32C-024 (13) The Commonwealth of Massachusetts
,a Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OrganizatioMndividual) : Marois Construction Co. , Inc.
Address: 262 OLd Lyman Road
City/State/Zip: South Hadley, MA 01075 Phone#: (413) A33-1320
Are you an employer?Check the appropriate boa: Type of project(required):
1. I am an employer with 25-35 4. I am a general contractor and I 6. 2 New construction
employees(full and/or part time).* have hired the sub-contractors ?_ E Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ! Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers'comp.insurance comp. insurance.+
required] 5.❑ We are a corporation and its 10. FI 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 perm MGL
insurance required]t c. 152, § 1(4),and we have no 12. ❑ Roof repairs
employees.[no workers' 13. ❑ Other
comp.insurance required.]
*Any applicant that checks boa ill must also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this boa must attach 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 thepolicy and job site
information.
Insurance Company Name: AIM Mutual Insurance
Policy#or Self-ins.Lic. #: MCC 200-2000336-2015A Expiration Date: 01/01/2016
Job 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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certi r the pains and penalties of perjury that the information provided above is true and correct.
Si ature: - Date: Ly 15
Print Name: c? ,_-, F— ,, Phone#:
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):
I.Board of Heath 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: �Jc <
The debris will be received by:
Building permit number:
Name of Permit Applicant ("(,, f�;5 �' A
Ll -j-z
Date Signature of Permit Applicant
Initial Construction Control Document
= To be submitted with the building permit application by a
d Registered Design Professional
for work per the 8th edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Repair and Preventive Maintenance of the EJ Gare Parking Garage—Phase 2
Date: September 1,2015
Property Address: Kirkland Avenue,Northampton,MA 01060
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: Concrete repair and waterproofing
I Wesley J. Wilson MA Registration Number: 42802 Expiration date: June 30,2016 , am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans, computations and
specifications concerning:
Architectural X 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 Co Document'.
� 4r
WESLEY J. d�
ace to the right a"wet"or ° WIWILSON N
Enter in the space g " STRUCTURAL
electronic signature and seal: No. 42802
Pp �
E q ^
Phone number: 617-778-9882 Email: wwilson @desman.com t',�S
S
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 I 1 2013
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 No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,�PK�,Z r�b as Owner of the subject property
reby authorize '`\� i �\ W• ,�'� to
a n e If, n all matters relative to work authorized by this building permit application.
Sig atur of Own r Date
s
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 �&Wk
. �•r�
Signature Owner/ ent Date
SECTION 12-CONSTR CTI N S R CES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jerome R. Ezold CS-098164
License Number
16 Maple Crest Circle, Unit G Holyoke, MA 01040 08/15/2017
Address Expiration Date
. (413) 530-3784
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 (F) 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 El
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Weseley J. Wilson Structural
Name Area of Responsibility
18 Tremont Street- Suite 300 42802
Address Registration Number
--- (617) 778-9882 06/30/2016
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
Marois Construction Co, Inc. Not Applicable ❑
Company Name:
Jerome R. Ezold
Responsible In Charge of Construction
262 Old Lyman Rd. South Hadley, MA 01075
Address
(413) 530-3784
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/Finding ever been issued for/on the site?
NO 0 DON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO (F) DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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.
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 Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing El Change of Use❑ Other❑
Brief Description Concrete Repairs, Caulking&Waterproofing
Of Proposed Work: 'I
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 El A-2 11 A-3 El 1A El El 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(sf)
1 St
1St
2nd 2nd
3rd 3rd
4m
4th
Total Area(so 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: F7.3 ewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ ipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
Lartment use only
AIN
r' City of Northampton Status of Permit
` Building Department Curb Cut/Driveway Permit
�? 212 Main Street SewerlSeptic Availability
Room 100 Water/Well Availability-
1o�o` Northampton, MA 01060 Two Sets of Structural'Plans
phone 413-587-1240 Fax 413-587-1272 Plottsite 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
EJ Gare Parking Garage Map Lot Unit
85 Hampton Ave.
'Northampton, MA 01060 Zone Overlay District
Elm St.District —CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
City of Northampton 240 Main St. Northampton,MA 01060 p
Name(Prin fZ Current Mailing Address:
(413) 530-3784
Signature Telephone
2.2 Authori ed A ent:
PqA3"t
fij
Name(Print) Current Mailing Address:
3'33 Iz v
Signature Telephone
SECTION 3-EST rMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building f-7 (a) Building Permit Fee
2. Electrical t (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) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0346
APPLICANT/CONTACT PERSON MAROIS CONSTRUCTION CO INC
ADDRESS/PHONE 262 OLD LYMAN RD SOUTH HADLEY01075-2653 (413)533-1320
PROPERTY LOCATION 85 HAMPDEN AVE-PARKING GARAGE-ARMORY ST
MAP 32C PARCEL 024 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
r
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid I VIA
Building Permit Filled out
Fee Paid
Typeof Construction: CONCRETE REPAIRS CAULKING&WATERPROOFING
New Construction
Non Structural interior renovations
Addition to Existing-
Accessofy Structure
Buildina Plans Included:
Owner/Statement or License 098164
3 sets of Plans/Plot Plan l ��
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORM TION 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
De olif
Sign Mre of Building O ici 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.
85 HAMPDEN AVE-PARKING GARAGE- RMORY ST BP-2016-0346
GIs#: ONWEALTH OF MASSACHUSETTS
Map:Block: 32C-024 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-2016-0346
Project# JS-2016-000555
Est. Cost: $178000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MAROIS CONSTRUCTION CO INC 098164
Lot Size(sq.ft.): 127195.20 Owner: NORTHAMPTON CITY OF PARKING GARAGE
Zoning: CB(100)/ Applicant: MAROIS CONSTRUCTION CO INC
AT. 85 HAMPDEN AVE - PARKING GARAGE - ARMORY ST
Applicant Address: Phone: Insurance:
262 OLD LYMAN RD (413)533-1320 Workers Compensation
SOUTH HADLEYMA01075-2653 ISSUED ON.•911712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONCRETE REPAIRS, CAULKING &
WATERPROOFING
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 9/17/2015 0:00:00 $0.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner