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18-007 (11) 216 NORTH KING ST BP-2020-0641 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18-007 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DON OT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Zoning Permit BUILDING PERMIT Permit.# BP-2020-0641 Proiect# JS-2020-000637 Est.Cost: $495796.00 Fee: $3741.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VANTAGE BUILDERS 070708 Lot Size(sq.ft.): 67822.92 Owner: RANDALL GERALD F Zoning: Applicant: VANTAGE BUILDERS AT: 216 NORTH KING ST Applicant Address: Phone: Insurance: 204 2ND AVE 781 895-3270 WC WALTHAMMA02451 ISSUED ON.121412019 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO EXISTING SPACE TO USE AS A MEDICAL MARIJUANA DISPENSARY 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 DeDartment 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: Feer e: Date Paid: Amount: Building 12/4/2019,0:00:00 $3741.00 12 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0641 APPLICANT/CONTACT PERSON VANTAGE BUILDERS ADDRESS/PHONE 204 2ND AVE WALTHAM (781)895-3270 PROPERTY LOCATION 216 NORTH KING ST MAP 18 PARCEL 007 001 ZONE . THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLIC HECKLIST ENCLO D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid Typeof Construction: RENO EXISTING SPACE TO USrAWA MEDICAL MARIJUANA DISPENSARY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildinp,Plans Included: Owner/Statement or License 070708 3 sets of Plans/Plot Pla THE FOLLOWING ACTIOP HAS BEEN TAKEN ON THIS APPLICATION BASED ON INJORMATION 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: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Co servation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay IV4M Sig ture of Building Official I U Date .Note: Issuance of a Zoning pe mit 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. RECEIVE Version 1.7 Commercial Building PeTn*May 15,2000 NOV 1 $ City of Northampton 2019 � n Building Department 212 Main Street Sx LN OF BUILDING INSPECTIONS Room 100 as. RTHAMPTON,MA 01060 Northampton, MA 01060 , p one 413-587-1240 Fax 413-587-1272 &' 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 Property Address: This section to be completed by office 216 North King St. Map ` Lot 00 q Unit Northampton,MA 01060 Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIPtAUTHORIZED AGENT 2,1 Owner of Record: !Eric Powers 13494 Martin Durst Road Tallahassee FL 32312 Name(Print) Current Mailing Address: (850)298-8640 Signature Telephone 2.2 Authorized Agent: f Devereux Sganunato L2p4 2nd Ave. Waltham,MA 02451 Name(Print) Current Mailing Address: (781)895-3270 Signature ,✓ _ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building _ _ $29,606.00 (a)Building Permit Fee 2. Electrical $110,000.00 (b)Estimated Total Cost of Construction from 6 3. Plumbing $47,390.00 Building Permit Fee 4. Mechanical(HVAC) - `} 5.Fire Protection $88,800.00 6. Total=(1+2+3+4+5) $495,796.00 Check Number This Section For Official Use Only Building Permit Number Date Issued Signa re: Buildin Commissioner/Inspeator of BuildingiV Date I Versionl.7 Commercial Building Pmmit May 15,2000 CSI&:CONS ON,SERVICES FOR fTtWECTS LESS THAN 85,QD4 CUBIC.RW-OF:9*LQSED BPACE Irdedar Alterations El Existing wall Signs ❑ Demolltlan❑ Repairs❑ AddMons ❑ Accessory Building❑ Ederior Aitaragm ❑ Existing around Sign❑ Now Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Renovate existing tenant space for retail marijuana store. Of Proposed Worts: SECTION 5-.USE GROUP AND.CONS1RUC ION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 28 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ N High HmWd ❑ 3A ❑ I institutional ❑ I-1 ❑ I-2 ❑ I- ❑ 3B M MaroanHte 0 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ spear.. M Mixed Use ❑ spew. S Special Use ❑ Specify: COMPLETE THIS SECTION IF DOSTING BUILDING UNDE11GOING RENOVATIONS,ADDIMNS.AND/OR CHANCE W.UBE Existing Use Group: MerCentile Proposed Use Group: M rCentffe Exbft Hazard Index 780 CMR 34: 2 tPmposed Hazard Index 780 CMR 34): --� SECTION 8 BUILDING.HBGHT;AND.ARFA BUILDING AREA EXISnNG PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) lot 3 809 1°l3,8091 2nd 2 Total Area(s) 3809 Total Proposed New CanstruCtion(51) 3,8091 Total Height(ft) 1 Total Height ft 16 �=�a m`t�'.•s' sib'+:"'_:., -.�clt•,?ni.'