ® TEM 6 12"x12"White Ceiling Tile PLM ® TEM 7 SheetrocklJoint Compound PLM ® TEM 8 Black Caulking On Covebase PLM ® TEM 9 Caulking On Intericr Take Out Window PLM ® TEM 10 Adhesive On Floor Tile PLM ® TEM 11 9"x 9" Floor Tile/Mastic PLM ® TEM 12 Plaster Skim Coat Back Wall PLM ® TEM (� 13 Adhesive On Cove Base PLM ® TEM 14 White Caulking On Sink PLM ® TEM 15 SheetrocklJoint Compound PLM ® TEM 0 16 9"x9"Floor Tile/Mastic PLM ® TEM 17 Sheetrock/Joint Compound PLM ® TEM 0 18 Yellow Adhesive On Walls PLM ® TEM [_7 19 Interior Caulking On Back Door PLM ® TEM [_] 20 Interior Caulking On Back Door PLM ® TEM 0 21 Interior Caulking On Back Door PLM ® TEM 22 Exterior Back Window Glazing PLM _X_] TEM (_] 23 Exterior Caulking Take-Out Windows PLM TEM 24 Exterior Front Door 18 If PLM ® TEM 25 Exterior Store Front Caulking PLM ® TEM Page—2—of 2_, VERSION CCOC.0214.2/2.LD Customer COC Page 2 ASBESTOS CHAIN OF CUSTODY C: EILAE3S LAB USE ONLY. 107 New Edition Court,Cary, NC 27511 CEI Lab Code: Tel: 866-481-1412; Fax: 919-481-1442 CEI Lab I.D. Range: COMPANY INFORMATION PROJECT INFORMATION CEI CLIENT#:1328 Job Contact:James Beaudry Com an :Ba state Contracting Services, Inc. Email!Tel: 413-781-0821 Address:352 Albany St. Project Name: The Former Friendly's Springfield, Ma 01105 Project ID#63 King Street Northampton, Ma Email:james@baystatecontracting.com PO#: Tel:800-448-2822 Fax:413-734-6224 STATE SAMPLES COLLECTED IN: Ma.. GENERAL INSTRUCTIONS POSITIVE STOP ANALYSIS 0 PLM DUE DATE: ! / ANALYZE NOB'S BY TEM TEM DUE DATE: ! ! IF TAT IS 140T MARKED STANDARD 3 DAY TAT APPLIES. TURN AROUND TIME ASBESTOS METHOD 4 HR 8 HR 24 HR 2 DAY 3 DAY 5 DAY PLM BULK EPA 600 ❑ ❑ ❑ ® ❑ ❑ PLM POINT COUNT(400) EPA 600 ❑ ❑ ❑ ❑ ❑ ❑ PLM POINT COUNT(1000) EPA 600 ❑ ❑ ❑ ❑ ❑ ❑ PLM GRAV w POINT COUNT EPA 600 �`°� �`�°' °`� PCM AIR NIOSH 7400 ❑ ❑ ❑ ❑ ❑ ❑ TEM AIR AHERA EPA AHERA ❑ ❑ ❑ ❑ ❑ ❑ TEM AIR NIOSH NIOSH 7402 ❑ ❑ ❑ ❑ ❑ ❑ TEM BULK CHATFIELOr� y" ,' ❑ ❑ ❑ ❑ ❑ TEM DUST WIPE ASTM 06480-05 ❑ ❑ ❑ ❑ ❑ ❑ TEM DUST MICROVAC ASTM D5755-09 ❑ ❑ ❑ ❑ ❑ ❑ TEM SOIL ASTM D7521-13 " ��' ❑ ❑ ❑ ❑ TEM VERMICULITE CINCINNATI METHOD ❑ ❑ ❑ ❑ FoTHER: ❑ ❑ Q E:1 0 0 REMARKS: Accept Samples _ 0 Reject Samples i Rehr► uished B • Date/Time Received By: Date/Time Ja -es Beaud 6/8/2015 AV I Sa p es will be disp sed of 30 days after hnalysis VERSION CCOC.0214.1f2.LD Customer COC Page 1 CEILABS LEGEND: Non-Anth = Non-Asbestiform Anthophyllite Non-Trem = Non-Asbestiform Tremolite Calc Carb = Calcium Carbonate METHOD: EPA 600/ R93/ 116 and EPA 600/ M4-82 / 020 LIMIT OF DETECTION: <1% by visual estimation REGULATORY LIMIT: >1% by weight Due to the limitations of the EPA 600 method, nonfriable organically bound materials (NOBS) such as vinyl floor tiles can be difficult to analyze via polarized light microscopy (PLM). EPA recommends that all NOBs analyzed by PLM, and found not to contain asbestos, be further analyzed by Transmission Electron Microscopy (TEM). Please note that PLM analysis of dust and soil samples for asbestos is not covered under NVLAP accreditation. This report relates only to the samples tested or analyzed and may not be reproduced, except in full, without written approval by CEI Labs, Inc. CEI Labs makes no warranty representation regarding the accuracy of client submitted information in preparing and presenting analytical results. Interpretation of the analytical results is the sole responsibility of the