32C-001 (56) 150 MAIN ST-REBEKAH BROOKS BP-2017-0728
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-001 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
Permax BP-2017-0728
Project# JS-2017-001204
Est.Cost:$5215.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: MARK SMITH 104325
Lot Size(sq. ft.): 16683.48 Owner: THORNES MARKETPLACE LLC C/O HPMG
Zoning:CBIl00)/ Applicant: MARK SMITH
AT: 150 MAIN ST - REBEKAH BROOKS
Applicant Address: Phone: Insurance:
5 ANNA ST (413) 531-7342
WAREMA01082 ISSUED ON:11/30/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:SOUNDPROOF 2 - 8X8 WALLS. BUILD 8X8
WOOD CEILING
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 q 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 11/30/2016 0:00:00 $100.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0728
APPLICANT/CONTACT PERSON MARK SMITH
ADDRESS/PHONE 5 ANNA ST WARE (413)531-7342
PROPERTY LOCATION 150 MAIN ST-REBEKAH BROOKS
MAP 32C PARCEL 001 001 ZONE CB(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
CLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid `
Building Permit Filled out
Fee Paid
TvpeofConstruction: SOUNDPROOF 2-8 ' • LS.BUILD 8X8 WOOD CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 104325
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
ire i //-3d/7
Sig . rre of Bu"ding •`ficial 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.
Versionl.7 Commercial Bulletin Permit May 15,2000
nBPerbnerlts_t ?..Y h4,"
City of Northampton *tun of Pernik y;5" c, afe ..L
Building Department
212 Main Street Se t - _ ,tr
Room 100
Northampton, MA 01060 Tr -Sets
phone 413-587-1240 Fax 413-587-1272 PIotSta
oho,.
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 Properly Address: This section to be completed by office
Rebekah Brooks Map Lot Unit
150 Main Street Suite 17
Zone Overlay District
Northampton, MA 01060
- -- - - -- Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Thornes Marketplace LLC 150 Main Street Suite 6 Northampton MA 01060
Name(Print) Current Mailing Address
0rJ , ^ (413) 5829970
Signature Telephone
2.2 Authorized Anent:
Mark Smith
Name(Print) Current Mailing Address
5Ma/.w.A�t�S. (AN rM4 Cron—
Signature
ron Signature 1/1/4-1‘11461.1' Ltr� Telephone 2]- Sat-73'LZ
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $3,500.00'. (a)Building Pem tt Fee
2. Electrical - $850.00 (b)Estimated Total Cost of
Construction from(6) --.
3. Plumbing -� - $0.00. Building Permit Fee
4. Mechanical(HVAC) - _--
5. Fire Protection $865.00
6. Total=(1 +2+3+4+5) `7 SZ( S . CCD . . . Check Number 4-/a3 /re7
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings 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 ❑ Existing Wall Signs ❑ Demolition❑ Repairs)/ Additions ❑ Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: �`U mb9cooF 2. - $x0p
144 5 '0,4.uu fizz Woof cc,( H
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) ICONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A I ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business g 2A ❑
E Educational ❑ 28 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A t�.❑,
I Institutional 1-1 011-2 ❑ 1-3 ❑ 3B 1�
M Mercantile 4 0
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 1--I
S Storage ❑ S-1 ❑ S-2 ❑ 58 as
U Utility ❑ Spedfy: ••
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)
gig 1" ICXg •
-
3itl 3m
Total Area(sf) Total Proposed New Construction(sfj_-__
Total Height(ft) _ --- _ ____. .
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood ZAn4Jnfonnation: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone __- Outside Flood Zone❑ Municipal 0 On site disposal system❑
Li
Version1.7 Commercial Building Permit May IS,2000
SECTION 10.STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, J0(V -VV--c--Ge—e,"
Rt C'Ti as Owner ofthe sublea property
hereby authorize .- lt"-SU- illt-__ _______._.._— MY`Yf^1 u1 GOMChJk�ri &ie- ito
act on my behalf,in al a%=rs relati , to work authorized by this building permit application.
On ,�/__
Signature of ODate
I, 44-.S.731-_-____._.- -- -_ 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 h airs d • s f_pgripry. •
Prim Name _""`
NArk. Sum (( (701f(. �__ _
Signature of Owner/Agent ate
SECTION 12•CONSTRUCTION SERVICES
10.1 Licensed Construction�Supervisor� _ Not Applicable ❑
Name of License Holder __7TtAL.k,k im•rl _ ___._ _ �.......J �{ CS -_to-F 3Z-5" _
License Number
•
5_AnNA _ W ill.L ___oto$2— 1711i i i2l(3 [20r1 _
Address Expiration Date
lout
Signature Telephone
)
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(61)
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
y�{ m
Signed Affidavit Attached Yes �7 No 0 !
.1
s
E
I
Versionl.7 Commercial Building Permit May 15,2000
8. 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&pave] ------
parking)
#of Parking Spaces - -- """- - _ --
Fill:
•
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Pagel i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued: •
C. Do any signs exist on the property? YES 0 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 0
IF YES, describe size, type and Location:
E. WII the construction activity disturb(clearing,grading,exczn(ation,or filling)over 1 acre or is it part of a common plan •
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 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 95,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
-9Al1\!_ C5 Not Applicable C
Name(R strant)
K
Aja- Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
• i I
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 ApplicableC
Company Name:
Responsible In Charge of Constmctlon
Address
Signature Telephone
4
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: 15) MAul S{.
The debris will be transported by: INOODNACI1t5
'I ' c� t
The debris will be received by: Ti CA ' r I K.ccyu i a;
l
Building permit number:
Name of Permit Applicant MPt{C- Mi
tT
Date Signature of Permit Applicant
1
l
. \
The Commonwealth of Massachusetts
=,.,=.r.... Department of Industrial Accidents
r=.. 1l
ilUO ce of Investigations
=x/r= l: 1 Congress Street, Suite 100
=1YIEI ' Boston,MA 02114-2017
•� www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( c- Please Print Leeibly
M
Name (Business/Organzationdividual): Wel0b5Y4l,(x(Sj P44I,.Ic. �. ACD-1
Address: 5 AAJf-'A- CJI
City/State/Zip: VP.'e, NIA C 2-'Phone#: `'[(3.5-3 -7312--
„
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
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' n
P ty 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.;
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
9 1
3.❑ I am a homeowner doing all work officers have exercised their 11.p Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] ' c. 152, §I(4),and we have no
employees. [No workers' 13.0 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. 1
tcontractors that check this box must attached an additional sheet showing the name of the subcontractors 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: a%rt Co.41.P”/4
Policy#or Self-ins. Lic. #:�'rV(�,YnJ, OIL* I LO?j3- 10 Expiration Date:, IrOr `L �" [�7 atq,t _ i
lob Site Address: t 0 I`I MPJ UT• City/State/Zip: 'bpd{ 110.49 n'J 1' A- I
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 3
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 l
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 9
Investigations of the NA for insurance coverage verification.
4
Ido hereby cert' under the p�g'iiyn�t ,{
kand penalties of perjury that the information provided above is true and correct
1.
Signature: `+"" ---- Date: ii(21 flip
•
Phone#:
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):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 3
6.Other
Contact Person: Phone 4:
4
/ 1/7 rot, "sr
liA\/
O;ty of P14"ttamPinn
Building Department
Iv,
Plan Review EXISTING TIN CEILING.TO
212 Main Street REMAIN.
NOTE'NO
Northampton,MA 01060 STORAGE ON
EXISTING HEIGHT CEILING
OF WALL TO
REMAIN
NEW SPRINKLER HEAD
,� CONNECTED TO EXISTING
( 2 D �` SYSTEM. LOCATION TO BE
`'7' CONFIRMED BY INSTALLER.
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THORNES
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MARKETPLACE
REBEKAH BROOKS
MARKELACE EMILY ESTES
iso Main west Nonnampbn,MA 10/25/16 PERMIT SET "RCXe"R1flH'""""LC
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\ I CEILING MOUNTED LIGHT
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EXISTING TO REMAIN
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(16"O.C.ASSUMED)
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7-2 WALL ASSEMBLY DETAIL
J Scale: 1 1/2" = 1'-0"HORS C
MARKETPLACE REBEKAH BROOKS _ C
EMILY ESTES
150 Main Slreel,Nodhampton,MA
10/25/16 PERMIT SET
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FIRST FLOOR PLAN
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ARKETS
MREBEKAH BROOKS
MARKETPLACE EMILY ESTES
150 Main Street,Northampton,MA 10/25/16 PERMIT SET 'o'RmCRIU•DUNK LLC
Code Review ESTES Architecture+Design,LLC
Rebekah Brooks Northampton,MA 01060
Thomes Marketplace 413.320.6199
Northampton,MA 01060
CODE REVIEW October 25, 2016
Thornes Marketplace
Rebekah Brooks-Acoustic Improvements
150 Main Street
Northampton, MA
Applicable Building Code:MA 780 CMR Eighth Addition
IBC, IEBC International EXISTING Building Code, 2009
ZONING DISTRICT: CB
Proposed Renovations:
Project Description:
• Improve acoustic performance between 2 tenant spaces by altering existing
partition wall and addition of new ceiling.
Use Groups
• No change to use groups. Private office to support M (Mercantile) Use
Group.
Construction Type
• 3B, Brick exterior walls, combustible framing.
Valuation of Project:
• This project's construction costs are: $9,000
• The assessed value of the building is:$3,854,400
• The cost of the project is 0.2%of the assessed valuation.
Areas
• The total building area is 76,876 square feet.
• The proposed renovated work area is: story, 6o square feet
• 0.78%of total area
704 Fire Protection:The building is fully sprinkled. Existing distribution will be
modified with new ceiling location.
According to the IEBC this renovation is being reviewed as:
Work Area Method, Chapter 4.Applicable Sections are:
Chapter 6-Alterations Level 1- New finishes and fixtures
Chapter 7-Alterations Level z-New construction.
Work Area Method Calculations
I of 4
Code Review ESTES Architecture+Design,LLC
Rebekah Brooks Northampton,MA 01060
Thornes Marketplace 413.320.6199
Northampton,MA 01060
The total building area is 76,786 square feet.
The existing renovated space is 1 story, 6o square feet
The work area is less than 0.01%of the aggregate area of the building.
The work area comprises less than 5o% of aggregate area of the building;therefore
this is not a level 3-alteration project. IEBC section 405)
The work area includes reconfiguration of the space and the reconfiguration of
systems (sprinklers, electrical). Most of this project will be classified as a level 1
project.The alterations will follow level r guidelines.
Level 1 work requirements:
The removal and replacement or the covering of existing materials, elements,
equipment or fixtures using new materials, elements, equipment or fixtures that
serves the same purpose
This Project will have new interior walls, ceiling, finishes, and lighting.
602.1 Interior finishes:All newly installed wall and ceiling finishes shall comply
with the IBC.
603 Fire Protection:Alterations shall be done in a manner that maintains the
level of fire protection provided. This project will not affect the level of fire
protection that is currently provided. Corridors throughout Thrones are non-rated
tenant separations.
Fire Resistive Required Types of Building Element Type 3B
Construction,Table 6m:IBC
Primary Structural o
Frame
Bearing walls, Exterior 2
Bearing walls, Interior o
Nonbearing walls and o
partitions, exterior
Nonbearing walls o
and partitions,
interior
Floor construction and o
secondary members
Roof construction and o
secondary members
2 of 4
Code Review ESTES Architecture+Design,LLC
Rebekah Brooks Northampton,MA 01060
Thornes Marketplace 413.320.6199
Northampton,MA 01060
704.2,912.2.1 Automatic sprinkler systems
Automatic sprinkler systems will be upgraded in the work area as needed.
704.4 Fire alarm and detection:
• The building has a fire alarm system in all areas. It will be maintained. No
new devices are required in this project.
705 Means of Egress
There will not be a reduction of means of egress in any part of the building.
IBC Table ior6a Exit Access Travel Distance:
For M use and sprinklers:ego ft maximum allowable travel distance.
The travel distance is 64'-8"feet from the most remote space in the space to the
nearest exit door.
IBC ior4.3 Common path of egress travel:
For M use and sprinklers:75 ft maximum allowable common path of travel.
The common path of travel from the most remote corner of the private office to a
point where there are 2 choices of exit routes is 25'-8".
711 and 607 Energy Conservation:
Level t alterations are permitted without requiring the entire building to comply with
the International Energy Conservation Code.Alterations (new construction)shall
comply with the International Energy Conservation Code.
Where there are reconfigurations of the space or new doors or windows, any such
new element is required to meet the International Energy Conservation Code.
Elements within the building that are not being affected do not need to be evaluated
and do not need to comply with the energy provisions. Essentially the entire building
is not required to meet the energy provisions;only a degree of possible improvement
in the energy performance of the building is intended to be achieved by making the
new elements meet the IECC. In certain cases where the reconfiguration of the space
might have resulted in the creation of new spaces the newly created space should be
evaluated as a whole for compliance with the energy provisions even though some of
the element within the space might actually not have been altered. Likewise, in a
case where an existing mechanical system is being extended to other areas or new
ductwork is being installed to reconfigure and reroute the ducts to various spaces, it
is only required to have the new elements meet the energy provisions and not the
entire system.
3 of 4
Code Review ESTES Architecture+ Design,LLC
Rebekah Brooks Northampton,MA 01060
Thornes Marketplace 4133204199
Northampton,MA 01060
thou Structural:
There is no structural work.
2700 Electrial
New electrical equipment will comply.
End of Document
4 of 4
WOODSMITHS
C/O MARK SMITH
5 ANNA STREET
WARE, MA 01082
1413-531-7342(BUSINESS CELL)
Nov, 30 2016
To the Northampton Building Deportment,
I request that you grant a modification to waive the requirement for
control construction for the Rebekah Brooks project at 150 Main St
Northampton because the work is of 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.
The scope of this proposed project is the removal of existing drywall from 2
8'x8' walls, the framing of an 8x8 wood framed ceiling, then soundproof and
drywall these 3 surfaces.
Thank you in advance for your consideration. Mass Amendments, sections 107.1
allows for an exclusion from control construction for this project.
Respectfully
Mark Smith
WOODSMITHS
5 Anna St
Ware, MA 01082
1 .41 3.531 .7342
VersionI.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O [1y�
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT// OR CONTRACTOR APPLIES FOR BUILDING PERMIT
__
t4c._ h" •:� r „NAL F CF
I, i s.c' T;;-zr) cF 4.1C.S s .''N Q z ,as Owner of the subject properly
LLC'
hereby authorize �.�-i �<.� r'J.o.�c25 to
act on my behalf, in all matters relative to work au0tonzed by this building permit application.
x- / ¢t :nos eF !�- -v�:r✓ PET
e c� -i- /Dale
Signature o'o s
11.1111111111111111111111111r—
I� /[ p / Dale
Ef� y /�wl 'c.( AG> N^Y , 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.
ams
G�ts,L President,KM
(! } S /( c,
Signature of Owner/Agent Dale
SECTOR 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor:' ' Not Applicable
Name of License Holder: )Sc a -y-y ( S — f O d 1 I 1—
License Number
5- oke. i S -1- rietwt,c4, A.A4- 6�Ar? tl R
A s Expiratlo Dale
ess
President,Kill 5 b+L LJ
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MAL 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 buil rdq permit.
Signed Affidavit Attached Yes 9
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 Budding Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MOL c 111, S 150A
Address of the work: 14 Green Street
The debris will be transported by: Keifer Builders, Inc.
The debris will be received by: vaiiey Recycling
Building permit number:
Name of Permit Applicant Keifer Builder, Inc
09.27.16 , &t
. ti � Proidcw.«r,
Date Signature of Permit Applicant
lije Common wealth of Massachusetts
Department ofIndustrial Accidents
i=t,.._" Office of Investigations
L�,F R- 1 Congress Street,Suite 100
€
3' — Boston,MA 02114-2017
'. ' ' www.ntass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Legibly
Name (Business/Organization/Individual): (e4_11n A tt,r— _
Address: _ _...._vu.Pa,ln ---....---.....- --.�..... .......
City/State/Zip: p/ (.ete.rn c.§„ AAA Phone ii: SIG rix '
Are you an employer? Check the appropriate box: Type of project (required):
L 0 I am a employer with 42t) 4. 0 I am a general contractor and 1 .
employees(full and/orpart-time}.' have hired the sub-contractors 6. ®Nen construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. (I Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
[No workers' comp. insurance comp.insurance.:
5. Wecorporation and its 10.0 Electrical repairs or additions
required.] ❑ are a
3.El
a homeowner doing all hark officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers right of exemption per MGI,
Y comp. 12.0 Roof repairs
insurance rcquired.J ' c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required]
`Any applicant hat checks hots dl must also till out Ilse section below showing their workers'compensationpolicy information.
I Honnv,eners 11110 submit this nllidavil indicating the,are doing all work and Ilion hire outside contractors must submit a new mdat II indicating such.
:Contractors that check this box must attached an additional sham slowing the name of fie sub-contractors and slaw+dulhee car run(hlne entities hare
anpkisees. if the sash-contractors have eopk,)yess the+must prosilk their wnekers comp.policy numkr.
I am an employer that is providing workers'cnnrpensatioa insurance for my employees. Below is the policy and job site
information. Q� /
Insurance Company Name:_. rr 44,2114`-- lit/ __
Policy k or Self-ins. Linc/. d: /_/f 2- tin 6 [ ) — Expiration Date: Fj it, /t '4-
Job Site Address: I (... 6i•-CAtn.- S4 City/State/Zip:7V (1Pt.. A/C1 de dd )-
Attach a copy of the workers' compensation policy declaration page(shoving 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
tine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the forth of a STOP WORK ORDER and a line
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 rtify under the pains and penalties of perjury that the information provided above is true and correct.
Sienature:?"/'Yr
President,KW Date: Lt /4)--t/4 C,
Phone b: 57-6 ` `
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License N
-
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 e:
ACORD CERTIFICATE OF LIABILITY INSURANCE6O
DATE
IM/RW n
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poIcylies)must be endorsed, It SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER eNnO TAcr Cynthia Henderson, CSR
Webber & Grinnell "OPE (413)586-0111 EAX 1
(A(C Ess:c _. ., igi;.No131566-6461
B North King Street Pe16411 hendersen@webborandgrinnell.com
IHVRERISJ AFFORDING COVERAGE NAIL'
Northampton MA „01060. IlN6UREAA Athena Protection 43360
4.15E0E0 .HOWERa •._ I
Reiter Builders, Inc. INSURER
Attn: Scott Reiter INSURER b:
35 wain Street - - --
Florence HA 01062 j,WsuRER G.
COVERAGES CERTIFICATE NUMBERsaster Exp 2017 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 LITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBES) HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE SEEN REDUCED EY PAID CLAIMS.
miR' TYPE O[INSVRAHCE -ADD SUBP' _. _ --. POLICY E[4 POLICY ESP -_.._...
m6f WV.. POUCV NUMBER . in.yon YYtLE4LOO ; WAITS
X COMMERCIAL GENERAL.LIAStITY EACH OCOCRREUCE $ 1,000,000
Cu;MS.MAGE X OMR M1 G'MinATET PET YEI}.
A . ...�—"..
„PSESL w,�nrq__ S 100,000
:norms 396 6/1/2016 6/1/2017 MEDE P y eP.tlmcnl S 5,000
_.... _.._..
rCCCSONAL anov NvnY $ 1.000,0000
X IP2GaTE LIMIT RiP4:Pi5 GEA ifGRQGcid I 3,000,009
POUC
LOG : PRODUCTS LOIMgPrGG4 2,000,000
IDMEN I .1
AUTOMOBILE WRntry I 'COM EO SENGt€UMC $ 1,000,000
LEaa t
A µ AUTO
BODILYINJURY( mum) 5
(MINED 71 BCrCOULEU '--
..
100$ I_X )AUTOS 103003936101 611/2016 6/112011 •OCOP N RYAP ecclev
i • in PROP Rtn NANA&c
S XIflEU AUTOS :� Xt
_ Sawa AUTOS I . rer y `
.c0.aloayven Ie S 5,000
M
X UMBRELLA UAE 000u : ' EACH OCCURRENCE 1e,0✓0 000
A EAOE96 LAB CLAIMS-MADE . . AOCREOATE $ $,000 000
1
CEO X AETENTION$ 10,000 ,9600060)99 6/1/2016 6/112013 $
WORREPSCWFENSATMm GEp .^1rv.
AND EMPLOYEPS'LIABILITY vHi 1S )UTE X F,4..
•ANY PNRMNETORIPFRT XECFVEEI EAC L !DENT S S000`000
A IOFfdEINEMSER EXCW0E0t NN/A
:Iyyen6selryInNH) -—_ 912)640616 : 6/11/2016 6/1112017 'EL G5 SE EA EMPLOYEES 1 000,000
01019109 Under .
AESCP Pt ON OF OPERATIONS e01100. 1 El. OIS€?SE-POLY!Nn I s 1 000,000
DESCRIPTION Or OPERATIONS/LOCATIONS/VEHICLES IACORD 101,Adnlllonii Remark.5eheclu,t mAy be attached Il mon,spate I.worn)
CERTIFICATE HOLDER CANCELLATION
1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
For Informational Purposes THE EXPIRATION GATE THEREOF, NOTICE WILL SE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE0 REPRESENTATN£
I
IC Henderson, [ISR/CIN •ir' V- ' '^•/6-Nara-"
1888-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
I6.1SO25nnvm,
�� Initial Construction Control Document v i It
( � i i n be auhntiucd ,sigh the hdldu:g ['tumid application ha a t
{ 1't I Registered Design Professional rl
J
1kt I ruudperih Cs dition . t the -_>
/ Ma ichusens Staid Buildtug Code. ?WI ( MR. Section I0
pr..-Cc: : ,tie. 14 Green St Repairs oat; 's \..,nab::
francs, Addres.'. 14 Cereal el AAnirr • 14.n. At
Ihr I ir 1 tF.rs s ,s i one or Nob as tpphcan.e- _v.ichu: A Eaisonq C umtriUiun
I. I It is KC tin-man. Al A. MA Ker Iratrn Nunn-ter, 1O4 S I spiration eatte. e -. am a r::tttit,e✓d.,:;yt
i rs u' and I have prepared or d.tc::1. su pen i scd the pr p ret e r:. ni ail design plans.conhpuwuons and
sixcifiicattons concerning':
Arc hitcctu ral
For the allot (maned project and that to the hot of my Anoss nrciae. [Warmanon. and he. e:such plans. contpatati.•n, sin.
',set inc an. meet the dppt:C.Inte pros , en.Ti the M.bubeibi,itit. Sane Roil ii1 t-tidal-Nn('t{R1. Ind A.e
entr.seerrni nrs,:ndes for the proposed pr reC i t teui.'.lid and ann., than l I e r sr, Lie,:-t s II II'. ntarlenn _,_roc;
,n _. ,:a I scrcn
r, ces and he tse t on the n n4' on hi rc
,'h.ernh ,: gulat arid 1, d
sr hasII
I. R.,i<,s. Im eontiumarree r :ins code and the acs iey e>ncept_shop dr ass ure-, za'l d rab;r ihIrc to-i, 'tr. IL
Lontra:IIT in aces.rdnnc' s 'th-thcrmi 'mania nt 'hc centnueiton L: cunsene.-.
_. f'erlorm ihe dutiesr r is toted dean p .r.._I, in'Xn(l9R( hapter IP.Li,appri..d-l-a.
3 Re presrm at itilenais appropriam to the Niece LII cpnsua:ttun to tItcrOrtrIltt hu crru: 'sin ii. roc r'h I ,t a.,•:.. in..:
quality piths,.orA and to determine:t the sore s bels,performed eta manner oil it es ICI: the ,IIIIthr._.
eotufructiou inkLan timl:Uhl than cede.
I
4. h t. 11'as d ct a en,r urn, 11 e _ 1t:zt r i .:�rC>�.o1 I d s re�r'd• :rrr:"r_ , of -X I t AI R I
'at hs required b-the hutIdiots ohAzia,, 1 stall submit :idd prostress reports' ee item ; liinethr n a turnrt.-ut
ewumcnts. III.I limn : ssailable to the building ofllcial.
II pill cotnplelou.P1 the xor4,I all submit toinc h ;i ..cn^.s i:eai a F inai t oh nstructioo t t
Jr):reurne
fnt.r l n:kir +pace t. ihr ri:,ht a "sen nr r*'
_ ee..,,ni: . :^ ere'and seal 1
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