23A-040 (25) 52 MAPLE ST BP-2019-1227
GIS s: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-040 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category,ROOF BUILDING PERMIT
R=A 4 BP-2019-1227
Projects JS-2019-001984
Est.Cost:$105600.00
Fee:5737.20 PERMISSION IS HEREBY GRANTED TO:
Const.Class; Contractor: License:
Use Group: MDM ENGINEERING INC 072493
Lot Size(sa.ft.): 20803.88 Owner: NORTHAMPTON HOUSING AUTHORITY
Zoning:GB(100V Applicant. MDM ENGINEERING INC
AT: 52 MAPLE ST
ApplicantAddress: Phone. Insurance:
51 SAWMILL RD (774)230-0734 WC
DUDLEYMA01571 ISSUED 01.5/2/2019 0.00:00
TO PERFORM THE FOLLOWING WORK:STRI P & SHINGLE ROOF
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: Houses 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 OccuoancY Siensture:
FeeTvpe: DatePald: Amount:
Building 3/2/20190:00:00 $737.20
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
,r �F
Versionl.7Commercial Building Pertmd M., L. _'000
—,n '-- rV
_J Department use only
�� -- -
Q4 of Northampton Status of Permit:
Bui ing,Department Curb CWDriveway Permit -
MAY �p�9 2 2Mainstreal Serer/Septic Availability
Room 100 Water/Well Availability
� ,r�T,�iNtha pton, MA 01060 Two Sets at structural Plans
1240 Fax 413587-1272 Plot(Site Plans
L 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 lT
SECTION 1 -SITE INFORMATION B i9 I7- ( �1
1.1 ProAciondss: Thiss7seWon to be compffi
completed by oce
Map 0
a�i7 Lot q0 Unit
Zone Overlay District
------ Elm St.District Ca District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner PfRecord: ���y
f S 5 4�' iPH `.
Name(Pont) , ,,,,;��(� Current Mating Address'. - _-.
Y13- 5-9Y- %� d
Signatue Telephone
2.2
rized
_.
Name(P ,
/�yj H,U / r fl Current Mailing Address:
/ rw.- /ApVt
Sbs f'sG t11l37'__ ----------
Signature Telephone
SECTION 3-ES D ONSTRUCTION COSTS
Item Estimated Cast(Dollars)to be Official Use Only
completed bperm itsop lident
1. Building 4, (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee p�
4. Mechanical(HVAC) Z6
5.Fire Protection
S. Total=(1 +2+3+4+5) /N.St OO Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
S 12019
Buildirg Commissioneramlmctar of BUldings Date
6-il d
Vemiont.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 Repairs Additions ❑ Accessory Bulldjng❑
Exterior Alteration [IExisting Ground Sign❑ New Signs[3 Roofing[] Change of Use[3 Other•a-E✓
Brief Description Enter a brief description here. C
Of Proposed Work: (/ r A- 1 -
SECTION S-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly11A-1 1:1A-2 11A-3 11 IA 13
A4 ❑ A-5 ❑ IS ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 1 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ se 1 ❑
U Utility ❑ Specify ,
M Mixed Use ❑ Specify:
-- — ._
5 Special Use Cl Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: posed Use Group:
Existing Hazard Index 780 CMR 34): - Proposed 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)2.
2.^°
I,IY 4m
4.
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height it
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private ❑ I Zone Outside Flood Zone❑ Municipal ❑ 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 vi by
�i00 _ Ao Building Del .-t
Lot Size
Frontage
Setbacks Front
Side L:.._.,,, R: I.: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(W.minae bug a Pnved __...
#of Parking Spaces
Fill:
.ol,we&IMsnovl
A. Has a Special Permit/Variance/Findin er been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Regis of Deeds?
NO O DONT KNOW YES O_
IF YES: enter Book Page: r� and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ( i1 DONT KNOW O YES O
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:
D. Are there any proposed changes to or additions of signs intended for the property? Y S
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excava .or filling)over 1 acre or is it part of a common plan
that will disturb over l ase? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Vemionl.7 Commercial Building Pennit 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 Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Exgration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telelahwre Expiration Date
9.3 GyyeA�n++eAAral Contra
{c
'tor
/(V .oai�P LWf a< Yy� Not Applicable❑
CompaM Name.
7d; tniet
Responsible In arge of Co aI of
T
Address
.•`S Z�-�31
Signature Telephone
Version L7 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 If-OWNER AUTHORIZATION-TO BE COMPLETEDWHEN
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 authonzed by this building permit application.
Signature of Owner Dale
as Owner/Authorzed
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 al' erjury.
i
Print Name
Signature of OvmedAge Date
SECTION I2-C UCTION SERVICES
10.1 Licensed Construction Supervisor: /f Not Applicable
/// ❑'/
Name of License Holder. 7Ji'47/e✓ ,/ 4r, LS— 0V yf3
f Lieense Number
S/ El G!t __o G /
Address Exp2kon Date
tea- yrd- ' 3
Signature Telephone
SECTION 13- RKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152,S 2SC(S((
Workers Compensation Insurance affida must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui ng remind.
Signed Affidavit Attached Yes No O
Z fnro C 2, CC(-
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: � /ala �G/�J
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant A4e1 1*z r Jrorz
6( 7
Date Signature of Applicant
r
The Commonwealth of Massachusetts
Department of IndusurialAccidems
I Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.mass.gov/dia
Wil.rkers'Compensation Insurance Affidavit:Builden/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Pleathe Print Leuribly,
Name(Business/Organizatiyowlndividua0; Of h-C.
Address: 04/
City/State/Zip: Phone#: Sb&' t JD' 3r
Me you an employee C'hecli the approprb box: Type of Project(required):
l. employm withemploY«s(fish aod/m peen-time).• 7. []New construction
2.❑lamamlepopsmrmparmershipadbwwe ployeawokm Ramiro 8. Remodeling
airy maxim .(No workers'comp.announce required.)
3.❑ m laa homeow«r doing all work myself[No woskcss'comp.insurance mumsfI 9. Demolition
4.❑Imoa�m tlbehvingsmnhaaussmcwwtallworkmmy ROMry [will 10❑Building addition
war
rows that an contractors eimhave workers'compensation momenta mare sole 11.❑Electrical repairs or additions
timeworn with no employees. 12.❑Plumbing repairs or additions
5.Ej 1 am a general contracmr and 1 have hated ac sub-mntrcmrs lassie.the manshed shat-
These sub-contractors have employees and neve workers comp.immaoce.: 13.E]Roof repairs
6.❑we area corpomtien and its omcere have exercised their right ofesemption M MGL c. 14.[]Other
152,41(4).ad we have w employe¢INo worke,s'comp.iacurauce required.]
•Any applicant out check box of must also fill out the section below showing their worker'compemation policy information.
I Bommwass who salami,this undavit Lwhoa mg Jury are doing all work and then hhe outside contramors must submit a new i flidavit indicating such.
:Cono-aten,out check this box most atuchd an Colum v it sheet showing the name of the sub-conhaeless and some whether nr no,those entities be—
employees. If the su4cnnrtaams base employees,they must provide dwir workms'camp.policy reenter
I am an employer that is providing workers'compe octan insurance for my employees. Below is the policy and job site
information. /�
Insurance Company Name: p NrB Naly� SuYn.rte �
Policy#or Self-ins.Lic.#: GZVC//f—S7=JcV///� Expiration Date:'
Job Site Address: /7`� SH City/State/Zip: lwI/ .,.a/ "'V'-
Attach a copy of the workers'compensalhon policy declaration page(showing the policy number and�expdatioo-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.
do hereby cerBfy under th penalties of perjury that the informationprovided above is ir e a d correct
Si alum: Date: S
Phone#: "ad
Official use only. of 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/To"Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Met
Contact Peron: 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 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)stales"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)name(s),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 m 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 listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sum 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 to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitAicense 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 furore permits or licenses. A new affidavit mug 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 me.)said person is NOT required to complete this affidavit.
The Departments 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
NORTHAMPTON HOUSING AUTHORITY 667- 3 = �i
TOBIN MANOR, ROOF REPLACEMENT
ii
52 MAPLE STREET, NORTHAMPTON , MASSACHUSETTS -
DHCD PROJECT # 214108
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
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LOCUTION M1P5 S A
LISTS, DRAWINGS
MAPS,
T TITLE,
L
S
PIA ,
LIST OF VIAnONS,
LFT OF OIWNS
1 ROOF PLANS
3 RLROALELEVATIONS/GU Ilt
MIN WATER LEADERS,DETAILS
i rr . - - IEGEND JOB NORTH
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Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the ninth edition of the
ul) Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Date: 2' !9
)7✓T'r'�Y�f, t�o lsw �C-N.dVt ✓Z"t'/rG{��'j'
Property Address: ,62 M4 (C(i ..s / P(�v�.w,�
Project Check(x)one or both as applicable: New construction (Existing Construction
Project description:
I MA Registration Number. G g1'OExpfration date: {(ply�am�registered design professional,and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerning':
dritectural,
Structural Mechanical
re`s—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 I (or my
designee) shall perform the necessary professional services 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.
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 Constivctio ent'.
d9~ ay R.P��
Enter in the space to the right a"wet' or a a°cam Fir
electronic signature and seal• 1W 887
GR
/ MA
Phone number: ¢13 64'1109 Email: rarcl�r� vFi Ut,Y, Lyit/l rrs s
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1.indicate with an Y project design plans,compulatiom and specifications that you prepared or d w ly supervised.lf'othef is
chosen,provide a description,
version 01 01 1018
,eco d CERTIFICATE OF LIABILITY INSURANCE F
04/02/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE GOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of tiW Policy,certain policies may reguirs an endorsement A sMemenl on this certificate does INN confer rights to the
certificate holder in Ilsu of such oMonemen ..
PRODUCER NAME: Suzan Trepamer _
O'CONNOR&COMPANY INSURANCE AGENCY INC P"DN$ 1, (509)943x333
i063: suzaM oconrxxkmr.can
P O BOX 1455 IxauRE IIFPoImINBCOVQWE xuc4-
DUDLEY MA 01571 oSURERA: AMGUARD INSURANCE CO 42390
INSURED scene"
MDM ENGINEERING COMPANY INC WSURERc:
SWREAe.
51 SAWMILL ROAD INSURER E:
DUDLEY MA 01571 W.RER F:
COVERAGES CERTIFICATE NUMBER: 385281 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF Al CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMSloi .
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Workers'Compensation ber efits will be Paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 OB B,no authorization is given to pay
claims for benefits t0 employees in states other than Massachusetts ifthe insured rate,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the dale that this certificate was issued(unless the expiration date on the above policy precedes the
issue data of this cerlificate of insurance). Tlx:ststue of th" cevemge can be monitored daiy by aax ng the Proof of Coverage-Coverage Verification
Search tool at .massgov/IwdNJodeers-compenaationfi v stigaOonsl.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Department of State Police ACCORDANCE WITH THE POLICY PROVISIONS.
470 Worcester Road
AYIXWaEEDREPRF9ENTATVE
Framingham MA 01702
Daniel Clr;ey,CPCU,Vxx President—Residual Market—WCRIBMA
01988-201{ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD mmol and logo am registered marks of ACORD
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS -072493 Expires: 09/06/2019
ZBIGNIEW MROCZKA
51 SAWMILL ROAD
DUDLEY MA 01571
Commissioner