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31A-076 (17) 264 ELM ST BP-2019-1299 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31 A-076 CITY OF NORTHAMPTON Lot -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category- INTERIOR DEMOLITION BUILDING PERMIT Permit# BP-2019-1299 Project JS-2019-002097 Est Cost $800000 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const Class Contractor: License: use roux. WILLIAM B GABEL 076435 LotSizg(sa ftl� Owner: COCHR.4NE REBECCA Zoning:URB(100)/ ApR scant: WILLIAM B GABEL AT: 264 ELM ST Applicant Address: Phone: Insurance: 88 fNDUSTRY AVE (41.3) 584-13010 SPRINGFIELDMA01104 ISSUED ON.512212019 0:60:00 TO PERFORM THE FOLLOWING WORK:DEMO DENTAL OFFICE POST THIS CARD SO IT IS VISIBLE FROM THE STREEET 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: Aire Mpartment 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: FeeTypee Date Paid: Amount: Building 5/22/2019 0:00:00 5100.00 212 Main Street,Phone(413)557-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File 0 BP-2019.1299 GDM C APPLICANT/CONTACT PERSON WILLIAM B GABEL ADDRESS/PHONE 88 INDUSTRY AVE SPRINGFIELD (413)584-1301 Q PROPERTY LOCATION 264 ELM ST MAP 31A EARCEL 076 000 ZONE URB(100)' THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Rdildinc Permit Filled out _ Fee FAid Tvoeof Construction, DEMO DENTAL OFFICE�� No Construction Non Struclumil interior renovations Addition to Existing _ _A_ccessory Structure Building Plana included, Owner/Statement of License 076435 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) 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 Demolition,Delay/ n Signature of Building Official Date Note: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. •Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Vcrsionl.7 Commercial Building Permit May 15,2000 use,only RECEIVEDcity fNorthampton t:Derml Puking Department CudNGubDrrvaway PmlftT_ MAY i 5 2019 21Main street Saxe isaPDg Aasljhl iity Room 100 WatenViell Availability N rtha Tipton, MA 01060 7vm Sets offiructural Plans oi RT.of ewLmNrp E1R& 58 1240 Fax 413-587-1272 PlWsits Plane'- N0RTHwrn0N.MA01060 Other Bps* APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER `' ("THAN�AA ONE OR TWO FAMILY DWELLING ///� /y w SECTION 1-SITE INFORMATION mG O4/J d& (U nS ftokital) 1.1 Property Address: ], This section to be completed by once ,....2. & Y... Sr__. _.. Map ✓/� Lot o /CI Unit Zone Overlay District ._..._ ._. _. .__ .. Elm St District ca District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curren Mailing Address *t�AIN I MA 1Io�U Signature Telephone 2.2 Authorized Agent: 13 �i+4f3 EZ Tr o!/STp� SUE Name(Print) Current Mailing Address Signature Telephone L113 36 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 16 5. Fire Protection 6, Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date �maf l wb�'( I ® yahe-c), com w Versionl.7 Commercial Building Permit May 15,2000 SECTION4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations Existing Wall Signs ErDemolition R@Pairs❑ Additions E] Accessory Building❑i�+� Exterior Alteration ❑ Existing Ground Sign[:] NewSigns[] Roofing❑ Changeof Use❑ Other❑ Brief Description Enter a brief description here. —^' or4je- ,� 0&—� � 6- Of Proposed Work: n. v®eL erF �Gf�IJ (j O>r/F�G SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A4 ❑ A-5 ❑ 1 B ❑ B Business 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ElH High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ -3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ Sq ❑ S Storage 13S-1 ElS-2El 5B ❑ U Utility ❑ Specify: ._. _..._... _.. M Mixed Use ❑ Specify S 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 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1' ... 1s 2m 3p _.... 3m _... ._... Total Area(at) Total Proposed New Construction (sf)... Total Height(R) Total Height It _. 7.Water Su ly(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage D' osal System: Public Private ❑ Zone Outside Flood Zone Municipal On site disposal system❑ r I Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON TONING Existing Proposed Required by Zoning This column to be filled in by Building Departmem FFronta ze aks Front Side L R ._ L ....... R.. Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved ,_. .... ..... .....__. Jam #of Parking Spaces Fill: volume&Locavion A. Has aSpecio Permit/Variance/Finding ever been issued for/on the site? NO DON'TKNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O. IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO P--`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 O NO 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 IF YES, describe size, type and location: E Will the construction activity disturb(cleaning,grading,exca)0ion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO UZ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.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 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: �Gl /lf.T� � ✓J��!`�fFi ..![Fc"z.( .. Not Applicable ❑ _.._.. . Name(Registrant)'. 2qG-2-1,1977- 2Q— STTr4 Registration Number Address Y/3 n0 79Ir -S- Expiration Date Signature Telephone 92 Registered Professional Englneer(s): 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 Telephone Expiration Data Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company NamNapp/Je'.� Responsible In Charge of Construction blt- T� ✓� i R y E• -�- AiR- O/✓ate Atltlress ye3736 Bq9 Signatur Telephone 10 Version 1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(730 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize 6e1J ( i 6C2, y G/i� to act on my behalf, all matterI e to work authorized by this building permit application SignaffirpofOwner Dale 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 penury. Pnnt Na -C�ji Sgnature of 0wna±2tt Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: lJ �r tt Not Applicable ❑ Name of License Holder ��(/(�!/�1`I B` LZ. 0`i License Number Atltlress ' Expiration Date e{! zLi D/ Jr Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152,§25C(6)) Workers Compensation Insurance affidavit t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil permit. Signed Affidavit Attached Yes a No O 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: " The debris will be transported by: e-S7� / �es; v/A� The debris will be received by: Building permit number: Name of Permit Applicant /9-6C TFY- '86//tf r^e Z C- Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite Boston,MA 02114-4-200177 www.mass.gov/dia N1 others'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -.rte, q Please Print Ledibly Name(Business/Organizationilndividuab: / p1Ci _80 Address: ltay City/State/Zip: -p'"�Y� A:�1 o' Phone#: Y 13 F7 3 b ' 069c? Are you employer". Check the appropriate box: Type of project(required): 1. lam a ear,byer withemployees, fuldmWmIntl-nmol" T gEon struetion 2.M l amasole proprietor or partnership and have no employees working hornets $, ing any capacity.Ma workers'comp.Irnumnce required.] 3❑1 am a homeowner doing all work myself[No workers'comp.saran ance required 1Building 4 E I an a homeowner and will x had excmrs[o conduct an work on swill lO�Building addition g con y property exc me that all contractors other have workers compensation insurance or are sole 1L[]Electrical repairs or additions Provriamrawaw oo employees. 12.❑Plumbing repairs or additions 5❑I am a general contractor and I have hired the sub-contractors listed on the atuched sheet. 13.�Roof repairs These subcontractors have employees pard have workers'comp. irtsuwre.• 6MWe are a cmparanon and its officers have exercised weir right ofexemptiun per MGL c t4.❑Olher 152,f u4),and we have no employees.[No wokers'comp_ivumnceregori •Any applicant war checks box pl most also fill Out the section below showing thcr workers'compensation policy inforneram t Homo wmns who submit this affidavit in lmanag they are doing all work and wen him oreade contractors most submit a new amdavir indicating such. :Contmcwrs that check this box area attached an addinooel sheet showing we name of we sub-contradma and slide whether or a0[those entities have employees. If the sub-contrecmrs have employees,they mast provide then workers 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 2,& ( 6:-- n— City/State/Zip!Il//a-e4//7C'fi471A) 010&V 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 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 fflperjury that the information provided above is true and correct Sumature, Date- L Phone#: T Oficial 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 tmstee 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 ofthis 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-contractor(s)name(s),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 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 ofthe 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 permitllicense 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 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 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 Initial Construction Control Document i To he submitted with the building permit application by a Registered Design Professional {y for work per the 9°i edition of the Massachusetts State Building Code,780 CMR, Section 107 Project Title:Cochrane Dental -Renovations to Dental Office, Date: May 14,2019 Property Address: 264 Elm Street- Second Floor,Northampton,MA Project: Check(x)one or both as applicable: ( )New construction (X) Existing Construction Project description: Demolition of existing plaster partitions,cabinetry,plumbing fixtures and electrical wiring in portion of second floor dental office for future office expansion. I Brian De Vriese MA Registration Number: 734SAR Expiration date:08-31-19 ,am a registered design professional. and I have prepared or directly supervised the preparation of all desilm plans,computations and specifications concerning : (X)Architectural (X) Structural Mechanical Fire Protection Electrical Other: for the above trained project and that to the best of my knowledge, infomuation.and belief such plans,computations and specifications mcct the applicable provisions of the Massachusc°tts State Building Cale,(780(:MR),and accepted engineering practices for the proposed project. l understand and agree that 1(or my designee)shall perform thenecessary professional services and be present on the mmctruction 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 professionuals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the Rage 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 3.1 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 Construction Control Document'. Ester in the space to the right a"wet'or electronic signature and seal: S.rERED ARchr µ Di No.7348 m N ry HEATH 'o MASS. r Phone number:(413)747-5285 Email: brian@J,idarehitects.com Building Official Use Only Building OtHGal Name Permit No Dale: V©,ion 06 I 1 2013