client. This report may not be used by the client to claim product endorsement by NVLAP or any other agency of the U.S. Government. ANALYST: '0 �_Z APPROVED BY: Z Sarah Talley Tianbao Bai, Ph.D., CIH Laboratory Director INVtA ED NVLAP Lab Code 101768.0 Page 6 of 6 ASBESTOS BULK ANALYSIS By: POLARIZING LIGHT MICROSCOPY L/�.E35 Client: Baystate Contracting Services, Inc. CEI Lab Code: A15-4717 352 Albany St. Date Received: 06-09-15 Springfield, MA 01105 Date Analyzed: 06-11-15 Date Reported: 06-11-15 Project: The Former Friendly's; 63 King Street Northampton, MA ASBESTOS BULK PLM, EPA 600 METHOD 1Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS Lab' ID Description Attributes Fibrous Non-Fibrous % 24 Front Door 18 If Heterogeneous 50% Caulk None Detected A1985499 White 50% Paint Non-fibrous Bound 25 Caulking Heterogeneous 5% Talc 45% Calc Garb None Detected A1985500 White 20% Binder Fibrous 30% Paint Bound Page 5 of 6 ASBESTOS BULK ANALYSIS C: E1 By: POLARIZING LIGHT MICROSCOPY L/�.DS Client: Baystate Contracting Services, Inc. CEI Lab Code: A15-4717 352 Albany St. Date Received: 06-09-15 Springfield, MA 01105 Date Analyzed: 06-11-15 Date Reported: 06-11-15 Project: The Former Friendly's; 63 King Street Northampton, MA ASBESTOS BULK PLM, EPA 600 METHOD 1Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS 1-ablD Description Attributes Fibrous Non-Fibrous % 17 Sheetrock Heterogeneous 10% Cellulose 60% Gypsum None Detected A1985492 White,Blue 25% Binder Fibrous 5% Paint Bound Lab Notes: No joint compound present. 18 Adhesive Heterogeneous 100% Mastic None Detected A1985493 Yellow Non-fibrous Bound 19 Caulking Heterogeneous 95% Caulk None Detected A1985494 White 5% Paint Non-fibrous Bound 20 Caulking Heterogeneous 95% Caulk None Detected A1985495 Clear 5% Paint Non-fibrous Bound 21 Caulking Heterogeneous 95% Caulk None Detected A1985496 White 5% Paint Non-fibrous Bound 22 Window Glazing Heterogeneous 60% Calc Carb A1985497 White,Gray 30% Binder Fibrous 8% Paint Bound �� t.�.��'✓✓�t'Jct/� a ` 23 Window Caulking Heterogeneous 50% Caulk None Detected A1985498 White,Clear 50% Paint Non-fibrous Bound Page 4 of 6 ASBESTOS BULK ANALYSIS CEIIAMS By: POLARIZING LIGHT MICROSCOPY L Client: Baystate Contracting Services, Inc. CEI Lab Code: A15-4717 352 Albany St. Date Received: 06-09-15 Springfield, MA 01105 Date Analyzed: 06-11-15 Date Reported: 06-11-15 Project: The Former Friendly's; 63 King Street Northampton, MA ASBESTOS BULK PLM, EPA 600 METHOD Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS' Lab ID Description _Attributes Fibrous "Non-Fibrous % 13 Adhesive Heterogeneous 100% Mastic None Detected A1985488 Clear Non-fibrous Bound 14 Caulking Heterogeneous 100% Caulk None Detected A1985489 White Non-fibrous Bound 15 Sheetrock Heterogeneous 10% Cellulose 60% Gypsum None Detected A1985490A Gray 30% Binder Fibrous Bound Lab Notes: No joint compound present. Layer 1 Plaster Skim Coat Heterogeneous 50% Binder None Detected A1985490B White 50% Calc Carb Non-fibrous Bound - - --- - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - Layer 2 Plaster Base Coat Heterogeneous <1% Cellulose 50% Binder None Detected A1985490B Gray <1% Hair 30% Perlite Fibrous 20% Calc Carb Bound 16 Floor Tile Heterogeneous 15% Cellulose 60% Vinyl None Detected A1985491A Tan 25% Binder Fibrous Bound A1985491B Mastic Heterogeneous 5% Cellulose 50% Mastic None Detected Yellow 45% Binder