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39-060 (22) �ic��on & �urCingnme. �.�tC. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Contractor's Statement of Responsibility Each contractor responsible for the construction or fabrication of a system or component designated in the Quality Assurance Plan must submit a Statement of Responsibility. The Statement of Responsibility is required for Seismic Design Category C or higher. Make additional copies of this form as required. Project: Contractor's Name Address: License No.: Description of designated building systems and components included in the Statement of Responsibility: Contractor's Acknowledgment of Special Requirements I hereby acknowledge that I have received, read, and understand the Quality Assurance Plan and Special Inspection program. I hereby acknowledge that control will be exercised to obtain conformance with the construction documents approved by the Building Official. Signature Date Contractor's Provisions for Quality Control Procedures for exercising control within the contractor's organization, the method and frequency of reporting and the distribution of reports is attached to this Statement. Identification and qualifications of the person(s) exercising such control and their position(s) in the organization are attached to this Statement. 16 of 16 icl� olt & urCingalne. V.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Quality Assurance Plan - Seismic and Wind QUALITY ASSURANCE FOR SEISMIC RESISTANCE CHECK LIST [IBC 17051 Seismic Design Category C ❑FOR SEISMIC DESIGN CATEGORY C OR HIGHER: Structural: ❑ The seismic-force-resisting systems ❑Steel Braced Frames and associated connections/anchorage ,tD t UJ lr0A ❑Steel Moment Frames and associated connections (` r I_3 ❑Shear walls:❑CMU❑Wood❑Concrete El Diaphragms:[I Floor[I Roof `\ ❑Other: QUALITY ASSURANCE FOR WIND RESISTANCE CHECK LIST [IBC 17061 Wind Exposure Category B W r� 9 ; U QUALITY ASSURANCE PLAN REQUIREMENTS D D � a (A Quality Assurance Plan is required where indicated below) Od x zxz � X In wind exposure Categories A and B, where the 3-second-gust basic wind speed is 120 miles per our(mph)(52.8 m/sec)or greater. X In wind exposure Categories C and D,where the 3-second-gust basic wind speed is 110 mph (49 m/sec)or greater. 1706.2 Structural Wood: (N/A) Continuous special inspection is required during field gluing operations of elements of the main windforce-resisting system. Periodic special inspection is required for nailing, bolting, anchoring and other fastening of components within the main windforce-resisting system, including wood shear walls, wood diaphragms, drag struts, braces and hold-downs. 1706.3 Cold-formed steel light-framed construction: (N/A) Periodic special inspection is required during welding operations of elements of the main windforce-resisting system. Periodic special inspections is required for screw attachment, bolting, anchoring and other fastening of components within the main windorce-resisting system , including shear walls, braces,diaphragms,collectors (drag struts)and hold-downs. 1706.4 Wind-resisting components: (N/A) Periodic special inspection is required for the following systems and components 1.Roof cladding. 2.Wall cladding. Prepared by: Building Code Official's Acceptance: ignature ate Signature Date 15 of 16 Mick on & 381[r[ingome. V.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspections SEISMIC RESISTANCE-STRUCTURAL EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETE IBC Section 1707 SUBMITTAL, D OR NONE 1.Special inspections for seismic resistance. Special inspection as specified in this section Seismic Design Category:B is required for the following: a.The seismic-force-resisting systems in structures assigned to N P IBC 1707.1 PEISE or EIT Seismic Design Category C,D,E or F 2.Structural steel:Continuous special inspection for structural welding in accordance N P IBC 1702.2 AWS-CWI with AISC 341. 3.Structural wood: a.Continuous special inspection during Held gluing operations of N C [BC 1702.3 PE/SE or EIT elements of the seismic-force-resist- in system. b.Periodic special inspections for nailing,bolting,anchoring and other fastening of components N P IBC 1702.3 PE/SE or EIT within the seismic-force-resisting system,including drag struts, braces and hold-downs 4.Cold-formed steel framing:Periodic special inspections during welding operations of elements of the seismic-force-resisting system. Periodic special inspections for screw N N attachment,bolting,anchoring and other fastening of components within the seismic- force-resisting system,including struts,braces, and hold-downs 4. Seismic isolation system.Provide periodic special inspection during the fabrication and installation of isolator units and energy N N IBC 1707.8 dissipation devices if used as part of the eismic isolation system 14 of 16 Mlcko t & JBurtingame. V.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspections WOOD CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.6 SUBMITTAL, OR NONE 1.Fabrication of high-load diaphragms LJ- a.Verify wood structural panel sheathing for grade and thickness N P IBC 1704.6 PE/SE or EIT b.Verify the nominal size of framing members at adjoining panel edges N P IBC 1704.6 PE/SE or EIT b.Verify the nail or staple diameter and length N P [BC 1704.6 - PE/SE or EIT b.Verify the number of fastener lines N P IBC 1704.6 PE/SE or EIT b.Verify the spacing between fasteners in each line and at edge margins N P IBC 1704.6 PEASE or EIT Load Tests for Joist Hangers:Provide evidence of manufacturer's load test in accordance with ASTM D1761 IBC 1715 including the vertical load bearing capacity,torsional N S [submit ICBO PE/SE or EIT moment capacity,and deflection characteristics when there reports] is no calculated procedure recognized by the code. 13 of 16 Dick on & 39urtitlaame. V.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspection Services FABRICATION AND IMPLEMENTATION PROCEDURES—WOOD TRUSSES EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.2 SUBMITTAL, OR NONE 1. Fabrications Procedures:Review of fabricator's written procedural and quality control manuals and periodic auditing of fabrication practices by an approved special inspection agency. At the Fabricator completion of fabrication,the approved fabricator shall N S shall submit PE/SE or EIT submit a certificate of compliance to the building code one of the two official stating that the work was performed in qualifications accordance with the approved construction documents. -OR- 2.TPI Inspection Program:Fabricator shall participate in the TPI Quality Assurance Inspection Program,and maintain a copy of the Quality Assurance Procedures N Manual,QAP-90. Submit copy of certificate. All cusses shall bear the TPI Registered Mark. 3.At completion of fabrication,the approved fabricatoflN hall submit a certificate ficate of compliance to the building S IBC (704.2.2 PE/SE or EIT ode official stating that the work was performed in accordance with the approved construction documents 12 of 16 Michon & 38urtingame. V.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspection Services FABRICATION AND IMPLEMENTATION PROCEDURES—STRUCTURAL STEEL EXTENT: VERIFICATION AND INSPECTION CONTINUOUS, AGENT TASK Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED IBC Section 1704.2 SUBMITTAL, OR NONE 1. Fabrications Procedures:Review of fabricator's written procedural and quality control manuals and periodic auditing of fabrication practices by an Fabricator approved special inspection agency. At the shall submit completion of fabrication,the approved fabricator shall Y S one 11 the two SI I PE/SE or EIT submit a certificate of compliance to the building code official stating that the work was performed in qualifications accordance with the approved construction documents. -OR- 2.AISC Certification N 3.At completion of fabrication,the approved fabricator hall submit a certificate of compliance to the building Y S (BC 1704.2.2 SI l PE/SE or EIT ode official stating that the work was performed in accordance with the approved construction documents. II of 16 Mich ou & 38urCingame. D.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspection Services: Structural Steel Erection EXTENT: VERIFICATION AND INSPECTION IBC Section CONTINUOUS, AGENT TASK 1704.3 Y/N PERIODIC, COMMENTS AGENT QUALIFICATIO COMPLETED SUBMITTAL, OR N NONE 1.Material verification of high-strength bolts,nuts and washers: a.Identification markings to conform to ASTM AISC 360, standards specified in the approved construction Y S Section A3.3 SI 1 PE/SE or EIT documents. and applicable b.Manufacturer's certificate of compliance required. ASTM material Y S standards SI 1 PE/SE or EIT 2,Inspection of high-strength bolting a:Snug-tight joints Y P S11 AWS/AISC-SSI b:Pretensioned and slip-critical joints using tum-of- nut with matchmarking,twist-off bolt or direct Y P AISC 360, SI l AWS/AISC-SSI tension indicator methods of installation. Section M2.5 c.Pretensioned and slip-critical joints using turn-of- IBC Sect. nut without match marking or calibrated wrench Y C 1704.3.3 S11 AWS/AISC-SS[ methods of installation. 3.Material verification of structural steel and cold-formed steel deck: a.For structural steel,identification markings to Y S conform to AISC 360. AISC 360, SI 1 PE/SE or EIT b.For other steel,identification markings to conform Section M5.5 to ASTM standards specified in the approved Y S Applicable p pp ASTM material PE/SE or EIT construction documents. Standards SI I c.Manufacturer's certified test reports. Y S SI I PE/SE or EIT 4.Material verification of weld filler materials: a.Identification markings to conform to AWS Y S AISC 360, PE/SE or EIT specification in the approved construction documents. Section A3.2 Si 1 b.Manufacturer's certificate of compliance required. and applicable —' Y S AWS A5 PE/SE or EIT documents S11 5. Submit current AWS DLI welder certificate for all field Y S AWS DI.1 SI 1 PE/SE or EIT welders who will be welding on this project. 6.Inspection of welding(IBC 1704.3.1): a.Structural steel: 1)Complete and partial penetration groove welds. Y C AWS-CWI 2)Multipass fillet welds. Y C AWS-CWI 3)Single-pass fillet welds>5/16" Y C AWS D1.1 SI 1 AWS-CWI 4)Plug and slot welds. Y C AWS-CWI 5)Single-pass fillet welds<5/16" Y P AWS-CWI 6)Floor and deck welds. Y P AWS D1.3 AWS-CWI b.Reinforcing steel(IBC Sect 1903.5.2): 1)Verification of weldability of reinforcing steel other Y P AWS-CWI than ASTM A706. SI 1 2)Reinforcing steel-resisting Flexural and axial forces in intermediate and special moment frames,and AWS D 1.4 AC boundary elements of special reinforced concrete shear Y C 318:Section AWS-CWI walls and shear reinforcement. 3.5.2 SI 1 3)Shear reinforcement. Y C SI I AWS-CWI 4)Other reinforcing steel. Y P SI l AWS-CWI 7.Inspection of steel frame joint details for compliance (IBC Sect 1704.3.2)with approved construction documents: a.Details such as bracing and stiffening. Y p S[1 PEJSE or EIT b.Member locations. Y P sit PE/SE or EIT c.Application of joint details at each connection. Y P SI I PE/SE or EIT 10 of 16 icE>; onurCingttme. J9.c. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspection Services LEVEL 2 REQUIRED INSPECTION OF MASONRY CONSTRUCTION(ESSENTIAL FACILITIES) EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.5 YEN PERIODIC, COMMENTS AGENT SUBMITTAL, QUALIFICATION COMPLETED OR NONE L Compliance with required inspection PE/SE, EIT or provisions of the construction documents and N P ACI 530.1, 1.5 ICC-SMSI the approved submittals. 2.Verification of f,,,and f;,„,prior to PE/SE, EIT or N construction and for every 5,000 square feet P ACI 530.1, 1.413 ICC-SMSI during construction. 3.Verification of proportions of materials in PE/SE, EI premixed or preblended mortar and grout as N P ACI 530.1, 1.5B or ICC-SMT delivered to the site. 4.Verification of slump flow and VS as N C ACI 501.1 PE/SE, EIT or delivered to the site for self-consolidating rout. 1.513.1.b.3 ICC-SMSI 5.The following shall be verified to ensure compliance: a.Proportions of site-prepared mortar,grout PE/SE, E[ and prestressing grout for bonded tendons. N P AC1530.1,2.6A or ICC-SMT b.Placement of masonry units and T or EI ,PE/SE construction of mortarjoints. N P AC1530.1,3.3B - /SE, EIT c.Placement of reinforcement,connectors AC1530, 1.12; PE/SE, EIT or and prestressing tendons and anchorages N P AC1530.1,3.4,3.6A ICC-SMSI d.Grout space prior to grouting. AC1530.1,3.21 PE/SE, EIT or N C ICC-SMSI e.Placement of grout. _ACI530.1,3.5 PE/SE, EIT or N C ICC-SMSI f.Placement of prestressing grout. N C AC1530.1,3.6C - PE/SE or EIT g.Size and location of structural elements. N P ACI 530.1,3.3F - PE/SE or EIT h.Type,size and location of anchors, including other details of anchorage of N C ACI 530 1.2.2(e), PE/SE, EIT or masonry to structural members,frames or 1.16.1 ICC-SMSI other construction. i.Specified size,grade and type of reinforcement,anchor bolts,prestressing N P ACI 530 L l5; - PE/SE, EIT or tendons and anchorages. AC1530.1 2.4,3.4 ICC-SMSI j.Welding of reinforcing bars. N C ACI 530 2.1.9.7.2, PE/SE, EIT or 3.3.3.4(b) ICC-SMSI k.Preparation,construction and protection of masonry during cold weather IBC 2104.3,2104.4; PE/SE, EIT or (temperature below 40°F)or hot weather N P AC1530.1 1.8C, - ICC-SMSI (temperature above 90°F). 1.8D 1.application and measurement of or EIT, prestressing force N C ACI 530.1 3.613 - PE/SE, EIT 6.Preparation of any required grout specimens IBC 2105.2.2, PE/SE, EIT or N and/or prisms shall be observed. C 2105.3;ACI 530.1,1.4 ICC-SMSI 9 of 16 Mick ou & 3surliugame. J).(E. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspection Services LEVEL 1 REQUIRED VERIFICATION AND ISNPECTION OF MASONRY CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.5 WN PERIODIC, COMMENTS AGENT SUBMITTAL, QUALIFICATION COMPLETED OR NONE 1.Compliance with required inspection PE/SE provisions of the construction documents and the Y P AC1530.1, 1.5 SI I or ICC-,EIT EIT approved submittals shall be verified 2.Verification of f,„and f;,.,prior to PE/SE construction except where specifically exempted Y P ACI 530.1, 1.413 SI I or ICC-,EIT EIT b this code 3.Verification of slump flow and VSI as Y C ACI 501.1 Si I PE/SE,EIT or delivered to the site for self-consolidating rout. 1.513.1.b.3 ]CC-SMS1 4.As masonry construction begins,the following shall be verified to ensure compliance: PE/SE,EIT or 2 SI 1 1, . a.Proportions of site-prepared mortar. Y P AC1530. ICC-SMSI Y P AC1530.1,3.313 SI I PE/SE,EIT or b.Construction of mortar joints. ICC-SMSI Y P ACI530.1,3.4, SI l PE/SE,EIT or c.Location of reinforcement and connectors. 