19-012 (21) 22 INDUSTRIAL DR BP-2018-1241
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 19-012 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:window replaced BUILDING PERMIT
Permit# BP-2018-1241
Project JS-2018-002214
Est Cost' $1000 00
Fee: 5100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: JDR BUILDERS 074105
Lot Size(sa. R)' 101930.40 Owner. MALVERN PANALYTICAL
Zone Applicant: JDR BUILDERS
AT: 22 INDUSTRIAL DR
Applicant Address: Phone: Insurance:
P O BOX 4 (413) 665-7587 WC
NORTH HATFIELDMA01066 ISSUED ON:5/23/2018 0:00:00
TO PERFORM THE FOLLOWING WORK REPLACE LEAKING 2ND FLOOR WINDOW
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 N 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 5/23/20180:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED a),400q
D Venal 1.7 mr,,"iaLBuilding ZI Maj 15,2000
Department use only
Ci Of Ortha ptt Statu of P rmit:
AYMA3(2231201 B I in Depa m nF r.,ai n .a 01 D wewey Pe mit
2 ainS nc""^'"O'` "�' l9aksutt cAvailability
SPpr,A ION R in 100 Water/Well Availability
NbRr MP'W, n, MA 01060 Two Sets of Structural Plans
-
p one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION g n--/s
1.1 Property Address: This section to be completed by office
P�/I✓1�✓ )f11+/t–L _C41 V £/1"a i— Map –1 Lot V t `' Unit
�. -�✓/ r _ '9 Zone Overlay District
Elm BL District CB Distd&
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record: �1
MAwjaN PAo✓RLNY![✓iL_ dcL /nf�JS hZ p2,✓r F
Name(Pant) Current Mailing Address:
-'//3-5 r7 0 -l5io
Signature Telephone
2.2 Auth ed Agent:
51L.(_ `cAs
Name(Print) �CONSTRUCTION
Current Mailing Address:
Signature ri Telephone
SECTION -ESTIMATED COSTS
Item Estimated Cost(Dollars)to be Official Use Only
mra feted Im,nennit ammlicant
1. Building /OO(J �. (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ,�7�U D
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signatu 7
B ding Cc sainted spec f Buildings Date i"
Version1.7 Commcmial 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❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: i
Q ce &
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 131A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U U61ity ❑ Specify:
M Mixed Use ❑ Specify:
5 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 a BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
.
1°1
2�a 2A
V 3.
4. 0
Total Area(sf) Total Proposed New Construction(at)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.C.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private 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 no be tilled in by
Building DeWribi t
Let Size
Frontage
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg. Square Footage °h
Open Space Footage %
(Lot arca minus bldg&pave,!
pinlon,)
#of Parking Spaces
Fill:
volume&Location)
A. Has/ea rmit/V ante/ ding ever been issued for/on the site?
NO D T KNOW YES O
IF YES, datIF YES: it recorded at the gistry of Deeds?
NODONT KNOW YES OIF YES: Book Page and/or Document#
B. Does thin a brook, body of water or we ands? NO ODONT KNOW O YES O
IF YErmit been or need to be obtained fr the Conservation Commission?
Needs to be obtained O Obtained , Date Issued:
C. Do any signs exist on the property? YES O O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Win the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Vecsionl.7 Commcrcial 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 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Data
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature To hone Expiration Date
Name Area of Responsibility
Atldress Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(760 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 1i -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to
act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10A Licensed Construction/S1u..pervis0r: \ Not Applicable ❑
N Li Holder
�n ix•�L5 „ `_I I �
License Number
1-0
Address Expiration Date
_�I7 t�__ �� 3�1N 79 8 7
Signature I I 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 bu Iding permit.
Signed Affidavit Attached Yes 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: x,11 D1)5r4L 'r>4W? �✓t
The debris will be transported by: P)hVW4 J
The debris will be received by:
Building permit number: 22
Name of Permit Applicant
Date Signat a of Permit Applicant
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street' Suite
Boston, MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:BuilderOConVactors/Electiicians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Infat n 1. Please Print Leeibly
Name(Business/s/7Organiz tiorknndlvidual): '?
Address: ry ? tett
City/State/Zip:OA A�g�l ti, M4 - L>07'Z, Phone#: &6,s - 7s —7
Are yo...employer?Check the appropriate has: Type of project(required):
L�Li am a employer wlm__i�employeas(ful other parotimel' 7. [] New construction
2.❑I.a sole por,inh r or pareascarp and he ve no empl w,v,working far mo tit g.fgfRemodeting
any,wous.IN.workers'comp.insurance mqufred.]
3.❑Iam a homeowner doing all work myself.[No workers'comp mebro nee required]' 9. ❑Demolition
41 1 am a homeowner and will be hiring contactors to conduct all work on my property. I will 10[3 Building addition
corman that all contractors Amer have workers'cememusmiou inwuanceorare aide IL❑Electrical repairs or additions
treatments with am employees. 12.❑Plumbing repairs or additions
5.rl I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet
These colo-ventraaon have employees and have worxers'comp.insurance. 13.]Roof repairs
b.❑We area corporation and its officers have exercised their right ofectualuon per MGL c. 14.QOlher
152,h l0r sod we have no employees.[No a orkms'cmmp.l.are required.l
"Any applicant can checks box#1 must also fill oto me section below showing thehworkers'compensation policy information,
t Homeowners who submit this affidavit indicating they are doing all work and then are outside contractors must submit a new affidavit indicating such.
?Contractors and check this box must attached an additional sheet showing the name of an,sul ractrecmrs and stale whether or not those entities have
employees. If the sub-contractors have employees,they most provide their wmkers 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: qS-e .QP(i(� ✓C � 7� ��
Policy#or Self-inti.Lia ^ 1
#:�AJ -1 o a nL4 9 Expiration Date:
Job Site Address: /V b0c [�� ��C - f 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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification/
L do hereby cerdfy un rate Royalist ormation provided above is true and correct
Si attire: Date: � _Z-2,
Ph tie#:
Oficial use on4V Do not write in this area,to be completed by city or town ofctat
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Budding Department 3.Cityrfown 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 in 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 m 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-contractors)camels),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 retumed 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 m 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 Department's address,telephone and for number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax At 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employ"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 a joint 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 your insurance company's time,address and phone number along with a certificate 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 fisted 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 eventthe Office of Investigations has to contactyou regarding the applicant.
Please be sure to fill in the permit/icense number which will be used as a reference number.In addition,an applicant that
must submit multiple pennitAicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stimpedor 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 cifiren is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves eta)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mms.gov/dia
Forth Revised 02-23-15
JDR Builders Inc.
PO Box 4
North Hatfield, Ma.01066
CSL tt 074105
HIC a 184755
(413)374-7983
jd@idrbuilders.com
April 25, 2018
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, Mass. 01060
Jobsite: 22 Industrial Drive East
Scope: Replace 1 leaking sliding windowl on the 2""floor with a new window.
Dear Sir:
I request that you grant a modification to waive the requirement for controlled construction for the
project at 22 Industrial drive East, Northampton, because the work is of a minor nature,will not affect
health,accessibility,life and fire safety,or structural requirements and is impractical in that the cost of
control construction is considerable when comparedto the cost ofthe proposed work. Thankyou for
your consideration.
Respectfully,
Jawlei- V. Roby
James D. Ross
President
OR Builders Inc.