Fibrous Bound Page 3 of 6 ASBESTOS BULK ANALYSIS By: POLARIZING LIGHT MICROSCOPY LAC35 Client: Baystate Contracting Services, Inc. CEI Lab Code: A15-4717 352 Albany St. Date Received: 06-09-15 Springfield, MA 01105 Date Analyzed: 06-11-15 Date Reported: 06-11-15 Project: The Former Friendly's; 63 King Street Northampton, MA ASBESTOS BULK PLM, EPA 600 METHOD 1Client ID Lab Lab NON-ASBESTOS COMPONENTS ASBESTOS LablD Description Attributes Fibrous Non-Fibrous 8 Caulking Heterogeneous 10% Cellulose 60% Binder None Detected A1985483 Black 5% Synthetic Fiber 25% Silicates Fibrous Bound 9 Caulking Heterogeneous 100% Caulk None Detected A1985484 Clear Non-fibrous Bound 10 Adhesive Heterogeneous 5% Cellulose 50% Silicates None Detected A1985485 Black,Yellow 30% Mastic; Fibrous 15% Binder Bound 11 Mastic Heterogeneous 5% Cellulose 50% Mastic None Detected Layer 1 Black 5% Synthetic Fiber 30% Binder A1985486A Fibrous 10% Silicates Bound - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - -- - - - - - - - - - - - - - -- - - - - - - - - - - - - Layer 2 Floor Tile Heterogeneous 60% Vinyl MAMMM A1985486A Red 30% Calc Carb Fibrous 7% Binder Bound A1985486B Mastic Heterogeneous 70% Tar Black 25% Binder Fibrous r� Bound 12 Plaster Skim Coat Heterogeneous 50% Binder None Detected A1985487 White 50% Calc Carb Non-fibrous Bound Page 2 of 6 ASBESTOS BULK ANALYSIS By: POLARIZING LIGHT MICROSCOPY L/�I�S Client: Baystate Contracting Services, Inc. CEI Lab Code: A15-4717 352 Albany St. Date Received: 06-09-15 Springfield, MA 01105 Date Analyzed: 06-11-15 Date Reported: 06-11-15 Project: The Former Friendly's; 63 King Street Northampton, MA ASBESTOS BULK PLM, EPA 600 METHOD Client ID. Lab Lab NON-ASBESTOS COMPONENTS I ASBESTOS I 1LablD Description Attributes' Fibrous Non-Fibrous I :`% 1 Ceiling Tile Heterogeneous 95% Cellulose 5% Paint None Detected A1985476 White Fibrous Loosely Bound 2 Joint Compound Heterogeneous 2% Cellulose 38% Binder None Detected A1985477 White,Orange 30% Paint Fibrous 30% Calc Carb Loosely Bound Lab Notes: No sheetrock present. 3 Caulking Heterogeneous 100% Caulk None Detected A1985478 Clear Non-fibrous Bound 4 Sheetrock Heterogeneous 10% Cellulose 60% Gypsum None Detected A1985479 Gray 30% Binder Fibrous Bound Lab Notes: No joint compound present. 5 Ceiling Tile Heterogeneous 40% Cellulose 30% Perlite None Detected A1985480 White 5% Fiberglass 20% Binder Fibrous 5% Paint Bound 6 Ceiling Tile Heterogeneous 95% Cellulose 5% Paint None Detected A1985481 White Fibrous Bound 7 Sheetrock Heterogeneous 10% Cellulose 60% Gypsum None Detected A1985482 Gray 30% Binder Fibrous Bound Lab Notes: No joint compound present. Page 1 of 6 Asbestos Report Summary By: POLARIZING LIGHT MICROSCOPY L/�C35 PROJECT: The Former Friendly's; 63 King Street CEI LAB CODE: A15-4717 Northampton, MA METHOD: EPA 600/ R93/ 116 and EPA 6001 M4-82/020 ASBESTOS Client ID Layer Lab ID Color Sample Description % ' 1 A1985476 White Ceiling Tile None Detected 2 A1985477 White,Orange Joint Compound None Detected 3 A1985478 Clear Caulking None Detected 4 A1985479 Gray Sheetrock None Detected 5 A1985480 White Ceiling Tile None Detected 6 A1985481 White Ceiling Tile None Detected 7 A1985482 Gray Sheetrock None Detected 8 A1985483 Black Caulking None Detected 9 A1985484 Clear Caulking None Detected 10 A1985485 Black,Yellow Adhesive None Detected 11 Layer 1 A1985486A Black Mastic None Detected - - - -- - - - - -- - y- - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - Layer 2 A1985486A Red Floor Tile - A1985486B Black Mastic 12 A1985487 White Plaster Skim Coat None Detected 13 A1985488 Clear Adhesive None Detected 14 A1985489 White Caulking None Detected 15 A1985490A Gray Sheetrock None Detected Layer 1 A1985490B White Plaster Skim Coat None Detected - - - -- - - - - -- - - - -- - - - - - -- - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - Layer 2 A1985490B Gray Plaster Base Coat None Detected 16 A1985491A Tan Floor Tile None Detected A1985491 B Yellow Mastic None Detected 17 A1985492 White,Blue Sheetrock None Detected 18 A1985493 Yellow Adhesive None Detected 19 A1985494 White Caulking None Detected 20 A1985495 Clear Caulking None Detected 21 A1985496 White Caulking None Detected 22 A1985497 White,Gray Window Glazing EMMEM 23 A1985498 White,Clear Window Caulking None Detected 24 A1985499 White Front Door 18 If None Detected 25 A1985500 White Caulking None Detected Page 1 of 1 CEILASS ASBESTOS ANALYTICAL REPORT By: Polarized Light Microscopy Prepared for Baystate Contracting Services, Inc. CLIENT PROJECT: The Former Friendly's; 63 King Street Northampton, MA CEI LAB CODE: Al 5-4717 TEST METHOD: EPA 600 / R93 / 116 and EPA 600 / M4-82 /020 REPORT DATE: 06/11/15 TOTAL SAMPLES ANALYZED: 25 # SAMPLES >1% ASBESTOS: 3 TEL: 866-481 -1412 IL_ www.ceilabs.com LADS June 11, 2015 Baystate Contracting Services, Inc. 352 Albany St. Springfield, MA 01105 CLIENT PROJECT: The Former Friendly's; 63 King Street Northampton, MA CEI LAB CODE: A15-4717 Dear Customer: Enclosed are asbestos analysis results for PLM Bulk samples received at our laboratory on June 9, 2015. The samples were analyzed for asbestos using polarizing light microscopy (PLM) per the EPA 600 Method. Sample results containing >1% asbestos are considered asbestos-containing materials (ACMs) per EPA regulatory requirements. The detection limit for the EPA 600 Method is <1% asbestos by weight as determined by visual estimation. Thank you for your business and we look forward to continuing good relations. If you have any questions, please feel free to call our office at 919-481-1413. Kind Regards, l Tianbao Bai, Ph.D., CIH Laboratory Director c� NV Q NVLAP Lab Code 101768-0 107 New Edition Court • Cary, NC 27511 • 919.481.1413 PANDO-2 OP ID: LH �►co�oe CERTIFICATE OF LIABILITY INSURANCE D 01 20/201 YY) 01120!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). CONTACT PRODUCER Phone:978433-2728 NAME: Brown&Brown(Pepperell) PHONE — - P.O.Box 1497 Fax:866-848-6097 AIC No Ext: IAIC_N_o1: Pepperell,MA 01463 E-MAIL pP BB of Hartford(DM) ADDRESS: - - - —--- - ---- - INSURER(S)AFFORDING COVERAGE _ _ F _NAIC# INSURERA:Acadla Insurance Company INSURED Pandolfo Company, Inc. INSURER B:Continental Western Ins Co _._10804___ PO Box 1068 1 Burlington,MA 01803-1019 INSURER C. INSURER D: i INSURER E: _.-_- INSURER F: 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. IN SR TYPE OF INSURANCE ADDLi WUDR POLICY NUMBER MM DDY/YYYY POLIO YYYY� LIMITS LTR GENERAL LIABILITY I EACH OCCURRENCE _$ 1,000,00 AMAGET NTED PREMISES_Ea occurrence1_ $ 250,00 B X COMMERCIAL GENERAL LIABILITY CPA0100280-21 01/0112015 I _ _-- 0 0 r CLAIMS-MADE a OCCUR MED EXP(Any one person).