3.6A ICC-SMSI Y P AC1530.1,3.613 Si I PE/SE,EIT or d.Prestressing technique. ICC_SMSI e.Grade and size of prestressing tendons and p ACI530.1,2.413, S[1 PE/SE,EIT or anchorages, ICC SMSI 2.During construction the inspection program shall verify: i 317 3 S1 PE/SE,EIT or 1, . a.Size and location of structural elements. Y P AC1530. ICC-SMSI b.Type,size and location of anchors, including other details of anchorage of Y P AC1530, 1.2.2(e), Sl 1 PE/SE,EIT or masonry to structural members,frames or L 16.1 ]CC-SMSI other construction c.Specified size,grade and type of AC1530, 1.15, pE/SE reinforcement,anchor bolts,prestressing Y P AC1530.1,2.4, Sl I or ICC-,EIT EIT tendons and anchorages. 3.4 d.Welding of reinforcing bars. Y C AC530,2.1.9.7.2, Si I AWS-CWI 3.3.3.4(b) e.Preparation,construction and protection 113C 2104.3, of masonry during cold weather Y p 2104.4 AC1530.1 SI I PE/SE,EIT or (temperature below 40"F)or hot weather (temperature above 90"F). L.8C, 1.8D ICC-SMSI f.Application and measurement of Y C ACI530.1,3.613 S[1 PE/SE,EIT or restressin force. ICC-SMSI 6.Prior to grouting,the following shall be verified to ensure compliance: Y P ACI530.1,3.2D SI 1 POSE,EIT or a.Grouts ace is clean. ICC-SMSI b.Placement of reinforcement and connectors and prestressing tendons and Y p ACI530, 1.13, SI I PE/SE EIT,or anchorages AC1530.1,3.4 ICC-SMSI c.Proportions of site-prepared grout and Y p AC[530.I,2.66 SI t PE/SE,EIT or restressin rout for bonded tendons. ICC-SMSI Y P ACI530.1,3.313 Si I PE/SE,EIT or d.Construction of mortar'oints. ]CC-SMSI 7.Grout placement shall be verified to ensure Y C AC1530.1,3.5 SI 1 POSE,EIT or compliance: ICC-SMSI Y C ACI530.1,3.6C SI 1 PE✓SE,EIT or a.Grouting of prestressing bonded tendons. ICC-SMSI 8.Preparation of any required grout specimens, IBC 2105.2.2, mortar specimens and/or prisms shall be Y P 2105.3 ACI SI 1 PE/SE,EIT or observed 530.1, 1.4 ICC-SMSI 8 of 16 �ic�5on & �urringttrne. �.l�. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspections CONCRETE CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.4 Y/N PERIODIC, COMMENTS AGENT QUALIFICATION COMPLETED SUBMITTAL, OR NONE 1.Inspection of reinforcing steel,including ACI 318:3.5, prestressing tendons,and placement. Y P 7.1-7.7 SI 1 PEISE or EIT 2.Inspection of reinforcing steel welding in AWS D1.4 ACI accordance with Table 1704.3,Item 513 Y 318:3.5.2 SI I AWS-CWI 3. Inspection of bolts to be installed in concrete prior to and during placement of concrete where ACI 318:8.1.3, allowable loads have been increased or where Y C 21 2 8 SI 1 PE/SE or EIT strength design is used 4.Inspection of anchors installed in hardened ACI 318:3.8.6, concrete. Y P 8.1.3 21 2 8 SI 1 PE/SE or EIT 5. Verifying use of required design mix ACI 318:Ch 4, Y P SI 1 PE/SE or EIT 5.2-5.4 6. At time fresh concrete is sampled to fabricate ASTM C 172 specimens for strength test,perform slump and air Y C ASTM C31 ACI SI I ACI-CF17 or ACI content test and temperature 318:5.6,5.8 STT 7. Inspection of concrete and shotcrete placement for proper application techniques Y C ACI 318:5.9, S11 PE/SE or EIT 5.10 8. Inspection for maintenance of specified curing AC[318:5.1(- temperature and techniques Y P 5.13 S[1 PE/SE or EIT 9. Inspection of Prestressed Concrete a.Application of prestressing force. N C PE/SE or EIT, b.Grouting of bonded prestressing tendons in ACI 318: 18.20 seismic force resisting system N C ACI 318: 18.8.4 PE/SE or EIT 10. Erection of precast concrete members N P ACI 318:Ch 16 PE/SE or EIT 11.Verification of in-situ concrete strength,prior to stressing of tendons in post-tensioned concrete and prior to removal of shores and forms beans N P ACI 318:6.2 ACI-STT and structural slabs 12.Inspect formwork for shape,location and dimensions of the concrete member being formed. Y P AC1318:6.1.1 - ACI-STT 7 of 16 icsun & nr[ingttme. P.C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspections SOILS&FOUNDATION CONSTRUCTION EXTENT: VERIFICATION AND INSPECTION IBC CONTINUOUS, AGENT TASK Section 1704.7,1704.8,1704.9 YEN PERIODIC, COMMENTS AGENT SUBMITTAL, OR QUALIFICATION COMPLETED NONE L Verify existing soil conditions,fill placement and load bearing requirements a.Verify materials below shallow foundations are adequate to achieve the design bearing Y P SI I PE/GE,EIT or capacity. ETT b.Verify excavations are extended to proper PE/GE,EIT or depth and have reached proper material. Y P SI I ETT c.Perform classification and testing of Y P Si I PE/GE,EIT or compacted fill materials. 16C 1704.7 ETT d.Verify use of proper materials,densities and lift thicknesses during placement and Y C PE/GE,EIT or compaction of compacted fill. S1 I ETT e.Prior to placement of compacted fill, observe subgrade and verify that site has been Y p Si I PE/GE,EIT or prepared properly. ETT 2.Verify driven deep foundation elements a.Verify element materials,size and lengths N C PE/GE,EIT or comply with the requirements. ETT b.Determine capacities of test elements and conduct additional load tests,as required N C PE/GE,EIT or ETT c.Observe driving operations and maintain complete and accurate records for each iv C PE/GE,EIT or element. ETT d.Verify placement locations and plumbness, confirm type and size of hammer,record number of blows per foot of penetration, PE/GE,EIT or determine required penetrations to achieve N C design capacity,record tip and butt elevations IBC 1704.8 ETT and document any damage to foundation element e.For steel elements,'perform PE/GE,EIT or inspections in accordance with Section 1704.3 N ETT f.For concrete elements and concrete-tilled elements,perform additional inspections in N PE/GE,EIT or accordance with Section 1704.4 ETT g.For specialty elements,perform additional inspections as determined by the registered N PE/GE,EIT or design professional in responsible charge. ETT 3.Verify cast-in-place deep foundation elements: a.Observe drilling operations and maintain complete and accurate records for each N C Si I PE/GE,EIT or element. ETT b.Verify placement locations and plumbness, confirm element diameters,bell diameters(if applicable),lengths,embedment into bedrock N C SI I PE/GE,EIT or (if applicable)and adequate end-bearing strata ETT capacity.Record concrete or grout volumes. c.For concrete elements,perform additional PE/GE,EIT or inspection in accordance with section 1704.4 N SI 1 ETT 6 of 16 Dlch on & 391trCingame. J).C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Schedule of Special Inspections Qualifications of Inspectors and Testing Technicians The qualifications of all personnel performing Special Inspection and testing activities are subject to the approval of the Building Official. The credentials of all Inspectors and testing technicians shall be provided to the Special Inspector for their records. NOTE VERIFICATION THAT QUALIFIED INDIVIDUALS ARE AVAILABLE TO PERFORM STIPULATED TESTING AND/OR INSPECTION SHOULD BE PROVIDED PRIOR TO SUBMITTING STATEMENT. AGENT QUALIFICATIONS IN SCHEDULE ARE SUGGESTIONS ONLY, FINAL QUALIFICATIONS ARE SUBJECT TO THE DISCRETION OF THE REGISTERED DESIGN PROFESSIONAL PREPARING THE SCHEDULE. Key for Minimum Qualifications of Inspection Agents: When the Registered Design Professional in Responsible Charge or Special Inspector of Record deems it appropriate that the individual performing a stipulated test or inspection have a specific certification, license or experience as indicated below, such requirement shall be listed below and shall be clearly identified within the schedule under the Agent Qualification Designation. PE/SE Structural Engineer—a licensed SE or PE specializing in the design of building structures PE/GE Geotechnical Engineer—a licensed PE specializing in soil mechanics and foundations EIT Engineer-In-Training—a graduate engineer who has passed the Fundamentals of Engineering examination Experienced Testing Technician ETT Experienced Testing Technician—An Experienced Testing Technician with a minimum 5 years experience with the stipulated test or inspection American Concrete Institute(ACI) Certification ACI-CFTT Concrete Field Testing Technician—Grade 1 ACI-CCI Concrete Construction Inspector ACI-LTT Laboratory Testing Technician—Grade 1&2 ACI-STT Strength Testing Technician American Welding Society(AWS) Certification AWS-CWI Certified Welding Inspector AWS/AISC-SSI Certified Structural Steel Inspector American Society of Non-Destructive Testing (ASNT)Certification ASNT Non-Destructive Testing Technician-Level 11 or III. International Code Council (ICC)Certification ICC-SMSI Structural Masonry Special Inspector ICC-SWSI Structural Steel and Welding Special Inspector ICC-SFSI Spray-Applied Fireproofing Special Inspector ICC-PCSI Prestressed Concrete Special Inspector ICC-RCSI Reinforced Concrete Special Inspector National Institute for Certification in Engineering Technologies(NICET) NICET-CT Concrete Technician—Levels I, II, III & IV NICET-ST Soils Technician-Levels I, 11, 111& IV NICET-GET Geotechnical Engineering Technician -Levels I, 11, III & IV Other 5of16 [tft�Dtt & 3purlingAmP. P. C. Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Statement of Special Inspections (Continued) Special Inspector's/Agent's Final Report Project: Special Inspector or Agent: (name) (firm) Designation: To the best of my information, knowledge and belief, the Special Inspections or testing required for this project, and designated for this Inspector/Agent in the Statement of Special Inspections submitted for permit, have been performed and all discovered discrepancies have been reported and resolved. Interim reports submitted prior to this final report form a basis for and are to be considered an integral part of this final report. Respectfully submitted, Special Inspector or Agent: (Type or print name) Signature Date Licensed Professional Seal or Certification Number 4 of 16 Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Statement of Special Inspections (Continued) Final Report of Special Inspections (SSIC/SI 1) [To be completed by the Structural Special Inspections Coordinator(SSIC/SI 1). Note that all Agent's Final Reports must be received prior to issuance.] Project: Location: Owner: Owner's Address: Architect of Record: (name) (firm) Structural Registered Design Professional in Responsible Charge: Kevin P.Burlingame Dickson and Burlingame P.C. (name) (firm) To the best of my information, knowledge and belief,the Special Inspections required for this project, and itemized in the Statement of Special Inspections submitted for permit, have been performed and all discovered discrepancies have been reported and resolved. Interim reports submitted prior to this final report form a basis for and are to be considered an integral part of this final report. Respectfully submitted, Structural Special Inspection Coordinator (Type or print name) (Firm Name) Signature Date Licensed Professional Seal 3 of 16 Project: Office Building Atwood Drive(Building A) Date Prepared: 9/29/11 Structural Statement of Special Inspections (Continued) List of Agents Project: Office Building Atwood Drive(Building A) Location: l Atwood Drive Northampton,MA Owner: This Statement of Special Inspections encompass the following discipline:Structural (Note:Statement of Special Inspections for other disciplines may be included under a separate cover) This Statement of Special Inspections/Quality Assurance Plan includes the following building systems: x Soils and Foundations x Cast-in-Place Concrete ❑ Precast Concrete System x Masonry Systems x Structural Steel ❑ Wood Construction ❑ Special Cases Special Inspection Agencies Firm Address,Telephone,e-mail 1. STRUCTURAL Special To Be Determined(TBD) Inspections Coordinator(SSIC) 2. Special Inspector(SI 1) To Be Determined(TBD) 3. Special Inspector(SI 2) 4. Testing Agency(TA 1) 5. Testing Agency(TA 2) 6. Other(01) Note: The inspectors and testing agencies shall be engaged by the Owner or the Owner's Agent,and not by the Contractor or Subcontractor whose work is to be inspected or tested.Any conflict of interest must be disclosed to the Building Official, prior to commencing work. 2 of 16 } i f'e ;- r. REGISTERED ENGINEERS: N }7 S. Bernard Dickson, PE. MASSACHUSETTS CONNECTICUT (508)430-8600 Fax:(508)430-9800 RHODE ISLAND NEW HAMPSHIRE Consulting Structural Engineers ineers VERMONT O Kevin P. Burlingame, P.E. MAINE 11 LARKIN LANE,HARWICH, MA 02645 (508)989-4396 Fax:(508)384-5012 NEW YORK Email:dea.engitteering @ comcast.net -BANK AND LEGAL INVESTIGATIONS INSPECTIONS -REPORTS -COMMERCIAL -INDUSTRIAL Structural Statement of Special Inspections -RESIDENTIAL -OFFICE BUILDINGS -ENVIRONMENTAL Project: Office Building Atwood Drive (Building A) -STEEL -CONCRETE -PRESTRESSED Location: 1 Atwood Drive Northampton, MA -MASONRY -TIMBER Owner: -DESIGN -DETAILING SPECIFICATIONS This Statement of Special Inspection encompass the following discipline:Structural -INSPECTION -SUPERVISION -JOISTS This Statement of Special Inspections is submitted as a condition for permit issuance in accordance with the -TRUSSES Special Inspection and Structural Testing requirements of the Building Code. It includes a schedule of Special -COMPOSITE Inspection services applicable to this project as well as the name of the Structural Special Inspection Coordinator -REPAIR (SSIC)and the identity of other approved agencies to be retained for conducting these inspections and tests. MODIFICATION AND USE IN RIGID AND SEMII-RIGID FRAMES The Structural Special Inspection Coordinator shall keep records of all Structural inspections and shall furnish vBRATIONOF inspection reports to the Building Code Official (BCO) and the Structural Registered Design Professional in FLOOR SYSTEMS Responsible Charge (SRDP). Discovered discrepancies shall be brought to the immediate attention of the Contractor for correction. If such discrepancies are not corrected, the discrepancies shall be brought to the attention of the Building Official and the Structural Registered Design Professional in Responsible Charge. The Special Inspection program does not relieve the Contractor of his or her responsibilities. Interim reports shall be submitted to the Building Official and the Structural Registered Design Professional in Responsible Charge at an interval determined by the SSIC and the BCO. A Final Report of Special Inspections documenting completion of all required Special Inspections, testing and correction of any discrepancies noted in the inspections shall be submitted to the BCO prior to issuance of a Certificate of Use and Occupancy. Job site safety and means and methods of construction are solely the responsibility of the Contractor. Interim Report Frequency: X Upon request of Building Official or❑ per attached schedule. Prepared by: Kevin P. Burlingame (type or print name of the Structural Registered Design Kevils P. Professional in Responsible Charge) c BaBow " 3tt'actotal No.46050 -...