23D-107 (6) 548 ELM ST-CALVIN COOLIDGE NURSING HOME BP-2016-1415
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 23D- 107 CITY OF NORTHAMPTON
Lot -001
Permit: Building
Category: FIRE BUILDING PERMIT
Permit$i BP-2016-1415
Project# JS-2016-002437
Est. Cost:$105000.00
Fee: $735.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group WKB CARPENTRY INC 96193
Lot Size(sq. ft.): 53143.20 Owner: 548 ELM STREET LLC C/O 548 ELM ST OPERATING CO RE TAX DEPT
Zoning: URB(100)/WP(I)/ Applicant: WKB CARPENTRY INC
AT: 548 ELM ST -CALVIN COOLIDGE NURSING HOME
Applicant Address: Phone: Insurance:
91 PINEVALE ST (413) 525-2914
INDIAN ORCHARDMA01151 ISSUED ON:6/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:EMERGENCY SERVICE & REPAIRS DUE TO
FIRE AND WATER DAMAGE - 24,538 Sq ft
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: O_ 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: FeeTvpe:
Date Paid: Amount:
Building 6/1/2016 0:00:00 5735.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
Versionl,?Commercial Haildin Permit May 15,2000
Department use only
City of Northampton Statue of Permit:
Butting Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 (Two Seta of Structural Plans
phone 413-587-1240 Fax 413-587-1272 'PlottSite Flans
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 i-SITE INFORMATION
1.1 Property Address: This section to be completed by office
54c _ ,.. . 5 re N. I Map Lot Unit
kr. 171.12171 (';(CYC Zone Overlay District
Alm SI.District Ca District
SECTION 2-PROPERTY OWNERSHIPIAUTHORLZED AGENT
2.1 Owner of Record
Name tenet) Cucent Mailing Address: Ci it r
Signature Telephoned
2.2 Authg[LLed Agent
("IAA; '.x ...Lt. ._.-‘ L I^tt,v t ) ;L;v'
Neve Avert Current Maine Address:
. 'Hl . ,a7
signature Telephone
SECTION 4-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost;Dollars)to be Official Use Only
completed by per 1appleant
1. Building 'y 51)-c
�� J71?)2 ��� rz z _ _o d00 (a)Building Permit Fee
irf t�9
2. Eledricei —7 A. {b}Estimated Total Cost of
S(�r IiCTC� 'j �}c7�Q00 Constnrclion from s
3. Plumbing — �.f Fir Building Permit Feeft
000 Finksµ c� /7 , -735, v0
4. Mechanical(HVAC}
5.Fire Pt-Meatier --
6. Total=(1 +2+3+4 it 5) (US-Ioad,Q 0 Check Number
This Section For Official Use Only
Buildng Permit Number Date
sled
Signature:
Dui-ding Cam'niseener/Tnspector of eukdngs Date
t'd 8688106E1b1 Ai uedieC emsA dZl:L091 LE Re VV
Version 1.7 Commercial Building Permit May 15,2000
B. NORTHAMPTON ZONING I
Existing Proposed F Required by Zoning
This column io betilled in by
eu:ld ng D panment
Lot Size
Frontage
Setbacks Front
Side L R: L: R' /
Rear )
Building Height �\
Bldg. Square Footage Ye '\
Opeu Space Footage
(Lor arc,.nines bide peseed
parkin¢)
k of Parking Spaces
F:LI:
puirme de tucaton)
A. Has a Special Permit/Variance/Fin. ng ever been t§sued for/on the site?
NO O DONT KNOW 0 Y\S
IF YES, date issued:
IF YES: Was the permit recon-. at the Registry of Deeds
NO O D• T KNOW O Y O
IF YES: enter Boo Page and/or Document#
B. Does the site contain . brook, body of water or wetlands? N O DONT KNOW O YES O
IF YES, has a perthit been or need to be obtained from the C nservaton Commission?
Needs to be obtained O Obtained Q . Date Issued:
C. Do any signs exist on the property? YES O NO Q
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended f r the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavat on,o f gig)ever 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES.then a Northamplon Storm Water Management Permit from the DPW is required.
£'d 26881OCR lbl Alued)ep 8MM dd lZO 91 L£ARA
Version IS Commercial Building Permit May15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs 0 Demolition Repairs 0 Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use Other 0
Brief Description Eater a brief description here, £>ctefe -7 -P(IIcr <..:^.a r`F 1-1E._4,.,-c
Of Proposed Work: I ,
.r,,,,:L.,SJ. 4:::,C Y ,,,c;,,.;_;4: tit_r^ e r.-(r..a2
SECTIONS-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A--" [] A-2 ❑ A-3 ❑ 1P, {
0
A-4 0 A-5 0 +.B 0
B Business 0 2A • 0
E Educational 0 28 0
F Factory 0 F-1 ❑ F-2 ❑ 2C 0
HHkill Hazard ❑ 3A ❑
I Institutional 0 -1 0 I.2 w I-3 ❑ 38i ❑
M Mercamae 0 4 ❑
R Residential 0 R-1 ❑ R-2 ❑ R-3 ❑ 5A 0
S Storage ❑ s-1 0 5-2 ❑ 58 0
U Utility ❑ Specify:
M Mixed Use ❑ Specify.
S Special Use ❑ Specify.
OOI LETE THIS SECTION iP EXISTING BUILDING UNDERGOING RENOVATIONS,ADJF TIONS AND/OR CHANGE Se USE
Existing use Group: Proposed Use Grown:
Existing Hazard Index 780 CMR 30): . Proposed Hazard Index 780 CMR'34)
SECTION G BUILDING HEIGHT AND AREA .
BJILDING AREA EXISTING PROPOSED NEW CONS UCTION OFFICE USE ONLY
Floor Area per Floor(st)
254
4 4'
Tota'.Area(st) Total Proposed New Construction(s,
Total Height(ft)
Total -le ght ft
7.Water Supply(M.GL.c.40,5 54) 7,1 Flood Zone Information: i 7.3 Sewage Disposal System:
Public ■ Private 0 i Zone Outside Flood Zane❑ Municipal ❑ On site dispose.system❑
Z,.d 96E9WEE lbI LdiuedieQB)1M dZCL09l l£LeN
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 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
__. __ _ _ _. _ _. _--,as Owner of the subject property
S �N'LN1
hereby authorze _. _. _.__ ._..-. __.__. _ __ _.._ . .. . __ .'to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, L,r.e__._ aJ� as Owner,'Authorzed
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 paras and penalties of perjury._.
13_rufe /Q rau/zL
n;Name /
rrClnr CE'/ii l/70aI fes` Wanly.c
Signature of Owner/Agent
Dete
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder: L2Lt'__—le�r�u
License Number
It SLv /rig S• ifr ___ CS0167 _
Adores ,_� Expiration Date
' i 3 39[ 88o�j_
uce ��
Signature Telephone
SECTION 13 -WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit. F
Signed Affidavit Attached Yes 1NJ No 0
Versions.7 Commercial Building Per„,it May 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) _
Ras at of(on Number
Signature Telephone
9,2 Registered Professional Engineer(s):
•
Name Area of Responsibility
Address Registration Number
I Signature Telephone Expiration Date
Name Area of Responsibility
Add"ess Se,g stralion Number
Signature Telephone ExpirationDate
Name Area of Respons bility
Adcress Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registradon Number
Signature Telephone Expiration Date
9,3 General Contractor(trJ.1
j,O p „. (" -- __ _-.. Not ApP!icade ❑
Company Name
_ E ...(p fr
Responsible In CTharge of Construction
I nk,4F'•-
Addressaf
Signature Telephone
ie ccansrorr „/ f?../1 a ce Au e.;:
�°'te=.� Office of Consumer A fairs d Business Kegulation
ts41,
10 Park Plaza Suite 5170
•
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165445
Type: Supplement Card
WKB CARPENTRY INC. Expiration 2117/2018
BRUCE TETRAUL7
91 PINEVALE ST. • — -
INDIAN ORCHARD, MA 01151
Update Address and return card.Mark reason for change.
Scat a aovrr L Address C Renewal 7 Employment r Lost Card
rn.,r14'r,.l.nUd
office of Consumer Affelrs&Business Regnlofion License or registration valid for individul use only
w in oME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
-�Rn isitalion: Office of Consumer Affairs and Business Regulation
iYsq 9 .155448. Type: ISPark Plaza-Suite 5179
Expiration: 211712012 Sipperneat Ca:c Boston,MA 02116
WKS CARPENTRY INC;
BRUCE - 4AJt.T i1I
91 PINEVALE ST- ,\ v;...._.—_ 4 j�.bfer
MAN ORCHARD,MA 01151 Undcrsvtretary Not valid without signature
•
igMassachusetts,
Department of Puoi!a Safe:
�
Board of Building Regulalians and Standards
Construction Saperrifer
License:CS{0G6193
BRUCE L TETRAFYLT --
115NOR'L7IBRANCH A%
SPRINGELELU MA 01
Z
mr.Y
Exration
oit*missl r 12(1912016
Cd 8699 LO££IbL Ai1uedreo BNM ddFLO9l L£AeIN
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 5-LA Fli i^,2 5r _ fit-y1
The debris will be transported by: _oft Upo s4c-Q-'
The debris will be received by: l/edie j Qr
Building permit number
Name of Permit Applicant tA.)V D u& �t-y
J
,''. ;:./) r�� '2 :f"n, �����'- r91vi��'! ,.- ��.L J ' d
Date Signature of Permit Applicant
9'd B68810££117l Aaluedie0 BNM dZ :L091 l£'C N
A✓oe CERTIFICATE OF LIABILITY INSURANCE 511/ mss'
PRODUCER (413)53E-3311 FAX: (413)536-0900 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Brochss xaaurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
725 Grattan Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 58
Chicopee MA 01021 INSURERS AFFORDINGCOVERAGE INAIC0
._.— _.._.._. _— . ..—
INSURER IYEw.eremNOrthland Insurance
WXB Carpentry Inc INEuPERB.Commerce insurance Company ' LOLL
.._ _. _._
91 Piaevala sC 'INNPEaG AIM Mutual Insurance Co ,Gms
•INEUPER P.
SPri.um9f field MA 01151 'PORTER E. _—.. —_.
COVERAGES
THE SME WGTERO LISTED BELOW PAVE BEEN ISSUEDTOOTHINSURED MENTOABOVE FOR THE POLICY PER100 INDICATED.NOTINITHSTANDING
ANY REQUIREMENT,
EQUI NM TERM CONDITION OF ANY CONTRACT OR OTHER DOCUMENT T RESPECT TO ERHISTHIS C MAYBE ISSUED CR
OL PESAI REEEURAN;EAFFORDED HAVBEEN EDESCRIBED HEREIN IS3L'BJECTOALL THE.TERMS,EXCLUSIONS AND CgND 6NS OMJGH
POLICIES.AGGREGATE IIMIi56HOVINMAY HAVE BEEN REDUCED EN PAID
CUMS
R
R! i{i _.__..._. —. a _. ' R
'. �' . - !�9tNw(£ e %TwNwaER PCUCYEEi i RT :..YELP ffi�T'ONTV uLHtt
GENERAL LAMM( i E.C.:OCCJEcenCE 5 1,00E1.000
tuAO Arc n "er i 50000
X CO VETO E c At I.an-i
A 1 CLANS R XI Y_CORGS 259370 14/22/2016 i 4/22/2017 ME0EX.(VT vb p NNE) S S000
I I PERSONAL A ,URE I. 1 000,000
_ _ Eaa R cA-N 2,Boo,oeo
CPLT'uf REGAL M APPLES EBB ( BECOMES COMF.EP ACC 2,000,+ODD.
I IXC PE.EY. n • I:cc ( i
`GTOND®ILEL!A LILY
CiOMMED SINGLE:MT
I— AM WFO _"corT: G
R I_ ALL OVP.1.uTc1 p,10 so }5/16/2016 6116/2019 BtIALV BRAE ,s 20,000
: X scEICIALPALTO (Rummy
£1 MISS 1 II IIPCO M RT
la Jc Grv1EDALTOS i
t %°PEPZ'DAMMCE 1 40.000
; 100,Doe
I P
GARAGE:AR N AUTO0YjY•EF TOTIDEIT S
I N imp •VIE I w r ...
ACP/ONLYI
=DC S
%C SSIUVSRE4LaUABIUTY I I yAc ODOMBENC. _ S
10008 ni Cm....PDE I A_GREC C $
REMOTION E
LcO nNSATON
! „
$
NDESPLOYERAtAILW r _111Vll_ PI
ANT OFNI OR M EtECLTYE� I
100,0E0
wcm.RMryEBOExcu¢DAC400-.031111,2016A 01/03/2016 101/03/2017 EL d E P ENNECYCdL 100 000
WielleWEINSERzw I
L- EL EbC SE PCLIC(M _I S _,$40,000
CMPR I
I
DESCRIPTIONOF DEPTET1GNS:LOa0.TONS+VEWCLES'EinLVSIepDOY OfDOMEYF}nPROV9aNS
andr
earpeesxy residential, interior, aiding and replacement vindavaws a. Killian Butler. the o.mmer is not covered by the
.(Erten EMT policy above, XeaeaeSuaetta enBloyaea ob1R
CERTIFICATE HOLDER CANCFI I ATIOEi_
529-1433 J MOUE ANY OF THEABWEDESCRIEED POLICIES B£CAECELEOBEFORETHE! EIRATION
Town of Easthampton DATE'HEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 OATS WRITTEN
50 Payson Ave MOTICETOTXECECTWCATE MtrFRNMIEOTOTHE LEFI,ROT BELPRE TODOS°MALL
Easthampton, MA 01027
IMPOSE NO OBLIGATION ON LIABILITY OF ANY HIND UPON THE INSJRER.ITS AGENTS OR
RTkGENIATIVES.
AO'MC!ZED REPRESENTATIVE
,Je£frcy Bracht/313C C3 „r�
ACORD 25(2009/01) 0158132009ACORN CORPORATION. AR rights reserved.
INSCarenwa+'. The ACORD name and logo are registered marks of ACCRD
L'd 86381Oti£LYL MUedJe3 HNM dLZ:LO9L L£�UW
- The Commonwealth of Massachusetts
'�'_ Department of industrial Accidents
',!—ft
' Office of Investigations
..'e — 1 Congress Street,Suite 100
4.17-11-t_
ta>? r Boston, MA 0211 4-2 01 7
' , 0 www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors!Electricians!Plumbers
Applicant Information Please Print Legibly
Name (Bus:ness'Omanization'Lnddidual): [JO 4.13 00L,r - f\C ' _. ______
Address: q i Thi r,etic'de_. 3trr=n'W --------------.—__._.__
City/StateJLip I_ ,'ARYL Vii"- ails( Phone#: ; _►_2 R).0 `t ": I I gcct
Areu an employer?Check the appropriate box: Type of project(required):
1.2 tJ' I am a employer with Q 4- 0 I as a general contactor and 1
— have hived the sub-contractors 6. ❑ Nieconstruction
employees (full proprietor or partner- listed on the attached sheet. 7. L Remodeling
ship and have no employees These sub-contractors have ( g. ❑Demolition
workir for ine in an capacity, employees and have workers'
g Y 2 7 1 9. ❑ Building addition
[No workers' comp.insurance comp. inscmnoc.n
regnired.J 5. Q We are a corporation and its + 10. ,eacorneal repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I 1 L Plumbing repairs or additions
myself. [No workers' cora right of exemption per MGl,
s+ P- �t :10 Roof repairs
insurance recuued.j' 152,eel(.[,and have no
employees. [No workers'
J kers' 134Ottxra -
comp.insurance required.} , J
"Ari appliouahet checks box dl must aim till out the section below showing their workers'compensationpclicy Infonnatiol.
7 homeowners who submit tris affidavit indicating they ace doing all work and Men Biz oatside contractors must submit n new affidavit,Mlcatiag anat.
:Cma<acto,s thet c iec*this box must attached an additional*cos showing Me name of the sub-com:ctors rad state whether or not Mose entities have
employees, it Ne eine-ooatractors have smpioyets,:hey nnrst provide their sun:kms'comp,policy number.
.1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. t.
Insurance Company Vvne. al. P-{U ryxp_�JG"VTSt,tt�n t^ `(-o yntrie,m -• - f
Polley d or Se;f ns. Lic.p: t`= LI. , 4 OO - 10,.72,E 7 q . 7.0[SA Expiration Date: 01 Il Qii 1 ([_
til ' N. _ t -
lobSiteaddress. . r i F_ �aVt �t 1 c'f�(,& City/Stae/Zip1''=_______ .
Attach a copy of the'workers' compensation policy declaration page(showing the policy number and expiration date)"
Failure to secure coverage as recurred under Section 25A o`MGL c. 152 can lead to fire 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 S350.00 a day against the violator. Be advised that a copy of this statement may be forwarded/o the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the ins and penalties of perjury that the information provided above is true and correct.
Sjmtarare_ f ,d ._ Dace: /4 /::
Phone 4: ` f "3 i 'Z,L) , , t_ __. __
IOfficial 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 Personr _ _ Phone x:_,
I
Muedie°8->w, dLL L09L bt/(?)31
831 8691/3109£LPL
DATE 61(i(
To City of Northampton
Building Department
Subject: Request for Waiver
I request that your department/grant a modification to waive the requirement for control construction
for the ,4e r7nr'Q'� r Dirk project at SLIir0-n Sl
in
far+k 0...co dIN because the work is of a minor nature,will not affect health,
accessibility, life and fire safer ,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, Tail/ / �j/ ,rq
SIGNATURE 71 j ,4/ ' /41,-, J'�
NAME Foxe ! &4 U/T
COMPANY or i? Gt�p f-tom
ADDRESS 9a M i40 tic?,p/4 S /-
•
CITY,STATE,ZIP .�. Q. `vll 01!/5/