25A-179 (21) 29 INDUSTRIAL DR BP-2017-0221
GIS=: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 179 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-2017-0221
Project# JS-2017-000378
Est.Cost: $12648.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SALOOMEY CONSTRUCTION 018780
Lot Size(sq. ft.): 240015.60 Owner: 29 INDUSTRIAL DRIVE EAST LLP C/O ACI INC
Zoning:01(100)/ Applicant: SALOOMEY CONSTRUCTION
AT: 29 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
P O BOX 1203 (413) 269-4360 Workers Compensation
W ESTF I E L DMA01086 ISSUED ON:8/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK INTERIOR BUILD OUT OF 2 NEW OFFICE
SPACE
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 8/19/2016 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEWED
1
A I9 I
pEP = 1 Vernal.1 Commercial[Wilda Permit May 13,2000
_,_ __...-J Department use only
City of Northampton Status ofPermit
Budding Department Curb CM/Driveway Permit
-
212 Main Street SewentSeptic Availability
Room 100 Water/Wed Availability
Northampton,MA 01060 Two Sets of Struaurai Plans
phone 413-587-1240 Fax 413-507.1272 Plot/Site Plans
Other Speedy
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOL1SH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 PrppetNA4dresg: This steamy to be completed by office
29 INDUSTRIAL DRIVE, EAST Map Let Una
Zone Overlay District
M./t&r deck
. - - Elm St.ONtet Ce DUMa
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
91 Orae+ofRacor4:
.29 IRl1. I % RAVE, FAST 12? 983 PAGE NSVD, &IIT*W21, Rn
Name(Print) Current Mailing Addmsa
��.,,.0//�/' 413 244 9006
5gnwe *^' ���'.d 'r" Telephone
$jAuthorised Agent
__. .. _ ..
SITER SALOOREX Ea.O. BM 1203+ fi6`Ei'.ffiDrIW 01086
Name(Penh Cowell tAaiRrg Addeaa:
STmi &7119 � - �7 - 413-531-0062
bearer f ,` ^,.>ry T
•.. 0 .. R tr. tr&
Item Esumaled Cost(Dollars)to be Official Use Only
completed by Perera applicant
I. Soil n0 #12,648.00 (a)Buidkg Permit Fee
2. Electrical 1321E (b)Estimated loosion C6)of
Constructf
3, Plumbing MtBuilding Permit Fee
4. Mechanical(HVAC) /(/
3.Fire PrMection III . .
6. Tatai (1+243+4+6) $12,648,00 Cheat Number aft,Y
This Section For Official Use Only
Sodding Permit Number Date
Issued
r, r
i
:m -. Inas �. .f Baadlega Date
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) I Existing Wall Signs ❑ Demolition 0 Repairs 0 Additions 0 Accessory Building
Exterior Alteration 0 Existing Ground Sign❑ New Signs 0 Roofing Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: INTERIOR BIKED (XMY Cr 2 NEW OFFICE SPACES, PER ATTtlRE° CRAWiNG
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-t 0 A-2 0 A3 0 to 0
A-4 ❑ A-5 ❑ 10 ❑
B Business ❑ 2A 0
E Educational 0 28 ❑
F Factory 0 F-1 0 F-2 0 - 2C 0
H High Hazard 0 3A ❑
I Institutional ❑ I-1 ❑ 1-2 0 I-3 0 3B 0
M Mercantile 0 4 ❑
R Residential 0 R-1 ❑ R-2 0 R-3 0 5A 0
5 Storage ❑ 5-1 ❑ 5-2 0 513 ❑
U Utility ❑ Specify:
Si 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 700 CMR 34):
SECTIONS BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(at)
251
253
3 3.d
411 451
Total Area(sl) Total Proposed New Construction(et)
Total Height(R)
Total Height ft
7.Water Supply(M.G.L.c,40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone Outside Flood Zane❑ Municipal 0 On site disposal system
Version).7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in be
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage .o
Open Space Footage
(Lot arca minus bldg k paved
parking)
k of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O 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 O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation, or filling)over I acre or is it part of a common plan
that will disturb over 1 acre? YES O 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 9.PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT T0789 CMR 116(CONTAINING MORE THAN 35.000 C.F.OF ENCLOSED SPACE)
R1 Registered Architect:
PEW BURDICK AftC.UTECP Not Applicable 0
Name(Registrant). 5693
5 ' oi.. en TERRACE, SPKI* IIID, MA 01105 Regtstrahan Number
AJdres •
j'/� /f', Expiration Date
I ♦ re,/ 1 ,4 ray` 413-222-9535
Signature r \\::.// Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Tetephone Expiration Date
Name Area of Responsibility
nd
Address R.y.3UattWi Number
_........ .... ......_ ��. .
Signature Telephone Expiration Date
Name Area of ResponslbRRy
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
SAI ET SON DC Not Applicable 0
Company Name.
2I1i R SATDOIlY
Responsible In Charge of Construction
P.O. 1308 1203, 6114STETELD, MA 01086
Address '
a.
^„ �CJVrt 413-269-4360
Si r � Telephone
Version!.?Commercial Building Permit May U.2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 4 No 0
SECTION 11 •OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, NARK &TAIT ,as Owner of the subject property
hereby authorize TITER SAILOMEY of SA1LXPEY OlMST UCPICN INC to
act on my behalf in all matters relative to work authorized by this building permit application.
July 26, 2016
Signature of()Ener Date
I. ZITER SAT/YIEN as Owner/Authorized
- Agent hereby declare that the statements and information on the foregoing application are true and accurate,to he best of my knowledge
and belief.
Signed under the pains and penalties of penury.
TITER SATOCHEY
Frint Name
JUIN 26,2016
Sign caner/Agent //'",/r/ Date
SECTION 12-CONSTRUCTION SERVICESt/
10.1 Licensed Construction Supervisor Not Applicable 0
Name of License Homer: ZITER SAKE ET _ 0018780
❑cense Number
F.O. 8)X 1203, WESTIELD, MA 01086 11113/17
Address / Expiration Date
• '31 0062
Si. ature Telephone
SECTION 13-WORKERS'COMPENSATION SURANCE AFFIDAVIT(M.G.L.o, 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 O
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: a2 , ( alr,iii i�
The debris will be transported by: ti ` M
The debris will be received by: C S 4
Building permit number:
Name of Permit Applicant S A tot 4M cedy Covs
Date Signature of Pe pplicant
. The Commonwealth of Massachusetts
=err— Department of Industrial Accidents
/
=UM= Office of Investigations
CM41111g
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): SALOCMEY OZR9MUCPICI9 INC
Address: P.O. BCE 1203
City/State/Zip: 49391FIELD, MA 01086 phone #: 413 269 4360
Are you an employer? Check the appropriate box: Type of project(required):
I I am a employer with 4. fl I am a general contractor and I
6. fl New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. 0 RemodelThese sub-contractors have ino
2.0 I am a sole proprietor or partner-
ship and have no employees 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
i
[No workers' comp. insurance comp. nsurance.-
required.] 5. fl We are a corporation and its 10.D Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their ILD Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] ] c. 152. §1(4),and we have no
13.0 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workerscompensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors inns(submit a new a Mt da.it 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.
lam an employer that is providing workers'compensation insurance for ny employees. Below is the polic.v and job site
information.
Insurance Company Name: MSS EMPLOYERS INSURANCE 0:149ANI
Policy 4 or Self-ins. Lie. MCC200121012009 Expiration Date:
Job Site Address: 29 ItlIETEIAI DRIVE, EAST City/State/Zip:NCIMEAMPION,MA 01060
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 $130000 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 certif.',under the pains tu 1 penalties of perjury that the information provided above is true and correct
Signaturc9( Date: JULY 26' 2016
Phone 4: 913 269 9360
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees.
Pursuant to this statute. an employee is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written."
An employer is defined as "an individual, partnership, association-corporation or other legal entity. or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152.§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and. if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or I-877-MASSAFE
Revised 7-2013 Fax #617-727-7749
www.mass.gov/dia