+..../ ` 9/29/11 Safi 9�gtsTE{t� Signature Date fisS�OMAL Design Professional Seal Owner's Authorization: Building Code Official's Acceptance: Signature Date Signature Date 1of16 REGISTERED ENGINEERS MASSACHUSETTS is you & urYiug�n�e � W♦ RHODE ISLAND NEW HAMPSHIRE VERMONT Consulting Structural Engineers N w ORK MARYLAND 11 LARKIN LANE, HARWICH, MA 02645 BANK AND LEGAL TEL. (508) 430-8600 FAX(508)430-9800 INVESTIGATIONS INSPECTIONS REPORTS Construction Control COMMERCIAL, INDUSTRIAL, RESIDENTIAL AND OFFICE BUILDINGS Project Number: 1001 MIISCELLLANEO SAND project Title: Office Building Atwood Drive(Building A) STRUCTURES STEEL Project Location: 1 Atwood Drive, Northampton MA CONCRETE PRESTRESSED Name of Building: Atwood Drive MASONRY TIMBER DESIGN Nature of Project: Structural design of a 3 story 40,000 square foot+/- (13,350 square foot plan DETAILING area) building including spread footing foundations. SPECIFICATIONS SUPERVISION INSPECTION In accordance with Section 105 and 107.6.2 of the Massachusetts state Building Code, 780 JOISTS,COMPOSITE STS d TRUSSES g +CMR-Eighth hth Edition I+ g g Kevin P. Burlingame, Registration No: 46050, being a registered JOI AoAFCIS,REPAIR professional engineer hereby certify that I have prepared or directly supervised the preparation of USE IN RIGID AND all design plans, computations and specifications concerning: SEMI-RIGID FRAMES VIBRATION OF FLOOR SYSTEMS Entire Project F1 Architectural nX Structural F] Mechanical Fire Protection Electrical ❑ Other For the above named project I certify that to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, 780 CMR-Eighth Edition, all acceptable engineering practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that I, or an authorized associate under my direct supervision and control, shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 107.6.2: 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 Chapter 17. 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 construction documents and this code. Pursuant to Section 1704.0, I shall prepare a Program of Structural Tests and Inspections which will be included with the permit application. I shall maintain records of tests and inspections provided to me by the Contractor and will submit these together with Progress Reports and pertinent comments to the Building Official promptly upon his/her request. Upon completion of the work, I shall submit a Final Report as to the satisfactory completion for the Program of Tests and Inspections and the readiness of the project for occupancy. Signature: Client#: 14280 RPMAS DATE ACORD� CERTIFICATE OF LIABILITY INSURANCE 1/10/20111vvrY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sullivan Insurance Group,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 10 Chestnut Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 1010 Worcester,MA 01608-2804 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hanover Insurance Company R.P.Masiello, Inc. INSURER B: P O Box 742 INSURER C: Boylston,MA 01505 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR N POLICY SR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE POLICY EXPIRATION LIMITS DATE MM/DD/YY DATE MM/RATI A GENERAL LIABILITY ZHN5107086 11/30/10 11130/11 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $100,000 CLAIMS MADE 51 OCCUR VIED EXP(Any one person) s5,000 X PD Ded: $2,500 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO LOC JECT • AUTOMOBILE LIABILITY AMN5276062 11/30/10 11/30/11 COMBINED SINGLE LIMIT $1,000000 (Ea accident) r X ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY (Per accident) $ X NON-OWNED AUTOS X Drive Other Car PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ • EXCESS/UMBRELLA LIABILITY UHN8186751 11130/10 11/30/11 EACH OCCURRENCE $5000000 X OCCUR E CLAIMS MADE AGGREGATE s5,000,000 DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND HN5470185 11/30/10 1 11 X WCSTATU- OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ---- -- E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Evidence of Liability Insurance for the Named Insured CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION FOR INFORMATIONAL PURPOSES ONLY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'In DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ,T d to ' ACORD 25(2001/08)1 of 2 #S140321/M137751 KJA © ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , 600 Washington Street — Boston, MA 02111 wt www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibly Name(Business/Organization/Individual): Y 011 1 e 1 L 1 t•( L Address:—,3 8 Do A,t�k 1�� 74 Z City/State/Zip: '-P�-,O,,LS -1 ml1• Phone#:/,;Z)b 06c( 6 6 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. P I am a general contractor and I 6. ( New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7: E]Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working or me in an capacity. employees and have workers' g Y P h'• � 9. E]Building addition [No workers'comp.insurance comp.insurance. 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ P officers have exercised their 1 1. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ 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. Contractors that check this box must attached an additional sheet showing the nacre 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: N!44 J4UU-e. /!4 5UA_4*.tc_tL_ Policy#or Self-ins.Lic. #: UJ 414 1;470/(!�55— Expiration Date: Job Site Address: / A&_tX ox–, City/State/Zip: Aak� ear 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 ce der the pains and enalties<fpe�rjury that the information provided above is t U and correct. Signature- Date: I / Phone#: Of 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 4 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 as Owner of the subject property hereby authorize— f�7 �.._._� _lL1x�.�. �. a_ . .. _ _...._ .._ _._ _.., _ _.._. _. ..�__=to act on my behalf,in all ers r ative to work uthorized by this building permit application. Signature o Date I, _• _ __ _ _ __ _ _ _.. _..___ _. ....._._ 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. _ Si ned.under the yarns and enalties of ep r'ur! Print Na Signature of Owner/Agent - ate SECTION 12-CONSTRUCTION.SERVICES 10.1 Licensed Construction Supervisor: � Not Applicable 0 Name of License Holder: J.�-G_�.��.,.�__e.a.�._�..�...�.A ...._ . ,.. ._.m.: '..._....N�� 1 '..-�.. _...... .. ._._..... „ License Number Address / r Expiration Date ..L.C. ignature Telephone SECTION 13-WORKERS,'COMPENSATION INSURANCE AFFIDAVIT(M.G-L.c.152z§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 Version 1.7 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): C� tM �yf Registration Number At 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 R29 stration Number__ -_ Signature Telephone Expiration Date Name Area of Responsibility i Address Registration Number Signature Telephone Expiration Date ..... _.. _.......... _. Name Area of Responsibility Address Registration Number i Signature Telephone Expiration Date 9.3 General Contractor .___.-.__.___ Not Applicable ❑ Company Name: Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON-ZONING Existing Proposed Required by.Zoning . This column to tie filled in by Building Department Lot Size Frontage Setbacks Front M" " Side L.-- --•—w R. _s L:L:—.._ R: Rear _ { Building Height Bldg. Square Footage % Open Space Footage _{ (Lot area minus bldg&paved d -- #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 Registry of Deeds? NO 0 DONT KNOW 0 MYES 0.- IF YES: enter Book ' Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW () YES 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 NO 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(clearipg,grading,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 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 e Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accesso Bui in Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Oth ❑ Brief Description nter a brief description here. � Of Proposed Work. Q � � ,`� ' ` 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 K 2A ❑ E Educational ❑ 28 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ _ 3A ❑ 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 E-1 Specify: S Special Use ❑ Specify: COMPLETETHISSECTION'IF EXISTING BUILDING UNDERGOING`RENOV -TIONS ADDITIONS ANDIOR CHANGE'IN USE Existing Use Group. _,__.__ __ w 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) 4, _..._.. _ 1St C,C>C SF 1 sc �� 2nd _._ _. „ _ 2nd 3 d 3 GY�d ....,__ 4th _ ____ _ 4t' Total Area(sf) 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 ��` k t �E Departure fuse on1� -� � City of Northampton S a�; RE E Building Department fb 4KuwDignveway Perr>t��, $�Uz 212 Main Street SevuerSep� Artlabtlt�! Ulu I ' Q Room 100aterUtiCe ` atalili �� N rthampton, MA 01060 �e �a �ScttMralfan� r 4 41 587-1240 Fax 413-587-1272 P1ottStterlIan � : �: C+ther S e .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 ......... /1a� Map Ll Lot / Unit H vl',- ' 1'�—"r`�` — Zone Overlayf District Elm St. ' '. __.m�... .......,...,.. ..., ._.�.-..-.,...R.-.-.�.�--�..•-,�.,..m...�,.� District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) r' Current Mailing Address: Signature I r-QW Telephone 2.2 Authorized Agent: 1�—�? �r�- -_ c�,!a y._._ w�v_._m ._.__. ._. ___` 3f3 tm✓��+.� T. .a a l p_ 74Z_ . ..._m_ Name(Print) Current Mailing Address: Signatur Telephone SECTION 3-'ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated'TotaLCost 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 Louis Hasbrouck From: Louis Hasbrouck Sent: Wednesday, October 05, 2011 7:50 PM To: Bob Egan (k)egan @rpmasiello.com) Cc: Charles Miller Subject: Atwood Drive Bob, I looked over the Atwood Drive permit application. We need some additional paperwork and information.The owner did not sign the permit application.We need the owner's approval for the project and authorization for you to act as his agent.You also did not submit:a construction control affidavit for the whole project. I also have not received a soils report for the project. Under-slab and foundation insulation is shown on the plans. Northampton has adopted the "stretch" energy code and that insulation will be a part of the building envelope.You should be certain that it will meet the energy conservation performance standards of the code. As you have not yet provided a complete set of plans and code review for the project,you will be proceeding at your own risk, per section 107.3.3 of the Mass Building Code: 107.3.3 Phased approval.The building official is authorized to issue a permit for the construction of foundations or any other part of a building or structure before the construction documents for the whole building or structure have been submitted, provided that adequate information and detailed statements have been filed complying with pertinent requirements of this code.The holder of such permit for the foundation or other parts of a building or structure shall proceed at the holder's own risk with the building operation and without assurance that a permit for the entire structure will be granted. Once you provide owner's authorization for the project, I will issue the foundation permit with the understanding that Kevin Burlingame is responsible for the foundation work. However, having no information beyond the foundation plans, I cannot determine if the proposed building can be built on that foundation. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg 212 Main Street Northampton, MA 01060 (413) 587-1240 1 ICIPAL WATER AVAILABILITY APPLICATION IZZ! North ampton Water Department 237 Prospect St. Northampton, MA 01060 587-1097 blic Works Trench Permit shall be required prior to any construction or connection activity associated with this application. Location: I Atwood Drive, Northampton/Atwood Drive Office Building Inquiry Made By: R.P. Masiello, Inc 508-869-6502 Bob Egan Date of Inquiry: 8/22/11 Number of Type of Single Family Type of Private;f Units: Unit(s): Accessory Apart. Ownership: Condo Multi-family Rental lAnalicant to fill ort the above) Municipal Water Main Existing service to in Yes: • No: site? Yes: X No Front of Location? cc( Size of Water Main: Material: Ci Age: Approximate Static Street /�j Q Flow Test Conducted: Yes: No: Pressure: ! If done attach results (( Size of Service Connection Suggested Meter Size: _ (A Comments: The Water Department cannot guarantee adequate water pressure during peak demand times at elevations above 320 feet. n,, eAC4 (99- 1 p lazwe AA.§5 t 2 . • A corresfInding water entrance fee shall be paid prior to making any connection to the municipal water system. • Arrangements of such installation shall he made with the Northampton Water Department with a minimum of 5 working days notification. • All work shall conform to Northampton Water Department specifications. David W. Sparks, Superintendent of Water Water Entry$;,0 Meter$/1h Radio$ f610 cc: Ned Huntley,Director cc: Louis Hasbrouck, Building Commissioner Note: If this availability is for a new construction, it must be hand delivered to the Buildinz Inspector. Clvt__A n,,. 3 f,. `..„.,r >` ";'s { a s _. .. a MUNICIPAL SEWER/AVAILABILITY APPLICATION E Northampton Streets Department 125 Locust Street OCT , Northampton,57-15MOA 01060 2 2011 e artme t o Public Works Trench Permit and Sewer Entry Permit shall be required , N ny onstruction or connection activity associated with this application. o1 oso Location: 1 A �-�1�� + � + � f, lice Building Inquiry Made By: Bob Egan Date of Inquiry: Reason for Building Request: Municipal Sewer Main in Front of Location: Yes _ No Municipal Storm Drain Available: 5 '/2 deep Yes No Size of Sewer Main: � Material: IL - Age: Depth of Sewer Main: Size of Service Connection: �liIkIE ooly,Ue��j 111E / N�6 /Y1 A�fbL� . Type of Service Connection: Tie-in to Sanitary Main _ Tie-in to Sanitary Stub Comments: Note: If this availibility is for new construction this form must be hand delivered to Building Inspector. A corresponding"sewer entrance fee"shall be paid prior to making any connection to the municipal sewer system.Arrangements of such installation shall be made with the Northampton Streets Department with a minimum of 5 working days notification. All work shall conform to Northampton Streets Department specifications. John Hall Sewer Department cc: Ned Huntley, Director DPW Louis Hasbrouck, Building Commissioner CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 11-683 DATE: 09/30/11 PROJECT TITLE: Building A, Atwood Drive, Northampton, MA PROJECT LOCATION: Buildinq A, Atwood Drive, Northampton, MA NAME OF BUILDING: Building A, Atwood Drive NATURE OF PROJECT: Renovation IN ACCORDANCE WITH SECTION 107.6 OF THE MASSACHUSETTS STATE BUILDING CODE, I, Gregory J. O'Connor REGISTRATION NO. 7914 BEING A REGISTERED ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS,AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT X ARCHITECTURAL STRUCTURAL MECHANICAL FIRE PROTECTION ELECTRICAL OTHER (SPECIFY) PLUMBING FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE PROVISIONS OF THE. MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERNG PRACTICES, AND ALL APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL_ PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 780 CMR 107.6, 8th EDITION OF THE MASSACHUSETTS STATE BUILDING CODE. SEAL et.GpED AHC�� cn r d `o No.7914 f ♦ -i, WORCESTER A MASS. ZJ I UR < l►. TH OF MPS�� On this 3f51v"- day of 20 k before me, the undersigned notary public, personally appeared Gregory J. O'Connor, proved to me through satisfactory evidence of identification, which was personal knowledge of identity, to be the person whose name is signed on the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief. ---------- Notary Public My Commission expires August 18, 2017 r r • Planning - Decision City of Northampton Hearing No.: PLN-2011-0015 Date: March 1G, 2011 Katharine G.Baker votes to Grant Stephen Gilson votes to Grant Mark Sullivan votes to Grant Francis Johnson votes to Grant MOTION MADE BY SECONDED BY. VOT=COUNT DECISION. Francis Johnson Katharine G. Baker 7 Approved with Conditions MINUTES OF MEETING Available in the Office of Planning&Development. 1, Carolyn Misch,as agent to the Planning Board, certify that this is a true and accurate decision made by the Planning Board and certify that a copy of this and all plans have been filed with the Board and the City Clerk on the date shown above. I certify that a copy of this decision has been mailed to the Owner and Applicant. Notice of Appeal An appeal from the decision of the Planning Board may be made by any person aggrieved pursuant to MGL Chapt.40A, Section f7 as amended within twenty(20)days after the date of the filing of the notice of the decision with the City Clerk. The date is listed above. Such appeal may be made to the Hampshire Superior Court with a certified copy of the appeal sent to the City Clerk of the City of Northampton. GeoTMSCR,2011 Des Lauriers Municipal Solutions;Inc. Planning - Decision City of Northampton Hearing No.: PLN-2011-0015 Date: March 16, 2011 IO.Shower stalls shall be located in each building for women and men 11.Covered bicycle storage racks shall be provided to accommodate 12 bikes In front of each building. 12.A covered bus shelter shall be installed at the proposed location shown on the plans, unless otherwise suggested by PVTA in writing. FINDINGS The Planning Board granted the special permit for 85,000+-sf of medical office space within two buildings based on the information and plans submitted with the application with stormwater assessment including: 1.Northwood Development Atwood Drive Permitting Plans by Tighe&Bond Consulting Engineers Revision date February 2011 plan sheets 1-12. 2.Landscape Plan Northwood Development by K.D.I.Landscape Architects Dated July 30, 2010. 3.Photoshop Renderings of buildings 4.Traffic impact Study dated June, S, 2010 by Fuss& O'Neill,lnc. 5.Letter regarding Traffic impacts dated Sept 29, 2010 from Fuss&O'Neill,Inc to MassDOT district highway Director. 6.Follow up correspondence from Tighe&Bond dated February 4,2011 to Northampton Planning Board. The Board made the following findings for its decision: (1) The requested use protects adjoining premises against seriously detrimental uses. The site is located at the 1-91 interchange and the commercial uses are compatible with the abutting hotel;The use is located on a former gas station site.and (2) The requested use will promote the convenience and safety of vehicular and pedestrian movement within the site and on adjacent streets,minimize traffic impacts on the streets and roads in the area.If applicable, this shall include considering the location of driveway openings in relation to traffic and adjacent streets, access by emergency vehicles, the arrangement of parking and loading spaces, and provisions for persons with disabilities;Several curb cuts have been closed and the total number of curb cuts minimized. Pedestrian flows have been designated with colorized material changes across Atwood,and striping within the parking lot.A designated sidewalk from a bus shelter connects to the buildings and (3) The requested use will promote a harmonious relationship of structures and open spaces to the natural landscape, existing buildings and other community assets in the area;and (4) The requested use will not overload,and will mitigate adverse impacts on,the City's resources including the effect on the City's water supply and distribution system,sanitary and storm sewage collection and treatment systems, fire protection,streets and schools;A stormwater permit has been issuedand (5) The requested use meets any special regulations set forth in this chapter including trip reduction by providing covered bike storage, common shower facilities and covered bus shelter. Site PLAN: Compliance with the following technical performance standards: (1) Curb cuts onto streets shall be minimized.Access to businesses shall use common driveways,existing side streets,or loop service roads shared by adjacent lots when possible.More than one curb cut shall be permitted only when necessary to minimize traffic and safety impacts. (2) Pedestrian,bicycle and vehicular traffic movement on site must be separated, to the extent possible,and sidewalks must be provided between businesses within a development. ;and (6) The requested use bears a positive relationship to the public convenience or welfare. The use will not unduly impair the integrity of character of the district or adjoining zones,nor be detrimental to the health,morals, or general welfare. The use shall be in harmony with the general purpose and intent of the ordinance;and (7)If applicable, the requested use will promote City planning objectives to the extent possible and will not adversely effect those objectives,as defined in City master or study plans adopted under MGL c.41,§81C and 81D. The reuse of this site for two story medical office space provides potential employment opportunity and services for Northampton residents COULD NOT DEROGATE BECAUSE: FILING DEADLINE. MAILING DATE HEARING CONTINUED DA E. DECISION DRAFT By APPEAL DATE. 2/17/2011 31312011 312412011 REFERRALS IN DATE- HEARING DEADLINE DATE HEARING CLOSE DA It FINAL SIGNING BY APPEAL DEADLINE: 1212412011 1/21/2011 311012011 312412011 415/2011 FIRST ADVERTISING DATE: HEARING DATE VOTING DATE DECISION DATE' i 3/10,12011 3/10,1201, 3,116,12011 SECOND ADVERTISING DATE: HEARING TIME VOTING DEADLWE. DECISION DEADLINE. 8:15 PM 61812011 6ISJ2011 MEMBERS PRESENT VOTE Andrew Weir votes to Grant Debin Bruce votes to Grant Marilyn Richards votes to Grant GeOTtJISv 2011 Des Lauriers Municipal Solutions,Inc. Planning - Decision City of Northampton Hearing No.: PLN-2011-0015 Date: March 16, 2011 APPLICATION TYPE: SUBMISSION LATE PB Special Permit with Major Site Pla 11/17/2010 Applicant's Name: Owner's Name: NAME NAME Atwood Partners Atwood Drive LLC ,ADDRESS ADDRESS One Atwood Drive 196 North Pleasant St, #16 TOWN STATE ZI°CODE TOWN. STATE. ZIP CODE NORTHAMPTON MA 01060 NORTHAMPTON MA 01002 PHONE NO_ FAX NO.. PHONE NO.. FAX NO.. EMAIL ADDRESS: EMAIL ADDRESS Site Information: Surveyor's Name: STREET NO SITE 20NING. COMPANY NAME. 11 ATWOOD DR GB(100)11WP TOWN: ACTION TAKEN ADDRESS NORTHAMPTON MA 01060 Approved With Conditions MAP: BLOCK. LOT MAP DATE: SECTION OF BYLAW 39 059 001 Chpt.350-10.1:Special Permit TOWN: STATE: ZIP CODE. Book. Page: 1517 103 PHONE ND.. FAX NO.. EMAI_ADDRESS: NATURE OF PROPOSED WORK: Construct two mixed office/medical buildings of 85,000+-square feet with associated site development.Project includes map ids:39-60, 61, 62, 63,46-14 HARDSHIP CONDITION OF APPROVAL 1) 1. Prior to issuance of a building permit, revised plans incorporating conditions herein shall be submitted to the Office of Planning and Development and Department of Public Works for final review to ensure conditions have been addressed. 2.The applicant shall submit construction drawings to Department of Public Works prior to commencement of work. 3.Clear pedestrian paths shall be delineated on the plans and constructed within the parking lot as follows: a.Handicap parking spaces shall be striped in each row leading from each of the buildings'entrances across the parking lot to the southern parking lot boundary. These handicap spaces will serve both function for parking and pedestrian safe zone. b.Fire lanes shall be extended from the building edge across the main drive aisles to serve as pedestrian crossing. 4.Colorized stamped concrete shall be used in the crosswalk across Atwood Drive. 5.All fighting fixtures must meet the zoning ordinance with full cut offs and lenses that are flush with the fixture head. The Board specifically allowed a lumen level of .2% above 90 degree plane. 6.Detail for lighting fixture should be replaced with correct fixture or eliminated from final plans. (model#correct) 7.Prior to issuance of the first certificate of occupancy the applicant must submit a fighting plan that is stamped by an engineer showing the light levels are consistent with those approved. E.A split rail or equivalent fence barrier shall be installed along the edges of pavement that abut the infiltration trenches that border the parking lot. The fence sections shall be installed in phases with the installation of the infiltration swales. 9.The 6-inch water shutoff valves at the property line shall been the grass area beyond the edge of the sidewalk GeoTMSC 2011 Des Lauriers Municipal Solutions, Inc. -----------------a Official Receipt for Recording in: Hampshire County Registry of Deeds 33 king St. Northampton, Massachusetts 01060 Issued To: ATWOOD PARTNERS 1 ATWOOD DR 413 789 3720 Recording Fees *----------------------------------------------* Document Recording Description Number Book/Page Amount --------------------------------- ----- DECIS 00020987 10684 51 $75.00 ATWOOD PARTNERS $75.00 Collected Amounts ----------------------------------------------* Payment Type Amount ---------------------------------------------- Check 1216 $75.00 $75.00 Total Received $75.00 Less Total Recordings: $75,00 Change Due $.00 Thank You PATRICIA A. PLAZA - Register of Deeds By: Debbie L Receipt# Date Time 0241503 10/13/2011 11:10a Reprinted By: Debbie L Reprinted On: 10/13/2011 11:13a File#MP-2011-0048 (1 APPLICANT/CONTACT PERSON ATWOOD DRIVE LLC ADDRESS/PHONE 23 ATWOOD DR (413)586-1211 PROPERTY LOCATION ATWOOD DR ° MAP 39 PARCEL 060 001 ZONE GB(100)//WP .l 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: ZPA-MEDICAL&OFFICE SPACE New Construction Non Structural interior renovations Addition to Existin¢ - Accessory Structure - Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 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 the Office of Planning&Development for more information. CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 11-683 DATE: 10/17/2011 PROJECT TITLE: Buildina A Atwood Drive Northampton MA PROJECT LOCATION: Buildina A Atwood Drive Northampton MA NAME OF BUILDING: Buildina A Atwood Drive NATURE OF PROJECT: New Medical Office Building Shell IN ACCORDANCE WITH SECTION 107.6 OF THE MASSACHUSETTS STATE BUILDING CODE, I, Gregory J O'Connor REGISTRATION NO. 7914 BEING A REGISTERED ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS,AND SPECIFICATIONS CONCERNING: X ENTIRE PROJECT X ARCHITECTURAL STRUCTURAL MECHANICAL FIRE PROTECTION ELECTRICAL OTHER(SPECIFY)PLUMBING FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEDGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERNG PRACTICES, AND ALL APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 780 CMR 107.6, eh EDITION OF THE MASSACHUSETTS STATE BUILDING CODE. SEAL � RP cn 1 �\ t4 r, No.7914 V40RCF_.STER ��A TvIA.SS. il�17— r�P On this day of 20± before me, the undersigned notary public, personally appeared Gregory J. O'Connor, proved to me through satisfactory evidence of identification, which was personal knowledge of identity, to be the person whose name is signed on the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief. Notary Public My Commission expires August 1 , 21017 ATWOOD DR BP-2012-0335 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block: 39-060 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:FOUNDATION BUILDING PERMIT Permit# BP-2012-0335 Project# JS-2011-000599 Est.Cost: $100000.00 Fee:$2600.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: R P MASIELLO 43970 Lot Size(sa.ft.): 194756.76 Owner: ATWOOD DRIVE LLC Zoning: GB(lOOL//WP Applicant: R P MASIELLO AT. ATWOOD DR Applicant Address: Phone: Insurance: 38 MAIN ST 508 869-6501 WC BOYLSTONMA01505 ISSUED ON:1012412011 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 13,000 SQ FT FOUNDATION FOR MEDICAL/OFFICE (BLDG 1) 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 10/24/20110:00:00 $2600.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2012-0335 APPLICANT/CONTACT PERSON R P MASIELLO ADDRESS/PHONE 38 MAIN ST BOYLSTON (508)869-6501 PROPERTY LOCATION ATWOOD DR MAP 39 PARCEL 060 001 ZONE GB(100)//WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out n n Fee Paid -` Typeof Construction: CONSTRUCT 13,000 SQ FT FOUNDATION FOR MEDICAL/OFFICE BLDG w New Construction Non Structural interior renovations Addition to Existiniz Accessory Structure Building Plans Included• Owner/Statement or License 43970 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I FO ATION 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 to ?� I Signa a�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. 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