. er; T.Water Supply(M.G.L.c.40,§54) 7.1 FIgA Zang nfomrallon: 7.3 Sewage Disposal 8ystem: Pubk ❑ Private❑ Zane Outside Flood zone m., Municipal t] On sfte disposal system Vereioal.7 Caurxnesciat Building Permit May 15,2000 MAI M" w. E�asting Proposed Required by Zaning lhis celaam tobe 9Wcd ffi by Bis Lot Size X7.8 167.914' Fronp 11290 Setbacks E= 5[Z MY t-- D && L 0 R= L:�R:= D D $� REM Building Height Bldg.Square FootageOpen ® � �Space bWg&Pm ® ® 'yo ME #ofPadcmgSpaces ® © 0 FiII Loc adon A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DANT KNOW O YES 0 IF YES: enter Book F Page and/or Doctunent# B. Does the site contdin a brook,body of water or wetlands? NO O 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 an the property? YES O NO (D IF YES, describe , type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E WO the constnwtlan activity dlst<ub(dioarittg,graciing,excavation,orffing)over 1 acre or Is It part of a common plan that wiEl disturb over 1 acre? YES O NO O IF YES,than a Northampton Storm Water Management Permft from the DPW Is required. Veisionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND 7 CO - UCTION CONTROL PSTRUCTURES SUBJECT 70 NSTURSUANT TO 139 CMR 1'16 CONTAINiNO MORE THAN 35,pp0 C.F.OF EfVCLO3ED SPACE 9.1 Re Istared A rcttitecL S hen A. Sousa . Not Applicable O Name(Re istrant): 81 B0 lSt411 St Brookline, NIA 02445 Registration Number Address ! ° (,j7�3i 2a2 0 (617)879-9100 ExPirabonDet sigr�ah>!e - T tone 9.2 R ped Profe tonal En jinee a): T.J.Conway Name -Mechanical . �.._�.. _ An3e of Re.�,onsibilrty 26 Progress Ave S .__.� eld,MA 01104 �- MGS Registration Number re {413)732-5131 ,-- --- TaE bane Esq tratl n DOE U "versal Blectr*C Co. Name - lectnCal 79 WaYside estMA 0148Are6 of Responsibilty r eld, 9 -- --- R istra8 r _ 1 SIS µµrsxr �-•'';"' "" Tele hone P Expiration Date Ares of Responsibility Address Reglsfmtion Number ! Signature .. Teleph expiration on Date �-- - NameName '— Area of Responsibility Address (' Reg(stration Number { - Signature Telephone t:.xpiratlon Date "` i X9.3 General Contractor (vantage Budders,INC Com any Name; Not Applicable Devereux Sizammato Responsible In Charge of Con 204 2nd Aver Wi I MAQ2451 w_ Addr (781)895-3270 S! t Telephone Version I.?Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes No %V SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Eric Powers as Owner of the subject property jVantage Buil C. hereby authorize to act an my behalf,in all matters relati,�e to work authorized by this building permit application. Signature of Owner Date L. eveTeux Sgammato as OwnerlAuthorized Agent hereby declare that the statements and information on the foregoing apptication are true and accurate,to the best of my knowledge and belief. Sijaqc�unqer the pains and penaitle of erjury- Prlame sit AFatof OwnVAgent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Sg2gaisor: Not Applicable 0 Name of License Holder: ICS-070708 License Number 204 2nd Ave.Waltham MA )2451 2/2_021 .................. Address Expiration Date 1�(7���S9�:b95-3270 _.._._...._3 Signature Telephone 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 building permit. Signed Affidavit Attached Yes No 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: I /�The debris will be transported by: �-, �, ��V The debris will be received by: Building permit number: Name of Permit Applicant P r j 71 � Date Signature f Permit Applicant A�" CERTIFICATE OF LIABILITY INSURANCE DATE(.MiDD[YYYY) 11/2812018 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 DOES 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(ies) must have ADDITIONAL INSURED provisions or be endorsed. It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Woodruff-Sawyer&CO. NAME; PHONE FAX One Liberty Square Suite 600 _(A/c •617-658-7100 No):617-658-7198 Boston MA 02109 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Admiral Insurance Company 24856 _ INSURED INSURER B:Safety Insurance Company 39454_ Vantage Builders, Inc. 204 Second Ave INSURER c:A.I.M.Mutual Insurance Co. 33758 Waltham IIIA 02451 INSURER D:Travelers Indemnity Company 25658 INSURER E:American Guarantee and Liability Insurance 26247 INSURER F COVERAGES CERTIFICATE NUMBER:102768578.5 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 ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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 CLAIMS. INSR TYPE OF INSURANCE ADDLISUBR- -- POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYY MM/DD/Y A X COMMERCIAL GENERAL LIABILITY CA00002292603 11/19/2018 11/19/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED' CLAIMS-MADE C'. OCCUR PREMISES Ea occurrence $300,000 MED FRCP Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY a jEC D LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: EBL $1,000,000 B AUTOMOBILE LIABILITY 5004521 11/1912018 11/19/2019 COMBINEDlden SINGLE LIMIT $1,000,000 Ea acc ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident E X UMBRELLA LIAR X OCCUR AUCO21748402 11/19/2018 11/19/2019 EACH OCCURRENCE $10,000,000 - EXCESS LU\B CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WMZ-800-8006601-2D18A 12/1/2018 12/1/2019 X I STARTUTE ER _ AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/ (Mandatory In NH) E.L.DISEASE-FA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 D Scheduled Aulos BA-2F991091-18-SEL 11/19/20°8 11119/2019 Combined Single Limit $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Proof of Coverage THORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts � Print Form Department of'Industrial Accidents ;� - Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 }` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Inc Builders, . Name (BusinesslOrganization/Individual): Vantage _ Address: 204 2nd Avenue City/State/Zip: Waltham, MA 02451 Phone #: (781) 895-3270 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑✓ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub-contractors have 8, 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.Q✓ Electrical repairs or additions officers have exercised their 11. ✓ Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *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. lContractors 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: AIM Mutual Insurance Company Policy#or Self-ins.Lic.