31B-159 Demo app ChrisLife 2012-05-17Version!.7 Commercial Buildin 2000
City of Northampton
Building Department
212 Main Street
Department use only
Status of Permit
Curb Cut/Driveway Permit _______ _
S~wer'Septi.c AVl:lilabllll:y ___ ~ ____ _
WaterlWeil Availability_o _______ -\ Room 100
,rthampton, MA 01060
1--~~:-=~~41 t587-1240 Fax 413-587-1272
Two Sets of structural
Plot/Site Plans ____ _
Other
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 _______________ --L-----------~:__~;.__:__;__--_;_;__;"_;__~~----l
This section to be completed by office
1.1 Property Add ress: · 99 Ki~~ s;~e;··Chri~t~ian'~··~L~i~f·e·'"-C-'«e~~nt~e·r·~~"-····--'~~'.' ... -.. -."~,
I
I I 00 ''', .«,,< " •• , ,.m, , •• , .•.. -... ~-, •• ,.-.-.,-.. -.-.' .00 .~ ~ ••• ,.~
I SECTION 2 • PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
2.1 ~:'v.!!:!~!~~~()~~:~_ "'~_' ___ w_ , __ , __ 'W',_'
'St. Elizabeth Ann Seton Parish
, ,_, ",. ".",=_",',. ~-'.~ .w;w~"."" __ .. _"_~'*-____ ,_"'."'_-"'""'_W'a.,.~,.,""",,,"~,,',,"~,._,,-~ .. --_ .. -.-.kw-><_,,~'''~ ____ ''''''',_M.·_'
· Name (Print)
Signature
2.2 Authorized Agent:
,Ri~hru::~~vyT~;~~<:I~~~l~~~f'f!~~i~~~~f:~~~~p"~=~=
Name (Print)
, Signature
SECTION 3 -ES1"IMATED CONSTRUC"nON COSTS
Item
, 1. Building
, 2. Electrical
3. Plumbing
" 4, Mechanical (HVAC)
• 5. Fire Protection
6. Total =:: (1 + 2 + 3 + 4 + 5)
Map Lot Unit
Zone Overlay District
Elm St. District CB District
¥",_, __ ",_",-"""",-"",-"-",,, ",'_""'" -~--_.¥_-<'~ __ "W+~-,~,~_" __ ,_ ~ 0-_', .~-----,---
1m Street N?!!~~Et<:l~,Massachusetts
Telephone
Telephone
Official Use Only
Building Permit Fee
(b) Estimated Total Cost of
Construction from 6
Building Permit Fee
This Section For Official Use Onl
Building Permit Number Date
Issued
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 0 Existing Wall Signs 0 Demolition [2] Repairs 0 Additions 0 Accessory Building 0
Exterior Alteration 0 of Use 0 Other 0
Brief Description
Of Proposed Work:
-'-''''1.U'"'U''LVU of the Former Sacred Heart Christian Life Center
SECTION 5 • USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
0 A-1 0 A-2 0 A-3 0 1A 0
A-4 0 A-5 0 1B 0
B Business 2A 0
E Educational 2B 0
F-1 0 F-2 0 2C 0
3A 0
1-1 0 1-2 0 1-3 0 38 0
4 0
0 R-2 0 R-3 0 5A 0
0 S-2 0 58 0
Specify:
Fvi<:,tinn 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)
Total Area (sf) Total Proposed
Total Height (tt)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54)
Public [2] Private 0 7.3 Sewage Disposal System:
MUnicipal [2] On site disposal system 0
. 7.1 Fl99dZone Information:
Zone L" .""~~."= Outside Flood Zone [2]
Version!.7 Commercial Building Permit May 2000
~"'-8-. -N-O-R-T-H-A-M-P-T-O-N-Z-O~N-::-I-:--N=-=G:::---1'
!
Existing Proposed Required by Zoning
Tllis column to be filled in by
I Building Dep(u'tment
. Building Height
I
Bldg, Square Footage
Open Space Footage
(Lot area minus bldg & paved
,pa~in~ ____________ ~ __ ~ __ ~ ________ +-______ ~ ________ ~ ________________ _
A. Has a Special PermitlVariance/Finding ever been issued forlon the site?
NO 0 DON'T KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the R<>r,id','" of Deeds?
NO 0 DON'T KNOW
IF YES: enter Book andlor Document #
B. Does the site contain a brook, body of water or wetlands? NO @ DON'T 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 o , Date Issued:
C. Do any signs exist on the property? YES o 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
IF YES, describe size, type and location:
NO @
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 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Pennit May 15,2000
I 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 ENCL.OSED SPACE)
9.1 Registered Architect:
I Signature Telephone
9.2 Registered Professional Engineer(s}:
Address
Signature Telephone
Name
Address
Signature
Name
Signature Expiration Date
of Responsibility
, Address
I Signatu~-r-e-----------~---Number
Telephone Expiration Date
9.3 General Contractor
Inc. Not Applicable 0
Andrew Mirkin
732-3179 ;
Telephone
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10-STRUCTURAL PEER REVIEW (780 CMR 110.11)
Inde Structural Peer Review No
SECTION 11 -OWN • TO BE COMP
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1.~=================================~,asO~ercl~e~*ctpro~~
hereby
act on my behalf, in all matters relative to work authorized by this building permit
Signature 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.
Signature of Owner/Agent Date
SECTION 12· CONSTRUCTION SERVICES
Not Applicable 0
01106
Expiration Date
. R~I}j=i1~~1I7J~~="::=~~.·::~:"]
Telephone
I 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 permit.
ned Affidavit Attached Yes
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
N arne (Business/Organization/Individual): Associa:ted Building Wreckers, Inc.
Address: __ 3_52~A_lb_a--.:ny=-----St_re_e_t~ ___________ _
City/State/Zip: Springfield, Massachusetts 01105 Phone #: 413 732-3179
Are you an employer? Check the appropriate box:
1. [K] I am a employer with ~__ 4. D I am a ~eneral contractor and I
employees (full andlor part-time). * ~ave hIred the sub-contractors
2. D I am a sole proprietor or partner-lIsted on the attached sheet.
These sub-contractors have ship and have no employees
working for me in any capacity. employees and have workers'
compo insurance.t [No workers' compo insurance
required.] 5. D We are a corporation and its
3. D I am a homeowner doing all work officers have exercised their
myself. [No workers' compo right of exemption per MGL
insurance required.] t C. 152, §1(4), and we have no
employees. [No workers'
compo insurance required.]
Type of project (required):
6. D New construction
7. Remodeling
8. ~ Demolition
9. D Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roofrepairs
13.00ther _______ _
* 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lfthe sub-contractors have employees, they must provide their workers' compo policy number.
I am an employer that is providing workers' compensation insllrance for my employees. Below is the policy and job site
information.
Insurance Company N ame: __ Great Divide Insurance Company
Policy # or Self-ins. Lic. WCA 154516510 Expiration Date: 02/01/2011
Job Site Address: q9 '(.(~S~tf"ee~ CCkv:sh'A.AA. UJe C~ev-~ City/State/Zip: 00,,.4fbvt ,){A 19fOG70
Attach a copy ofthe workers compensation policy declaratIOn page (showmg the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA:£ \ insurance coverage verification.
!
1 I do hereby c~ tifY ;1Zder t lel\.:ns and J!!!...nalties of perj~l~ that t~e information provided above is trlle and correct.
Si nature: ~ ~'-. "-Andrew Mlrkm, PreSident Date: fu 1.0 ( 2.-
Phone #: 413 732-3179
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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0ther ________________________ __
Contact Person: Phone #:
mfo~t of fi>pringfftlb
65 Elliot Street -P.O. Box 1730
~prtnlJfftlb .. :fI~'u4tbU'uttt,U 01102
OFFICE FOR FISCAL AFFAIRS
william.labroad@diosDringfield.org
Mr. Andrew Mirkin, President
Associated Building Wreckers, Inc.
352 Albany St
Springfield, MA 01105
Re: St. Elizabeth Ann Seton Parish, Northampton
Dear Mr. Mirkin:
Tel: (413) 452-0687
Fax: (413) 785-5449
April 24, 2012
Enclosed is an original, fully executed Contract between the Roman Catholic Bishop of
Springfield and Associated Building Wreckers, Inc. for demolition of the fonner Christian
Life Center and Rectory at St. Elizabeth Ann Seton Parish, Northampton.
By copy of this letter, I am sending an original of the fully-executed Contract to Rev. John
E. Connors, Pastor of S1. Elizabeth Ann Seton Parish. We have retained an original for our
file.
Thank you and if you have any questions, please give me a calL
Ij
Enclosure
Sincerely yours,
William F. LaBroad, Jr.
Finance Officer
c: Rev. John E. Connors, Pastor, St. Elizabeth Ann Seton Parish (wi enclosure)