22B-040 (17) 221 PINE ST BP-2019-1111
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mno:Block:22B-040 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinc DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:renovation BUILDING PERMIT
Penni[# BP-2019-1111
Project# JS-2019-000699
Est.Cost:$11500.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Grow: JESSE BEREZIN 102213
Lot Sudan. fn145926.00 Owner: BRUSH WORKS THE LLC
Zoning: Sl(l15)/WP(I15)/WSP(I)/ Applicant. JESSE BEREZIN
AT: 221 PINE ST
Ann(icant Address: Phone: Insurance,
245 TANGLEWOOD DR (413) 374-2729 WC
LONGMEADOWMA01106 ISSUED ON.41912019 0.00:00
TO PERFORM THE FOLLOWING WORK.BUILD WALL IN SPACE 130 AND FIX
BATHROOM"FIRE PROTECTION SHOP DRAWINGS PRIOR TO FINAL INSPECTIONS
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 Fireplece/Chlmney:
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 Shinsture:
FeeType: Date Paid: Amount:
Building 4/9/20190:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
ST _ oG
File 4 BP-2019-1111 0�!� - /D.3
APPLICANT/CONTACT PERSON JESSE BEREZIN
ADDRESSIPHONE24STANGLEWOODDR LONGMEADOW (413)394-2729
PROPERTY LOCATION 221 PINE ST
MAP 22B PARCEL 040 001 ZONE SI(I I5VWP(115VWSP(1V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONINGFORM FILLED OUT
Fee Paid
Building Permit Filled out 4A NW
Fee id I
Tvneof Construction: BUILD WALL IN SPACE 130 AND FIX BATHROOM FI P( TECTI a N r"Q r
New Construction hmw'mr'C PftlaR '}U frN/Al
Non Structural interior renovations I N SR2`rn N S
Addition to Existinu
Accessory Structure
Building Plans Included:
Owna/Statement or License 102213
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF
QRMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Projea: 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 Varian"'
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 ofHeahh
Permit from Conservation Commission Permit from CB Architecture Committee
_Permit from Elm Street Commission Permit DPW Storm Water Management
_Demolition Delay
Signature of Building Official Date
Nae: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.
s Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Version].?Commercial Building Permit May 15,2000
Department use only
City of Northamp it:
Building Departm qnt RECE119 y Permit
212 Main StreSewer/slept c vailabiliry
Room 100 APA & aier/wee A ilabiuy
Northampton, MA wo Sets of S ctural Plans
phone 413-587-1240 Fax 13- 7-1272 PlottSite,Plani
DEPT_OF EU11 DIV,igars sla ciy
APPLICATION TO CONSTRUCT,REPAIR,RENOVA7 UPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This seeeon to be cotnpieisd by olllw
3.�1 (gisv. S+ flot•ehw Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Oamer of Record:
He 6'+ Butz,- _ (,G7 1`t'lw h ${ of JYIA 01040
Name(Pring Current Mailing Address:
1113 331
Signature Telephone
2.2 Authorized Acent:
3 e.45e. 13v1.2ir 1N5 tw l...w• �. lnny^rw.sow el
Name(Print) Current Mailing Address:
• NI3 37`i 7.11,1 J
Signature Telephone
SECTION3-E I UCTION
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building 3 O o (a)Building Permit Fee
2. Electrical LOO 0 (b) Construction
Total Cost of —�
Construction from 6
3. Plumbing 7.S 90 Building Permit Fee
4. Mechanical(HVAC)
_ 1
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Up Onty
Building Permit Number Date
Issued
Signature:
Building Commissbnedinspects,of Buildings Date
vE�_
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 1:1 Repairs❑ Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ Now Signs❑ Rooting Change of-Use,0 Other❑
Brief Description Enter a brief description here. (i41L%,m all in spwce 130
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A4 ❑ A5 ❑ Ill
❑
B Business 2A ❑
E Educational ❑ 2B ❑
F Facto ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 1 4 ❑
R Residen0al ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage ❑ S-1 ❑ S-2 ❑ SB ❑
U Utility ❑ Specify:f
M Mixed Use ❑ Specify:LC
S Special Use ❑ Specify: j
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 8 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
2n° _ � 2- —.
3' 3-
4m
0
Total Area(sf) Total Proposed New Construction(sq
Total Height(e)
Total Height R
7.Water Supply(M.G.L.c.40,§54) 7.1 Fl ZAane nformsOon: 7.3 Sewage Disposal System:
Public 0 Private ❑ Zone a Outside Flood Zone[] Municipal 0 On she disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Dcpormmnt
Lot Size
Frontage
Setbacks Front
Side U R: L R: �-
Rear
Building Height LJ
Bldg. Square Footage %
Open Space Footage % _
ILM mea minus bldg&paved
akin
#of Parking Spaces;
Fill:
volume&Location
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO O DONT KNOW YES Q
IF YES, date issued: I
IF YES: Was the permit recorded at the R try of Deeds?
NO O DONT, YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained O , Data 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 O NO V
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,0 Ion,or filling)over 1 acre or is a part of a common plan
that will disturb over 1 acre? YES O NO /lel(
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 119(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registentl Architect:
-- Not Applicable Ot
Name(Registrant):
i Registration Number
Address _
Fxpiretion Date
Signature Telephone
9.2 Regluftnid Professional Engineer l:
C _
Name Area of Responsibility
_ I
Address Registration Number
Signature Telephone Expiration Date
NameArea of Responsibility
L ---- _ J
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
J
Signature Telephone Expiration Date
Name Area of Responsibility
Address Regist-b- Number
Signature Telephone Expiration Date
9.3 General Contractor
':_'0{ �'�p�D�4. " M _L(—C Not Applicable ❑
Company Name:
3r-Sic �¢ttLi\
ri\ __. .
Responsible In Charge of Construction p _
FYS 1wv )a �- c1r I.y%j g b ,L1 N% 01104
AdAniss
wIre X113 37N 7,71"1
Telephone
Versionl.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 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR n CONTRACTOR APPLIES FOR BUILDING PERMIT
Htf6e 4 r�1ycZ1 vs as Owner of the subject property
herebyauthonze.. '1CSSt. P[7C.Zt h. —... to
act on my behalf,in all matters relative to work authorized by this building permit application.
Y )1 J
Signal of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and spotlrete,to the best of my knowledge
and belief.
Signed under the pains and penalties of pequry.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: St5$C I�CyC,tj N 10"13
License Number
2�)5 +tn.�nkyoa�. Tlr loyw�,ytct�,a ^(Y'Pc 011oG_ a��o�s1
Address l Date
)LME 413 31`I 171�I
Sign a Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Ill c.152,§25C(8))
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 bulkling permit.
Signed Affidavit Attached Yes No O
,3H - 6955
>x �, ..
[Sl
ets are sufficient in r
0, so brg as there
Elevator at least5separateits
m >. r
18 2 2 2
9 .o..d. '. 3
3-
- 7//Z / \
8 5 5 5
}ycw V.1u•lI �n 'Ra.B„
i
�\ The Commonwealth ofMassachuseffs
Department of IndustrialAcclidents
7 Congress Street,Suite 100
Boston,MA 02114-2017
www n%zssgov/dia
\1 orkers' Compensation Insurance Affidavit:Builders/Contmetors/Ekclricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/OrgmimtialMdividual): Mount Holyoke Management LLC
Address: 667 Main Street
City/State/Zip: Holyoke, MA 01040 Phone#: 413-534-0955
Are race am employer?Cheek the appropriate hos: Type of P ro 1eat(required):
LQ l am a employer with 89 cawloyees(full and/or pot-time).• 7. []New construction
2.❑Ismasole goprimumparmardpand have no employees working famein g. ❑K Remodeling
any .cwwity.Mo worman comp.insumnce regithad.l
3.❑1 am a homeowner doing ell work myself[No workers'comp.insummce required.]r 9. ❑Demolition
❑1.❑1 mm a homeowner and will b ahiring contractors ro conduct all work on my property. 1 will 10 Building addition
um
'mthan all<omnmots either have workers'compensuion insurance or are sok 11. Electrical repairs or additions
proprktorswithno employes.