#: WMZ-800-8006601-2018A Expiration Date: 12/01/2019 Job Site Address:216 North King St. City/State/Zip: Northampton, MA 010 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. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci ' rider the sins and pees of perj ry that the information provided above is true and correct Si ..afore: jigDate:.__ Phone#: (781) 895 3270 Official use on63. 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#: Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 9th edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Trulieve,Northampton Date: 11.06.2019 Property Address: 216 North King St.Northampton,MA 01060 Project: Check(x)one or both as applicable: (X)New construction (X)Existing Construction Project description: Mercantile fit-out of existing space. I,Stephen A.Sousa,MA Registration Number: 9587 Expiration date:August 31,2020,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning]: (X) Architectural Structural Mechanical Fire 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 worn,I shall submit to the building official a'Final Construction Control Document'. .tea Enter in the space to the right a"wet'or i A, � electronic signature and seal: No i4ss: MA a Phone number: 617.879.9100 Email:sousa sousadeslgn.com Building Official Use Only Building Official Name; Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.if`other'is chosen, provide a description. Version 06112013 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 a joint 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) 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 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-contractor(s)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 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 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 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 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 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia Initial Construction Control Document W To be submitted with the building permit application by a d Registered Design Professional for work per the ninth edition of the Massachusetts State Building Code, 780 CNIk Section 107 Project Title:Trulieve Dispensary Fit-out Date:08/02/2019 Property Address:. 216 North King St in Northampton,MA 01060 Proj ect: Check(x) one or both as applicable: New construction X Existing Construction Project description:Renovation and fit-out for a dispensary for Trulieve. I,Paul Babin,MA Registration Number:33975 Expiration date: 06/30/2020, am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural Structural Mechanical Fire Protection X 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 fot 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 Con ntrol Document'. P,'(N OF L9gsS9cy Enter in the space to the right a"wet" or oa PAULT. electronic signature and seal: s WON.JR. U No.33979 m ftIC Phone number. Email: pkbabin.work(a_),amail.conn A 9 fro CIA Building Official Lase Only Fssl F Building Official Name: PermitNo.: Date: v Note 1.Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised.If'other'is chosen,provide a description Version 01 01 2018 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 Y Massachusetts State Building Code, 780 CMR, Section 107 Project Title:Trueliev-Northampton Date:November 6,2019 Property Address: 216 north king Street,Northampton MA Project: Check(x) one or both as applicable: New construction (x) Existing Construction Project description:Gut rehab of existing office building for a new medical and adult use cannabis distrabution,including new mechanical,upgrades. I James P Stroke MA Registration Number: 20068 Expiration date: 6/30/2020 , am a registered design Professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural Structural X Mechanical Fire Protection Electrical Other. B for the above named project and that to the best of my knowledge,information,and belief such plans, E 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 in accordance with the Professional Standard of Care,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.Such review shall not diminish or relieve the Contractor of its submittal and other responsibilities. 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.The contractor shall be responsible for performing the work in accordance with the contract documents and shall be exclusively responsible for its construction means,methods,sequences and procedures,and for construction safety. 4. The performance of the services shall not require any special testing or inspections unless specifically stated in the 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 Construction Control Document'. Enter in the space to the right a"wet"or electronic signature and seal: oma' JAMES P. ST Kr= F_ r J � N0,20068 �SiOM Phone number:413-732-5131 Email:ddangelo@gconway.com Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an'x project design plans,computations and specifications that you prepared or directly supervised.If'other'is chosen,provide a description. Version 01 01 2018 Commonwealth of Massachusetts + Division of Professional Licensure Board of Building Regulations and Standards t Con str .etior Supervisor CS 07x708 i�Pires: 02/28/2021 =� EDWARD J SILVA. 21RTOWPATH DRr WILMINGTON MA887. 01 ," � _jo „ • Commissioner Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. t Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpi i 3 {i� i� I CITY OF NORTHAMPTON PERMIT DECISION Y ° DATES PROJECT INFORMATION E Submitted 9/26/2019 Owner Gerald Randall POB 623,Williamsburg MA 01096 Name/Address Hearing 10/24/2019 Applicant Name/ Life Essence, 56 Canal St, Holyoke MA 01040 Address(if different) DBA Trulieve LLC Extension Applicant Contact Elliot Wentworth Elliot.wentworth@trulieve.com 678-749-9726 Hearing 10/24/2019 Site Address 216 N. King St Northampton Closed Decision 10/24/2019 Site Assessor Map ID 18-7 1 B 2642 P 145 Filed with 10/31/2019 Permit Type PLANNING BOARD Clerk Site Plan Approval Appeal 11/18/2019 Project Description Occupy one tenant space within the building for medical Deadline marijuana dispensary. An appeal of this decision by the Planning Board may be made by any person within 20 days after the date of the filing of this decision with the City Clerk, as shown.Appeals by any aggrieved party must be pursuant to MGL Chapter 40A, Section 17 as amended and may be made to the Hampshire Superior Court with a certified copy of the appeal sent to the City Clerk of the City of Northampton. Plan Sheets/Supporting Documents by Map ID: 1. Site Plans Life Essence Inc by VHB Plan Sheets C-1 to C-3 dated 9/24/2019. 2. Architectural Plan Sheets, Building Elevations, Photometric Plans, Planting Plans by Greylock Design Associates and Sousa deign Architects dated 9/24/2019. BOARD MEMBER PRESENT FAVOR OPPOSED ABSTAIN/NO COUNT VOTE TALLY (Favor-Opposed) Mark Sullivan,Chair ✓ ❑ ❑ George Kohout,Acting ✓ ❑ ❑ Vice Chair Euripedes DeOliveira `/ ❑ ❑ Marissa Elkins ✓ ❑ ❑ Christa Grenat ✓ ❑ ❑ Sam Taylor ✓ ✓ ❑ O Alan Verson `/ ❑ ❑ Janna White ❑ ❑ `/ 7-0 APPLICABLE ZONING APPROVAL CRITERIA/BOARD FINDINGS 350-11.2 A..The requested use protects adjoining premises against seriously detrimental uses. Including surface 350-11.6 water drainage,sound and sight buffers and preservation of views, light, and air;and B.The use will improve the convenience and safety of vehicular and pedestrian movement within the site and on adjacent streets and minimize traffic impacts on the streets and roads in the area.The applicant is reducing cross access to reduce traffic through secondary curb opening() The Planning Board allowed reduction in parking spaces to increase safe pedestrian access to the site. jZLThe project will not decrease the level of service(LOS)of all area City and state roads or intersections affected by the project. The applicant has offered to make a payment-in-lieu of traffic mitigation. pg. 1 i► x.�llJ �t CITY OF NORTHAMPTON PERMIT DECISION C.The site will function harmoniously in relation to other structures. There are no building changes. New landscaping will improve buffers D.The requested use will not overload,and will mitigate adverse impacts on,the City's resources. E.The requested use meets any special regulations set forth in this chapter. F.Compliance with the following technical performance standards: (1)The two existing curb cuts will have improved control through increased buffers and landscaping. (4)Medical marijuana dispensary were shown to meet the criteria for setbacks from schools. CONDITIONS Prior to Any Site Disturbance General Conditions 5) Lighting shall be turned off 1 hour after close of business. Prior to Issuance of a Building Permit 1) Revised plans shall be submitted showing 5'cement concrete sidewalk in-lieu of the parallel parking spaces. 2) Employee parking shall be shown for the rear 4 spaces. Prior to Issuance of a Certificate of Occupancy 3) As offered by the applicant and prior to issuance of a Certificate of Occupancy,the applicant shall make a payment in lieu of traffic mitigation of$82,000 to address their incremental increase in traffic on the network. Payment shall be Made to the City,delivered to Office of Planning and Sustainability. 4) New trees shall be selected from the street tree planting list. Minutes Available at WWW.Northampton Ma.Gov I, Carolyn Misch, as agent to the Planning Board certify that this is an accurate and true decision made by the Planning Board and certify that a copy of this and all plans have been filed with the Board and the City Clerk and that a copy of this decision has been mailed to the Owner,Applicant. See PB pre-permit and pre-Ca conditions above. NO ZBA conditions apply to building permit or CO. pg. 2