23B-046 (265) 30 LOCUST ST BP-2017-0235
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-046 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-2017-0235
Project# JS-2017-000394
Est. Cost: $1263329.00
Fee: $8841.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RAYMOND R HOULE CONST INC 066227
Lot Size(sq. tt.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning: M(99)/WP(21)/URB(l)/ Applicant: RAYMOND R HOULE CONST INC
AT: 30 LOCUST ST
Applicant Address: Phone: Insurance:
5 MILLER ST (413) 547-2500 0
LUDLOWMA01056 ISSUED ON:2/7/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:Create a Comprehensive Breast Care Center
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 2/7/2017 0:00:00 $8841.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File P BP-2017-0235
APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC
ADDRESS/PHONE 5 MILLER ST (413)547-2500 O
PROPERTY LOCATION 30 LOCUST ST
MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(I)(
THIS SECTION FOR OFFICIAL USE ONLY;
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ,\\
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: Create a Comprehensive Breast Care Center
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066227
3 sets of Plans/Plot Plan
THE FO OWING 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 I
/01(((( 01 l6
Signature of Building Official 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 the Office of
Planning&Development for more information.
Versions.7 Commercial Building Permit May 15.2000
Department use only
RTCCE}VFf City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
AUG 2 2 2016 I i 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
_ Northampton, MA 01060 Two Sets of Structural Plans
°` • phone 413.587.1240 Fax 413587.1272 Plot/Site Plans
Other Speedy
APPUCATION 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 Pronnv Address: This section to be completed by office
30 Locust St. Map Lot Unit
Northampton, MA 01060 zone Overlay District
Elm St District CS DItrict
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
$1 Owner of Reco4d:
Cooley Dickinson Hospital 30 Locust St. P.O. Box 5001
Name(Mint) JaN _e Ng ii a-.d I IDIR04-pc I, 171 (5 Gummi Melina Address:
J ., . '' 1-413-582-2313
Autz
Signature ... - . Telephone
L
Timothy S Pelletier 5 Miller St. Ludlow, MA 01056
Name(Print) Current Manna Adelman
1-413-547-2500
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
Completed by Permit applicant
1. Building 630,802.00 (a)Building Permit Fee
2. Electrical 159,425.00 (b)Estimated Total Cost of
Construction from(6)
3. Plumbing 131,780.00 Building Permit Fee
4. Medmnical(HVAC) 341,322.00 IV
5.Fire Protection /�
6. Tocol=(t +2+3+4+5) 1,263.329.00 checkNumbe�t 42/a? _
This Section For Official Use Only
Building Permit Number Date
a 0/ ? — 6 S Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versioni.7 Commercial Building Permit May Id.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
Martin J. Batt Not Applicable 0
Name(Registrant):
321 Summer St. Suite 401 Boston, MA 02210 Registration Number
Address 11098
See affidavit attached 1-617-419-466C Expiration Date
8-31-2016
Signature Telephone
92 Registered Professional Engineer(e):
Jeffrey S. Cichonski Fire Protection-Mechanical
Name Area of Responsibility
50 Griffin Road South Bloomfield, CT 06002 49384
Address Registration Number
See affidavit attached 1-860-286-9171 6-30-2018
Signature Telephone Expratan Date
Thomas J. Denis Structural
Name Area of Responsibility
50 Griffin Road South Bloomfield, CT 06002 41168
Address Registration Number
See affidavit attached 1-860-286-9171 6-30-2018
Signature Telephone Expiration Date
Alan K Vanags Electrical
Name Area of Responsibility
50 Griffin Road South Bloomfield, CT 06002 49981
Address Registration Number
See affidavit attached 1-860-286-9171 6-30-2018
Signature Telephone Expiration Date
Name Ama of Responsibility
Address Registration Number
Signature Telephone Expiration Date
23 General Contractor
Raymond R. Houle Construction Inc. Not Applicable 0
Company Name:
Timothy S. Pelletier
Responsibie In Charge of Construction
5 Miller St. Ludlow, A 01056
Address ,.,�"
1-413-547-2500
Signature Telephone
Version!7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.111 pp;;
Independent Structural Engineering Structural Peer Review Required Yes Q No 1C,J
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i. Cooley Dickinson Hospital ,as Owner Wine subject property
hereby authorize Raymond R. Houle Construction Inc. to
act my beha in a matters relative t work authorized by this building permit application.
€17-3/he
te
Raymond R. Houle Construction Inc.
I, ,as Ovmer/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.
Timothy S. Pelletier
2- ?3
Signature o1 pwr,cr'�/ -/6
e�IAg '� Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed ConstnscVon SupeMsor: Not Applicable 0
Nome of License Holder: Timothy S. Pelletier 066227
License Number
5 Miller St. Ludlow, ° 01056 07-07-2017
Address 1-413-547-2500 Ewirebon Date
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(e))
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 Q No 0
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: 30 Locust St. Northampton, MA
The debris will be transported by: USA Hauling
The debris will be received by: USA Hauling
Building permit number: Pending
Name of Permit Applicant Raymond R. Houle Construction Inc.
rP. 2?/G
Date Signature of Permit Applicant
•
The Commonwealth of Massachusetts
Department oflndustrialAccidents
==�lc , I Congress Street,Suite 100
_ Boston, MA 02114-2017
www.mass.gov/dia
- Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): RAYMOND R.HOULE CONSTRUCTION, INC.