12.❑Plumbing repairs or additions
s.❑lamagecemlmnu and have dthe
aveboomscmrahstad on tn<anuhed slsxL 13.❑Renfrepeirs
These subcwbacwrs have employees and love woheri comp.insmutc<:
6.❑we ere a corporation..it its officers have exercised their right ofexemption per MGL c. 14.E]Other
152,11(4k and we have w empleyces.Mo worker%com,insurance requhed.]
'Airy applicant that checks box N must also fill out the section below showing their workers'wmpm titan policy information.
t Homeowners who submit this affidavit indicating they am doing all work and than hire outside wnimctors must submit a taw affidavit indicating such.
lConnactnrs that check this Mm must attached m additional zhcm zhowim,the name ofthe sub-eontactnb end sate whether or not thmx entities have
employees_ If the suM1umnncmrs have employes,they muni pmnde Iheir woken'comp policy number.
I am an employer Mat Is prodding workers'Compensmod l lasuranee for any employees. Below is the policy and job sire
Information.
Insurance Company Name: Wesco Insurance Company (AmTrust North America)
Policy#or Self-ins.LiaM WWC3372226 Expiration Date: 9/9/2019
Job Site Address: 481 Belmont Avenue City/State/Zip: Springfield, MA 01108
Attach a copy of the workers'compensation policy declaration page(showing/he 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 54500.110
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is nue and correct.
Sitma mor Date: April 8, 2019
Phone#: (413)534-0955
Off eiat use only. Do not write in this area,to be completedby city or town official
City or Town: Permit/Liceose#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.CRy/rown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Wesco Insurance Company
A Stock Insurance Company
WORKERS COMPENSATION WC 99 00 01 8
AND EMPLOYERS LIABILITY
INSURANCE POLICY INFORMATION PAGE
Neci Code: 26135
L Insured: Policy Number: W WC3372226
Mount Holyoke Management LLC
667 Main Street
Holyoke,MA 01040 _Individual - _Partnership
Other workplaces not shown above: _Corporation X LLC
See Extension of Information Page Federal Tax ID: 261912755
Producer: Risk Id:
AmTmst North America,Inc. Renewal ol': W WC3305132
c/o Amity Insurance Agency,Inc.
500 Victory Road,Marina Bay
Noah Quincy,MA 02171
2. The policy period is from 9/9/2018 to 9/9/2019 12:01 a.m.at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of
the states listed here:Massachusetts,Vermont
B. Employers Liability Insurance:Part Two of the policy applies to work in each stale listed in item 3.A.
The limits of our liability under Pan Two are:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$500,000 each accident $500,000 policy limit $500,000 each employee
C. Other States Insurance:Pan Three of the policy applies to the states,if any,listed here:
All states except ND,OH,WA,WY and States)Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating
Plans.All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
STATE ASSESSMENT
TOTAL ESTIMATED COST
Minimum Premium
Deposit Premium
Issue Date: 8/15/2018 Countersigned by:
Authorized Representative
4
Prom: ,
csr.sse c3ax..Zr..
I�FNtirt,,diao�w � O1106
To'
Louis Hasbrouck
Building Cormnissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control In certain situations.In accordance with code section 104.10, 1 request that you
grant a modification to waive the requirementyfor construction control of the project at
8�wl.wo�ka )34 P:ve 5� klavty Lc' 11n
because the work is of a minor nature,will not affect structural elements,health,accessibility,life or fire
safety,and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,