- $ 10 OO PERSONAL&ADV INJURY $ 1,00 MO GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE ATE LIMIT APPLIES PER: I PRODUCTS-C O _OMPI_P A -__GG $ - 2,000,00 X POLICY PRO- LOC Emp Ben. $ 1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident) A _ ANY AUTO IMAA0100281-21 01/01/2015 01/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident)) $ AUTOS X AUTOS - -- NON-OWNED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS (Peraccident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE _ $ 6,000,00 A EXCESS LIAB CLAIMS-MADE CUA0100283-21 01/01/2015 01/01/2016 nGGREGarE $ 6,000,00 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY �— TORY LIMITS _ ER A ANY PROPRIETORIPARTNERIEXECUTIVE YN WCA0100284-21 01/01/2015 01/01/2016 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMP_L_OYEE $ 500,00 If yes,describe under 500,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Equipment CPA0100280-21 01/01/2015 01101/2016 Leased 25,00 Ded. 1,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TBURLIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE SSEE/NJTATIVEE DR //� ' `�" 4N ©19888-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Iii Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual):�z�� MI!0 Address: City/State/Zips%��;76119V 4!�W-3 Phone #: (17- ��V­121,77 Are ou an employer?Check the appropriate box: Type of project(required): 1 I am a employer with A 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 employees. [No workers' 13.❑ 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. tContractors 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: Policy#or Self-ins.Lic.#:_ /C/ ®� ✓ Expiration Date: Q1 Job Site Address: 66 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�nst the violator. Be advised that a copy of this statement may be forwarded to the Office of InvestiRatioris.4the DIA nsurance cov a e verification. I do her y certify u er ai nd al ' s of perjury that the information provided above is true an�rect. Si nature. / Date: Phone#: 1,V 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#: City of Northampton 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: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant r 12, Date Signature of Permit Applicant 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 as r of the subject property hereby authorize Jo action nay lqehalf,in all matters relative to work authorized by this building permit application. Signature of CiiwMr sj6,f;14y 14�1y6j �"��.-.g,.✓j Date as 9wftr/Authorized Agent hereby declare that the statement d information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed un r the i p i o rjury. z Prin Nam /"' /J�a /L� ' yy �4 Si atur r/Age Date ION 12-COIATRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �41 License Number Ad ss Expiration Date Sig to 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 T7 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: lVj Not Applicable Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): /,Oe Name Area of Responsibility Address Registration Number k Signature Telephone Expiration Date E 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 t Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor �✓�� C.G�� Not Applicable ❑ Compan Name Responsible In Charge of Construction Address Signat Telephone Versionl 7 Commerc uilding Permit May 15,2000 8. NORTHAMPTON ZORiTG—] G Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _..w_, ... ..._._ _ .._., _ ___...K...... Setbacks Front Side L: . R: L:f R. ,. . Rear V.. 