38B-006 (76) �.:,�,
i
Iles
w�
c- ��o
a
k
ro
v
AL
Commissioner Hasbrouck
February 10,2016
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the
electrical shop office project room number 100E2 at 126 West Street in Northampton because the work
is of a minor nature,will not affect health,accessibility, life and fire safety,or structural requirements
and is impractical in that the cost of control construction is considerable when compared to the cost of
the proposed work.All work will be completed within the prescriptive requirements of 780 CMR.Thank
you for your consideration.
"Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
Nicholas Zayac
Zayac Construction
64 Redfern Drive
Longmeadow MA 01106
i
The COInllioliwealth o' 31assacliusetts
Department o f fndus�rial Accidents
- ^ r Office of Iizvesigations
- , 600 ffl'ashing tQ71 Street
Boston, M 02111
- www.mass.gpv/dia
Workers' Compensation Insurance Affidavit: Bgilders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print LeaibI)
Name (Business/Organization/Individual): 2�a y19c COrnS-}r64(_+1 Un �-�-C _
Address: �7L( Ae<4
City/State/Zip: nc neachVl( mP v//06 Phone#:
Are you an employer? &fieck the appropriate box: Type of project(required):
1.® I am a employer with Z- 4. ❑ I am a general contractor and I
have hired the sb-contractors 6. ❑New construction
employees (full and/or part-time).*
2.❑ 1 am a sole proprietor or partner- listed on the atta1Lhed sheet. 7• ❑ Remodeling
ship and have no employees These sub-contr*ctors have 8. ❑ Demolition
working for me in any capacity. employees and hjave workers' 9 ❑ Building addition
[No workers' comp.insurance comp. insurance t
required.]
5. ❑ We are a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exorcised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
13.7 Other
employees. [No workers'
comp. insurance xequired.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then h�e outside contractors must submit a new affidavit indicat ng such.
Contractors that check this box must attached an additional sheet showing the narr�othe sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation:insurange for my employees. Below is the policy andjob site
information.
Insurance Company Name: S%k j; Ne�U r&4(4 —
Policy#or Self-ins.Lic.#: W S31S�D�j (90� 19 Expiration Date: /7- /7
Job Site Address: Ix City/State/Zip: fake an/,��-'
Attach a copy of the workers' compensation policy declaration pae(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 52 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 p�alties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do-hereby certify under the pains and penalties of perjury that the 4nformation provided above is true and correct.
Signature:
Date: - 10—
Phone
0-Phone# Atli -SSS
Official use only. Do not write in this area,to be completed by cite or town offcciaL
City or Town: Permit' icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
- y
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes Q No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
nom/ _�_s_-' _.. . _ . .. .....
as Owner of the subject property
hereby authorize �f" —"4 sto
act on my behal 'n all matters relative to � thorized by this building permit application.
Signature of Ow Date
I, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.._
_ .. _........... _
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES /a-l
10.1 Licensed Construction Supervisor: Not Applicable ❑
/ ..... ..... _.
Name of License Holder: iCr{W..\. .....
License Number
Cs-- 4.a�1
Address Expiration Date
-71 h,�A br w, SP;-_Ft rig_ a/o$�J rl /4/lo17S' ture Telephone v �3-7 ?-34'
SECTI 3-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 No 0
f �
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(CONTAININGI MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
...._..,_ M .., Not Applicable ❑
I
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
NameArea of Responsibility
............. ............ ........
Address Registration Number
Signature Tele hone Expiration Date
..._._.
NameArea of Responsibility
Address Registration Number
Signature Tel phone Expiration Date
........ __... $ ................. ...........
Name Area of Responsibility
Address Registration Number
...... ..... ......... .......... ....... _.
Signature Telephone Expiration Date
Name Area of Responsibility
„ _.... _.
Address Registration Number
........._....G _.............. ....: ...._.......... .... ........_._....... .....___...._ _...__.. ..
Signature Tele,hone Expiration Date
9.3 General Contractor
PGt w�. .x.r� _. _ ...._:._,. _...H_,.„ .,.,_.. Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_. ........ .. _.............
Address
?i( hi b n'+l d Vv �#id fnfl `f/3 if
Signature Telephone
i
Ij
1
Versionl.7 Commercial Building Permit May 15,2000
S. 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 Ala( YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page, and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 4) DONT 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 , 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 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? YESQ NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f +
I
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN$5,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repailrs[:1 Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofirig El Change of Use El Other E] a
_ .....: .
Brief Description Enter a brief description here.
Of Proposed Work:.
p X (�j OqZe—.,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ElA-2 11A-3 ❑ 1A
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 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 F-1Specify:
........
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING ENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group. =- PP
po9ed Use Group:
Existing Hazard Index 780 CMR 34) posIed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONS RUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
I
st
1
1 Si .. ...... . . .... ......
,
2nd
2"d
I
3rd
3rdth „_ ..
4`h . .... .. ........_ ........--- ...... ...;
...__.-..........__..._.._............................._..................................
Total Area (sf) Total Proposed New.Construct�on_(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 FI'od Zone❑ Municipal ❑ On site disposal system❑
I �
I
r.. Versionl.7 Commercial Building Permit May 15,2000
- Department use only
City of Northampton Status of Permit:
FEB 1 1 2016 Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
DEPT.of uu.-o:r G i SPEG'IONs ROOM 100 WaterNVell Availability
NORTHAMPTON,MA r1060 Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
1.1 Property Address: This section to be completed by office
We Map � � Lot Unit
Zone Overlay District
_.._. ._._...._...... .. ...- .......... ........._. Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
X13 S�� � 'f12_
Signature Telephone
2.2 Authorized Agent:
12-6 N4
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3-ESTI ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building �; /) (a) Building Permit Fee
to !�
2. Electrical (b) Estimated Total Cost of
Construction from 6 _..._.
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ..
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:_J
Building Commissioner/Inspector of Buildings Date
126 WEST ST-RM 100E2 BP-2016-1007
GIS#: COMMONWEALTH OF MASSACHUSETTS
MAp.Block: 3813 -006 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-2016-1007
Project# JS-2016-001703
Est. Cost: $10000.00
Fee: $70.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: ZAYAC CONSTRUCTION LLC 074881
Lot Size(sq. ft.): 9365.40 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: SI(100)/WP(6) Applicant: ZAYAC CONSTRUCTION LLC
AT: 126 WEST ST - RM 100E2
Applicant Address: Phone: Insurance:
7914IGHMEADOW DR (413) 896-9346 WC
WEST SPRINGFIELDMA01 089 ISSUED ON.211112016 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT PARTITION OFFICE WALL
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 REVD E Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND
Certificate of Occupanc Signature:
04V
FeeType: Date Paid: Amount:
Building 2/11/2016 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner