31B-311 (23) 42 GOTHIC ST BP-2018-1322
GIS a: COMMONWEALTH OF MASSACHUSETTS
Man,Biwk:31B-311 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-2018-1322
Proiect# JS-2018-002347
Est. Cost:$2000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CITY OF NORTHAMPTON CENTRAL SERVICES
Lot Size(sp.ft.): 16814.16 Owner., NORTHAMPTON CITY OF CITY PROPERTY
Zoning:CB(100]/ Applicant. CITY OF NORTHAMPTON CENTRAL SERVICES
AT: 42 GOTHIC ST
Applicant Address: Phone: Insurance:
Memorial Hall (413) 587-1260 0
NORTHAMPTON MA01 060 ISSUED ON.611 912 01 8 0:00:00
TO PERFORM THE FOLLOWING WORK BUILD 10X11 OFFICE IN EXISITNG
CLASSROOM - LOWER LEVEL
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 ft 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 6/19/2018 0:00:00 $0.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2018-1322
APPLICANT/CONTACT PF-ISON CITY OI'NORTHAMPTON CENTRAL SERVICES
ADDRESSTHONE Memorial Hall NORTHAMPTON (413)58-14260()
PROPERTY LOCATION 42 GOTHIC ST
MAP 31B PARCEL 311 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT d
Fee Paid
Building Permit Filled out
Fee Paid
TypeofConstruction: BUILD IOXI I OFFICE IN EXISITNG CLASSROOM-LOWER LEVEL
New Construction
Non Structural interior renovations
Addition to Existing
Accessom Structure
Building Plans Included
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
(Approved Additional permits required(see below)
F �
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:
Cub 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
em-Mition Delay
e of Build ng Offrr�' Date
Note: Issuance of a Zomng permit does no[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 BmIdin¢Pemmt Nl av 15.2000
Department Use only
RECEIVED Ci of Northampton Status of Permit
Bu ding Department Curb Cut/Drivewey Ferit
12 Main Street Sewer/Septic Availability
JUN 12 2018 Room 100 b�eterN eu Aballabllrty
orth Tipton, MA 01060 Two Sets of Structural Plans
3-5 =1240 Fax 413-587-1272 PibUSde Plans
DEPt OF BUILDING INSPECTIONS Other SpeClfy -
FBUIL BUILDING
INPFCTI
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 P,.P.M Add,.", This section to be completed by office
�ZG��t�t�� Staff Map 3iY3 Let H,it
Naa-%Ak* WA oto6o Zone Overlay District
Elm St.District CD DisMct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C rIo_ tAuIF
y01GC44AWPV
Nam �eS'1. C H,t�M��lingA}d�tl ess Q
�l-�5 Va. a .._
Elonature Telephone
2.2 Authorize A nE
Name(Poo) Current Ma Img Address
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
com lend b ermit a olicant -
1. Building ( )Building Pen-nit Pemit Fee
2Electrlcel (b) Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. echanical(HVAC) - ----
5.Fire Prolection _
6. Total=(1 +2 +3+4 +5) Check Number
This Section.For Official Use Only
Bcild!ng Permit NumberDate
Issued
Slonatur r
Eur 'Ina Co' inner speclo Bulld'rnes Date
- V ersir.l -1 Comme¢ial BuPldmg Permit May 15 2DDD
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition 1:1 Repairs Additioni Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Rocfng❑ Change of Use❑ Other❑
Brief Description Enter a brief description here -%�.AN.O ,k byll , \�
Of Proposed Work: V~\ _r
SECTION 5 -USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ to ❑
A-4 ❑ A-5 ❑ 13 ❑
e Business ❑ 2A ❑
E�Facto�
ional ❑ - 28 I' ❑
F ❑ F-1 ❑ F-2 ❑ 2C II ❑
Hzard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3D ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ElR-2 EDR-3 ❑ 5A ❑
5 Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U U!ility ❑ Specifyc.
M Mixed Use ❑ Specify.
5 Sped.[Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS ADDITIONS ANDiOR CHANGE IN USE
Existing Use Group' .... .._ Proposed Use Group _.___...._ ..
Existng Hazard Index 780 OMR 34) Proposed Hazard Index 780 CMR 34) _
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEV, CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(x�
ci
2n°
3
4th
Total rea(an Total Proposed New Construction)af)
Total Height(ft)
Total Height 't -
]. Water Supply;M G.L. r,40, § 54) r 1 Flood Zone In ormaticn: r 3 Sewage Disposal Systzm:
Pubfm ❑ ❑
PNVare - Zen: Outside Toed Zo-e❑ f1 r; ioai ❑ J sa dsposal system❑
Version17 Co=or-tial Eollding P,,h:t bSay U,_>000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR EUILDiNGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR N6(CONTAINING MORE THAN 35,000 0.F.DF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicaole ❑
Name(R gstanp_
Regstration Numaer
-
Fxplration Date
Sgneture Telephone
9.2 Registered Professional Engineer(s):
- Neme Area of Responsibility
Aeeress P gstravon Number
Signature Telephone E p atioo Dale
Name Area of Respon5sbiiRy
Actress Reg saatioq number __
Signator. Telephon Expiration Nate
Nome Area of Respons b I ty
Acores Registration Numb
Signature Telephone Expiration Dets
Name Area of Respons b Lfy
Aetlress P,eg'stra'on N 5
SlgnaNra Telephone Expiration Date
9.3General Contractor
UL/
�t.1���Q"�
V{ 1 L 40?w/ — __ __ __. I Not Applicable ❑
Company Name
Responsible In Chaise of Construct ar
, r
5 •Nbrb
SO a ielechene
Version i.'ComTnercal Buddica Permit May 15. 2000
8. NORTEL4MPTON ZONING -
Ezi some Proposed Requtre2 by Zones
This column to be n1ledm M
Ruflding De=nrmrenT
Lot Size
Frontxoe ___
Setbacks FTont _- - --�
Side L RL:.. R
or
Buildira(dight
B]dg. Squarc Footage ---- _.-_ Sd
Open Space Footage — / — - - ----
(Loearee minus bid-&paved ---
o=eking)
kof Parking Spaces --------
is Lna.t—i
A. Has a Special Permit/Variance/Finding ever been issued for,'on the site?
NO O DONT KNOW 0 YS 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DOME 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 0 DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C, Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and loca;10n:
D. Are there any proposed changes to or additions of signs intended for the property i YES 0 NO O
IF YES, describe size, type and location
c Wili the construction activity disturb (clearing, grading, excavaticn, or IIllirg)over 1 acre or Is It part of cD cr plan
that will daLrb over 1 acre? YES 0 NO O
IF YES, then a Nochampton Stcrm Water Management Permit from t�e DF'.N o requ,zo
• .`=- The Contenonweaitn of fassachusetas
�-c -- Department of lndusbdaiAccidenis... - - .
Office of Investigations
— - 600 TFaslaine on Street
Boston, MA 03211
_ www.mass.gov/dia
N'orlcers' Compensation Insurance Afdacit: Builders/Contractors' lectriciausfPtumbers
ADnticant Information Please Print Leeibly
,\]aIle ;Business/oraaninm'ior Indioidual):
Address:
City/State/Zip: Phone n:
Pse you an employer? Check the appropriate box: Type of project(required):
4. I am a ecne:al conuactor and 1
i.❑ I ac a employer with ❑ - /. ❑hew construction
employees(full a df oc part-rime)v have hired the sub-contractors
2-❑ I am a sole proprietor or partner- listed o¢the attached sheeC 7. ❑ Remodeling
slup znd have no employees These sub-wntractors have S- ❑Demolition
worlag for me in anan
y capacity. employees d have workers' 9 Ll Building addition
I [Ivo workers' compinsurance comp.insurance.:
regmredI �- ❑ We are a corooration and its 10-❑Bladders]repairs or additions
officers have exesrscd their 11. Phunbias re aus or additions
3. ❑ I am a homeowner do-.ng all work � ❑ _ P.
mvself c warkats'comp. right of exemption per MGL ❑ p
[N 1_ Roofre airs
insurance required.]t c, 152, §1(9),and we have no
implovees. [No workers'
❑ Oo
ther
comp.insurance required.]
-Any ayphc-t that cnc_las box kl rv¢also fill out Nr Schon eclow snowing thcr workers'comocnsan'on oolicy infirmenon-
r Hanmw-tars who submit chis aFiLsm i,dicocuu thev are doing all work atd then hire ou¢ide conrcmrs must submit a new teFc,i:indicative suet.
-ootro=,tiro[check this box must attached av admtioval shot showing the race of he subaontractots oral stat_wnethn ornot to...entiies have
If the stio-collvaorl have employe,fney I.n,rovide uir w kers'colt[,-puliryvumbar
Lane an employer that is providing workers'compensation insurance for my employees, Below is the policy and job site
information.
Irurzoce Company Name:
Policy T or Sell ins.Lic. b Expirarion Date:
Job Site Address- Cry/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 Section 25A of MGL e. lit can lead to the imposition of criminal penalties of a
tine up to SI,500,00 and/or one-year imprisonment, as well as coil penalties in the form of a STOP WORK ORDER and a Cure
ofap to 5250 00 a day aga.st rhe violator Be advised that a copy of this statement may be forwarded to the Office of
Invesdeations o f the DLA for insnance coverage verification
I do hereby certify under the pains and penalties afperjupr that the information provided above is true and correct.
Simam:e: Date'
Phone
Official use only. Do tmt write in this area, to be completed by city or toren offic[aL
Cit,or Town. Permit'Ltcense ti
Issuinu Authority(circle one):
Ld of Health .Building Department 3..Gnllow'n Clerk Elect-ical Inspector 5.Ptu Whine Inspecmr
r
pe son Phone '.:
Versionl.7 Co,.ti_ml Bmomg Permit Msy 1-,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Stmone[Engineering Struch-ral Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS�(ER�AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V� �� r Vr'vD � _ as Owner of thr:suoject property
he yauthonze - _ _ 1 131cs-.1>1
act `mal 'n natters relative to work authored by this buildng permit application=
&- lf_13
Si azure of at Date
as Owner Amhorzed
Agent hereby dec:are that the ata!emen-s and information on the foragoino application gra true and accurate,to the best of my kpow!edge
and belief.
Signed under the came and.,pana hies of aepury.__,
Mint Name — - --
Signature of Owner/Agent Date
r=Addresc ===
NSTRUCTION SERVICES
struction Supervisor: Not Aoplicable ❑
lder _ —----
License Number
Fxpirauon Date
Telephone
SECTION 13 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MGL c. 152,§25C(6)) .I
Workers Compensation Insurance affidavit must be completed and submitted with this zpf icafion. Failure to provide this affidavit will result
In the conical of the Issuance of the building_ permit.
Signed Affidavit Attached Yes No 0
City of Northampton, Mass4chusetts
Central Services
Memorial Hall,240 Main Street
Northampton, MA 01060
David Pomerantz (413)587-1238 Fax: (413)587-1248
Dieeaor ofCntral S,�icrs
To: Louis Hasbrouck, Building Commissioner
From: David Pomerantz
Date: June 12,2018
Re: Waiver- Construction Control
Central Services will be undertaking some minor interior renovations at the Center for
Community Education at James House.
Based on the scale and scope of the work I request that you giant a modification to waive the
requirement for control construction in this situation because the work is of a minor nature, it
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.
Thank you.
The Commonwealth efMassachusetts(A�sz�q z u%-� Ut`
Department oflndustrialAccidents nA`
1 Congress Street,Suite 100 C, .T 1 1�Sr u to Y0(-1—
Boston,MA 02114-2017 1
w%,mmass.gov/dia
M orkers'Compensation Insurance Affidavit:Builders/ContraRorsiElectricians/Plumbers.
TO BE FILED)ATTH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/OrganizatioNIndividuap:
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.[:]l am a employer with employees nuft snare pan must., 7. ❑New construction
4.❑I am a sole proprietor or parmeroup and have no employees working for me in $, ❑Remodeling
ano capacity.[No wurkerscompinsmmce required.]
3.Olamahomerwner doing all work thyself[Noworkers comp.iosuncerocteed.]' 9. ❑Duildin lop
m
4.❑lama homeowner and will be hiringcrntr .m conduct all work on my property. Iwill 10 ❑Bilding addition
ore mat on comtmGorseimer navewrrkws wmprnsatioo nammroc or as rule 11.❑Electrical repairs or additions
empowerswim no employees_ 12.Q plumbing repairs or additions
S❑1aa
m ,emend caotr eawand l have hiredhsu
e b<ontramors lismd on mfattaehedsheet.
These sub comorders have emo,loyees and have workers comp.insurance 13.E:]Roof repairs
6 we mea corpontum and osofficershaveexacisedtheirngld ofteord roper MGLc 14.❑Other I
152,p 44L and we have no employees.[Nm wodacrs comp-insurance required
"Any apphcmm mat cheeks box#1 most also fill out the section below showing hourworkers'compensation policy Infommtion.
'Homeowners who submit am affidavit indicating thev arc doing all work and men hire outside con6'aGrrs must submit a new affidavit indicating such.
Cosmo ic,that check this box must attached sn additional sheet showing the name of the sub-owe setors and smte whether in ora those entities have
employees. If the sub-contactors have employees,me,must provide heir waken'comp.policy member.
I am an employer that Is providing workers'compensation insurance far my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
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 fee up to$1,500.00
and/or ane-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.
I do hereby certify under thepains and penalties of perjury that the information provided above is true and correct
Suffiature7 Date'
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
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
ofthe 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,§25CC)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublie 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-contracter(s)name(a),addresses)and phone numbers)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 ifyou 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 collie appropriate line.
City or Town Officials
Please be sure that the affidavit is complete mid 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.
PI ease be sure to fill in the perm 0l'icense 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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat 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 bum leaves etc.)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, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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: A'1A1sC AVt
The debris will be transported by: AM OE hGc((�\.
The debris will be received by: )I;� 1ci'l �t '(L`�fL\/�►f� W.S�L�
Building permit number:
Name of Permit Applicant 011 AV PC
1�r*
Date Sig at re f Permit Applicant
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