Address:5 MILLER STREET
City/State/zip:LUDLOW,MA 01056 Phone#:(413)-547-2500
Are you an employerf Check the appropriate box: Type of project(required);
ICIm
laa employer with 30 employees(Mt and/or paruinsc).' 7. ❑New construction
CI am a sok proprietor or partnership and hats no employees working for me in 8, I Remodeling
any capacity.[No workers comp,insurance required.]
i�I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. Demolition
4.0i am a homeowner and will be hiring contractors to conduct all work on my property. I will 16Building addition
ensure that all caters either have workers'compensation insurance or are sok 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet. )) Roof repairs
That sub-contractors have employees and have workers'comp.insurance:
6.0 We are a corporation and its officers have exemised their right of exemption per MGL c. 14 DOther
152,11(4),and we have no employees.(No workers'comp.insurance requiredI
'Any applicant that checks box#1 must also fill out the section below showing their worked compensation policy information.
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 sate whether or not those entities have
e,ploytes. If the subcontractors have employees,they must pmride their workers'cow.policy+amber.
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.I.M. MUTUAL INSURANCE CO.
Policy#or Self-ins.Lie.#:WMZ-800-8605579-2015A Expiration Date:12/3112°16
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 MGL c, 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
etc
Ido hereby cm),under the pai andpe,i a of perjury that the information provided above is true and correct.
Signature: �T~al<+' � L/C�G''rar> ........ Date:
Phone#; / y/3.S Y 7— 2 .Sol:
Official use only. Do not write in this area,to be completed by city or town aJJSsxal.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Version!?Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBS FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wail Signa ❑ Demolition Repaha 0 Additions 0 Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use❑ Otter 0
Brief Description Enter a brief description here.
Of Proposed Work:
SECTION 6-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Cheek as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 0 fA ❑
A-4 0 A-5 0 18 0
B Business ❑ 2A ❑
E Educational 0 28 ❑
F Factory ❑ F-1 0 F-2 0 2C 0
H High Hazard 0 3A ❑
I Institutional 0 I-1 0 1-2 )Q] I-3 0 38 ❑
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 0 R4 0 SA 0
S Storage ❑ S-1 0 S-2 0 58 0
U Utility ❑ Specify:
M Mixed Use 0 Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: 1-2 Proposed Use Group: 1-2
Existing Hazard Index 780 CMR 34): 4 Proposed Hazard Index 780 CMR 34): 4
SECTION$BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1^ 6800 1" 6800
2 2"°
3i° 3b
4e 4°i
Total Area(s@ Total Proposed New Construction(s8
Total Height(ft)
Total Height ft
7.Water Supply(MAX.c,40,§54) 7.1 flood Zone Information: 7.3 Sewage Disposal System:
Public Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal System
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 969,427.8 969,427.8
Frontage 2658' 2658'
Setbacks Front 102' 102'
Side L: 88 R; 42' L: 88' R: 42'
Box 18' 18'
Building Height 64.5' 64.5'
Bldg.Square Footage 402,861 % 402,861
((Lpen Lot area Space nus bids&paved 40.6 y 40.6
puking)
#of Parking Spaces 761 761
Fill: N/A N/A
(volmne a Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES
IF YES,date issued: Dec 13,2001
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES C
IF YES: enter Book 6504 Page 239 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
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 ® NO O
IF YES,describe size, type and location: Various
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 ace? YES O NO ID
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Initial Construction Control Document
( lf
To be submitted with the building permit application by a
I1 I Registered Design Professional
of for work per the 8th edition of the
Ute,,. Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Cooley Dickinson Hospital Comprehensive Breast Care Center Date: 8/15/2016
Property Address: 30 Locust Street, Northampton, MA 01060
Project: Check(x)one or both as applicable: New construction (x) Existing Construction
Project description: Interior renovation of an existing space to create a comprehensive breast care center.
1,Martini. Ban, MA Registration Number. 11098 Expiration date: 8/31/16 ,am a registered design professional, and I
have prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
(x) Architectural Structural Mechanical
Fire Protection Electrical Other
for the above named project and that to the best of my knowledge,information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that 1(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
L Review, for conformance to this code and the design concept,shop drawings. samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments,in a form acceptable to the building official,
Upon completion of the work, I shall submit to the building official a 'Final Construction Control Document'.
Enter in the space to the right a"wet"or , . 444
electronic signature and seal: tt, f}t
II r*1 t• +no.1ii
Phone number: 617-019-4660 Email: mban@isgenuity.com �' 'l:
QF
Building Official the Only
Building Official Name: Permit No.: Date:
Note I. Indicate with an'x'project design plans.computations and specifications that you prepared or directly supervised. If'other'is chosen,
provide a description.
Version 06_I 1_2013
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
^ for work per the 8th edition of the
the.
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Cooley Dickinson Hospital Comprehensive Breast Center Date: 8/15/16
Property Address: 30 Locust Street,Northampton, MA 01060
Project: Check(x) one or both as applicable: New construction X Existing Construction
Project description: Renovation of former surgical suite and current office area to provide a new location for the
outpatient breast imaging suite.
1,Jeffrey S.Cichonski, MA Registration Number: 49384 Expiration date: 6130/2018,am a registered design
professional, and hereby certify,to the best of my knowledge, information and belief,that I have prepared or directly
supervised the preparation of all design plans,computations and specifications concerning':
Entire Project Architectural Structural X Mechanical
X Fire Protection Electrical Other:
for the above named project and that such plans,computations and specifications meet the applicable provisions of the
Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee)shall perform the necessary professional services in accordance with the
Professional Standard of Care,and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the
contractor in accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means, methods,sequences
and procedures, and for construction safety.
4_ The performance of the services shall not require any special testing or inspections unless specifically stated in the
Code.
When required by the building official, 1 shall submit field/progress reports(see item 3_)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction • cumene.
Enter in the space to the right a"wet"or /f
electronic signature and seal: /*xE4,111 '{b
g
Phone number:(860)286-9171 EmaiLjeffc@bvhis.com • ` mi,
Building Official Use Only
Building Official Name: Permit No- Date:
Note I.Indicate with an 'x'project design plans,computations and specifications that you prepared or directly supervised, If`other'is chosen,
provide a description.
Version 10_09_2012—Draft modified by AIA MA
Initial Construction Control Document
1+ z7
To be submitted with the building permit application by a
Registered Design Professional
for work per the 8th edition of the
ghr.�x Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Cooley Dickinson Hospital Comprehensive Breast Center Date: 8/]5/16
Property Address: 30 Locust Street, Northampton,MA 01060
Project: Chock(x) one or both as applicable: New construction X Existing Construction
Project description: Renovation of former surgical suite and current office arca to provide a new location for the
outpatient breast imaging suite.
1,Thomas J. St.Denis, MA Registration Number: 41168 Expiration date: 6/30/2018, am a registered design
professional, and hereby certify, to the best of my knowledge, information and belief,that I have prepared or directly
supervised the preparation of all design plans,computations and specifications concerning':
Entire Project Architectural X Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that such plans,computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,(780 CMR), and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee) shall perform the necessary professional services in accordance with the.
Professional Standard of Care,and be present on the construction site on a regular and periodic basis to:
L Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means,methods, sequences
and procedures, and for construction safety.
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the
Code.
When required by the building official, I shall submit ficldiprogress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a `Final Constructioj , intro' Document'.
Enter in the space to the right a "wet'or �yt
electronic signature and seal: T 'fid' •'`t
t2ro ,j I ML
Phone number:(860)286-9171 Email: tomsd@bvhis.com tiiSrE,
r 4ttiONAIt!5.=
Building Oficial Use Only
Building Officio!Name: Permit Nor. Date:
Note I. Indicate with an 'x'project design plans,computations and specifications that you prepared or directly supervised.If'other' is chosen,
provide a de cripnon.
Version 10_09_2012—Draft modified by AIA NI A
Initial Construction Control Document
l lIft If To be submitted with the building permit application by a
Registered pe the
aProfonsofthe
'tom for work per the 8u edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2
Project Title: Cooley Dickinson Hospital Comprehensive Breast Center Date: 8/15/16
Property Address: 30 Locust Street,Northampton,MA 01060
Project: Check(x) one or both as applicable: New construction X Existing Construction
Project description: Renovation of former surgical suite and current office area to provide a new location for the
outpatient breast imaging suite.
I, Alan K. Vanags, MA Registration Number: 49981 Expiration date: 6/30/2018,ant a registered design professional,
and hereby certify,to the best of my knowledge, information and belief, that I have prepared or directly supervised the
preparation of all design plans,computations and specifications concerning':
Entire Project Architectural Structural Mechanical
Fire Protection X Electrical Other:
for the above named project and that such plans,computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project, I
understand and agree that I(or my designee) shall perform the necessary professional services in accordance with the
Professional Standard of Care,and he present on the constmction site on a regular and periodic basis to:
I. Review,for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code. The contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means,methods,sequences
and procedures, and for construction safety.
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the
Code.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a 'Final Construction Control Document'.
Enter in the space to the right a"wet"or
electronic signature and seal: I'OF MAg
p1 G
3
Phone number: (860)286-9171 Email:alanv@bvhis.com � ELECTFIlPAL
. 49981
Building Official Use Only c{8
Building Official Name: Permit No: Date: ,
Note 1.Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised.If'other' is chosen,
provide a description.
Version 10_99_2012—Draft modified by AR MA