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 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page', and/or Document #! B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW t YES Q 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 0 NO 0 IF YES, describe size, type and location: /4 �l�� ✓�� i D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, xcavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O 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 A 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 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 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 313 ❑ 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) _.____ __ _ . .,..__,a Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW ONSTRUCTION OFFICE USE ONLY /d•2 =►?mod Floor Area per Floor(sf) 1st St 2nd Q. 2nd 3rd f 3rd 4tn 4 th Total Area(so Total Proposed New Construction .......... Total Height(ft) ( •- Total Height ft , 7.Wat r upply(M.G.L. c.40, §54) 7.1 Flood Zone,Information: 7.3 Sewa isposal System: Public Private ❑ Zone; Outside Flood Zone Municipal a On site disposal system C] Versionl.7 Commercial Building Permit May 15,2000 Department use onflr, City of Northampton status'of permit L Building Department Curb�CutlDnveway Fermat 212 Main Street Sewee/Septic:AVatleb"I" a'.� Room 100 WaterlWelf A iiil 110 Northampton, MA 01060 Two Sets of Structural harts o phone 413-587-1240 Fax 413-587-1272 Plot/Site plans '` Qther Specif�r' APPLICAfM4.lb 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 K`yy� �T_4/ �� Map Lot Unit Zone Overlay District �..__..._ . . ..,._ ,..wv. .._ _._. Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: w Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address. Signature Telephone SECTION 3 MATED CONSTRWTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building `T�. �© i►y�/yy (a) Building Permit Fee 2. Electrical �, ©' ' (b) Estimated Total Cost of Construction from 6 3. Plumbing d Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) eev °cV Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2016-0179 APPLICANT/CONTACT PERSON Pandolfo Company, Inc. ADDRESS/PHONE P O BOX 1068 BURLINGTON01803 (617)908-1227 Q PROPERTY LOCATION 65 KING ST MAP 32A PARCEL 123 001 ZONE CB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 4 gg 1E O Building_Permit Filled out Fee Paid Typeof Construction: INTERIOR DEMOLITION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 6892 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOATION 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 D ti Delay 47-11f/s 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. 65 KING ST BP-2016-0179 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A- 123 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INTERIOR DEMOLITION BUILDING PERMIT Permit# BP-2016-0179 Project# JS-2016-000301 Est. Cost: $20000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Pandolfo Company, Inc. 6892 Lot Size(sq. ft.): 24001.56 Owner: Northampton Cooperative bank Zoning: CB(100)/ Applicant: Pandolfo Company, Inc. AT. 65 KING ST Applicant Address: Phone: Insurance: P O BOX 1068 (617) 908-1227 O WC BURLINGTONMA01803 ISSUED ON.811312015 0:00:00 TO PERFORM THE FOLLOWING WORK:INTERIOR DEMOLITION 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 8/13/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner