32A-143 (10) pages
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MA REG #132824 MARTIN CUSTOM MASONRY CO- LICENSED
103 SHERIDAN STREET REGISTERED
(413 )331 -0043F CHICOPEE, MA 01020-2725 INSURED
email:Dmartinmason@amail.com
PROPOStit UBMFFFED To: J06 NAME lOBt
Rad Nutting Flo Mill 160012
ADDRESS JOB LOCATION
1 ,(V-6 4 36 Main St. Florence, MA01060
DATE DATE OF PLANS
01 /19/16
PHONE I ARCHITECT
(413 )320-4859 1 1
SMOKESTACK/CHIMNEY ALTERATIONS
IVe hereby submit specifications and estimates to,,:
-Obtain necessary Demolition Permit
-Erect scaffolding
-Demolish existing brick chimnev/smoke
stack by hand using chipping hammers. . etc.
down to predetermined height (last above
cooing on naranit roof ) between 12-14 '
-Erect wood forms for new concrete can
on too of remaining chimney
Install flashing & pour. & finish new
concrete can (includes 8ga wwf)
-Strip forms . remove scaffolding. general
59@
cleanup
to be maje-as fol!ows: '
the balance due uDon complet#)n1�1_1_17__
o-cie,;a-n,-t'jT abs e sp-.Imaa;73invaivEll E!M. Ms U 1
----------------
es�,rn,:c
COMPLETION: 14
MARTIN CUSTOM MASONRY CO.
Veteran Owned Small Business
Patrick J.Martin
Commissioner Hasbrouck Phone: (413)592-3595•Fax: (413)592-3508 February 3, 2016
Mass Reg#132824
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the partial
chimney removal at 36 main Street in Florence 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"
Respectfully,
/V-1111(�
Patrick Martin
Martin Custom Masonry
130 Sheridan Street
Chicopee, MA 01020
103 Sheridan Street • Chicopee, Massachusetts 01020
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
-''
k - 600 Washington Street
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): '4�'�j�G'G^'
Address:
City/State/Zip: Wv"C-�- r l�// A L" Pkione #: qq zS u tf q/
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New constru .on
eoyees (full and/or part-time).* have hired the sub-contractors
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Re eling
ship and have no employees These sub-contractors have g, emolition
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.❑ Electrical repairs or additions
officers have exercised their 11. 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 name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
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 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 c py of this statement may be forwarded to the Office of
Investigations of the DIA for ' ce coverage verificatio
I do.he y certify er the pains and pe t s f H t �zatthenformation provided above is ti a and correct.
Si nature: Date:
Phone#: t�
Of use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License# i
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#:
i
• R
Version 1.7 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 Q
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, - ---- - - --- -- as Owner of the subject property
hereby authorize'_ __ _. _. ____ _ ._to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Signed under the pains.and penalties of perjury. ..._.___.. .......
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ._, __ _ _ __.._
Number
��-L C.� � I�'►j�t�c�f/�/ ���e7
Address , % c / A Ut Expiration Date
nature L%L�►/" /�T lephone
SECTION WORKERS'C MPENSATION 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 bui ' g permit.
Signed Affidavit Attached Yes No 0
Version 1.7 Commercial Budding 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):
Registration Number
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 Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
......_
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
I
I
`"wwwwww�m�ww�wu.ww�w�� _.
Versionl.7 Commercial Building Permit May 15,2000
7--j8. 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/Findiner been issued for/on the site?
NO 0 DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page; and Document#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
....................................._.......................
Needs to be obtained Obtained , Date Issued
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 intende11 d for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excava 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 Buil g❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other rt
Brief Description 'Enter a brief description here. , `y
Of Proposed Work:: C,� - 1 00 !Z '��t t3 J f %� VVIa —5
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 [] A-3 1:11A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business 2A II ❑
E Educational ❑ 2B 1 ❑
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 ❑ 56 ❑
U Utility ❑ Specify: .
M Mixed Use ❑ Specify:
S Special Use ❑ Specify.
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: 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)
1st
2nd 2nd _. .
_.._ 3`d
3a .
th
.4
...
Total Area(sf) Total Proposed New Construction,(§f}_,
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[3 Municipal ❑ On site disposal system E]
f
i
{
Versionl.7 Commercial Building Pen-nit May 15,2000
ERE
, Department use only
1 7
_ � Ci of Northampton Status of Permit:B lding Department Curb Cut/Driveway Permit016 12 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
oi" o hampton, MA 01060 Two Sets of Structural Plans
N "413- 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/ilAl`N �� Map Lot 143 Unit
i Zone Overlay District
___ _... ......._...__. Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Ut�7Af v
Name(Print) Current Mailing Address:
Signature Telephone
mELo r �dr►7
2.2 Authorized Agent: � (Je'��� /✓�,. Salt1_. .
Name(Print) Current Mailing Address
, /�
Telephone
Signature p S Z `7
SECTION 3-ESTIMATED CONST UCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building (a) Building Permit Fee
�i
2. Electrical (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
312 1
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0976
APPLICANT/CONTACT PERSON PATRICK J MARTIN
ADDRESS/PHONE 103 SHERIDAN ST CHICOPEE01020(413)250-4641
PROPERTY LOCATION 36 MAIN ST-FLORENCE
MAP 32A PARCEL 143 001 ZONE C13
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Tyl2eof Construction: DEMOLISH 12-14 FT OF CHIMNEY,CAP W/CONCRETE
New Construction
Non Structural interior renovations
— Addition to Existing
— Accesso!y Structure
Building-Plans Included:
Owner/Statement or License 77732
3 sets of Plans/Plot Plan
TH EOLL90.AING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF
(
R 17ION PRESENTED:
7;9proved-_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
Jy_/
Sig Swttr'reof uildirrl'Offlirial 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.
36 MAIN ST-FLORENCE BP-2016-0976
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mqp:.Block: 32A- 143 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-0976
Project 9 JS-2016-001659
Est. Cost: $2500.00
Fee: S 100.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: PATRICK J MARTIN 77732
Lot Size(sq.ft,): Owner: NUTTING RADLEY
Zoning
CB Applicant: PATRICK J MARTIN
AT. 36 MAIN ST - FLORENCE
Applicant Address: Phone: Insurance:
103 SHERIDAN ST (413) 250-4641
CHICOPEEMA01020 ISSUED ON.21512016 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH 12-14 FT OF CHIMNEY, CAP
W/CONCRETE
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 2/5/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner