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22B-043 (32) 296 NONOTUCK ST-MA ADAPTIVE TECH CENTER BP-2021-0004 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22B-043 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2021-0004 Proiect# JS-2021-000005 Est.Cost: $605000.00 Fee: $4235.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CROCKER BUILDING CO INC 067805 Lot Size(sq. ft.): 130680.00 Owner: NONOTUCK MILL LLC Zoning: SI(I 10)/WP(73)/URA(2)/ Applicant: CROCKER BUILDING CO INC AT. 296 NONOTUCK ST - MA ADAPTIVE TECH CENTER Applicant Address: Phone: Insurance: 186 STAFFORD ST (413) 737-7803 SPRINGFIELDMA01104 ISSUED ON.7/2/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO LOWER LEVEL FOR MA ADAPTIVE TECH CENTER 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 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: FeeType: Date Paid: Amount: R u i l d i n<( 7/2/2020 0:00:00 $4235.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Version I.-, Commercial BuildinE fl-unit\L:, use onlyaeparimertt of Northampton Status of Permit: ilding Department Cut CutfDrivewav Perms* 01- Main Street �Sewerl"Septic Availatd-t%— om 100 t%+aterN'Vell Availao;l ort mpton, MA 01060 Tvic Segs or S-ructural Plans ho 41 87-1240 Fax 413-587-1272 'P!0'-;Site Plans Other speci J"APPLICATION TO NST " (UCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION I- 11 Property Address This section to be completed by office 296 Nonotuck St. Map 6 Lot6 y Unit Florence, N4A Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nonotuck Mill. LLC 296 Nonotuck St.,,f-- Name{Punt; Current Mallkq Addma., Signature S413)_519-0765 ....... Telephone 2.2 Authorized Anent: Seth Cro&er 186 Stafford St., Springfield, MA 01164 Name(Print) Current Mailing Address, A (413) 737-7803 Signature -- Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use onlj completed by permit,applicant 1. Building $350,000.00 (a)Building Per,"nit Fee 2 Electrical -7 (b)Estimated Total Cost of $140.000.00 Construction from(6) 3, Plumbing $50,000.00 Building Permit Fee 4. Mechanical(HVAC) 5, Fire Protection $65.000.00: 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature. ar Bulletin Commionerilnspector of Builth Date ............ Versionl.7 Commercial Building Permit`vlay 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 Building❑ Exterior Alteration ❑ Existing Ground Sign ❑ New Signs❑ Roofing[] Change of Use❑ Other ❑ Brief Description Of Proposed Worki Renovate lower level f�.r Massachusetts Adaotive Technology Center SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable)' CONSTRUCTION TYPE A Assernb;y ❑ A-1 ❑ A-2 ❑ t'-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ( ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 1 36 j ❑ M Mercantile ❑ 4 ❑ R Residenbal ❑ R-1 ❑ R-2 ❑ R-3 ❑ ' 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mlxed Use ❑ Specify S Special Use ❑ j Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE Existing Use Group B Proposed Use Group B 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) 1S` 8.854 1s. 7'" 2ryv 3`� 4� 4m Total Area (sf) 8.854 I Total Proposed New Construction (sf) Tctal €gip:grrr(ft) Total Height It i 7.Water Supply(M.G.L. c.40, § 54) 7.1 Flood Zone Information: ! 7.3 Sewage Disposal System: Public Private 0 Zone Outside Flood ZoneO Municipal [] On site disposal system❑ _ ersion 1.7 Commercial Building Permit May 1512000 I Existing Proposed Required by Zoning This column to be filled in by Building Department LotSize ' Frontage � ...�._ ..� Setbacks Front L: R: L: Rear Building Height Bldg.Square Footage "/e _ Open Space Footage t (Len area mutes bldg&paved parking A[of'Parking S rices Fill: (volume&Uication) -- �._.. _ ........, A.. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW � YES i IF YES: enter Book Page and/o- Document "" B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date issued: C. Do any signs exist on the property? YES s NO T YES, describe size, type and location. D. Are there any proposed changes to or additions of signs-intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading.excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO k IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1:7 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 G.F.OF ENCLOSED SPACE) i 9.1 Registered Architect: 1-116 Pleasantt, tiite 1. Easthampton.MANot Applicable � .._. .. Marne(Registran0l 6634 116 Pleasant St, Suite 11. Ea,;thanvon. MA Registration Number Address 08/31/2020 47 (413) 529-9434 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Numb1.er .................................... ...... . Signature ele burse Expiration_.. _.. _. P gate Name Area of Responsibility { Address Registration Number } i Signature Telephone Expiration Date .�----- Name Area of Responsibility Address Reoistration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Telephone _ . r Signature ration Date 9.3 General Contractor Crocker Building Company, Inc. Company Name, Not Applicable ❑ William Crocker Responsible In Charge of Construction 1$8 Stafford St- Springfield, MA 01104 Address (413) 737-7803 Signature Telephone Version].7 Commercial Building Permit lloiav 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(.?&L CMR 110,11) Ir ciape der-St%lctu°al E-gneenn�j Str=ural Peer Review YesIv SECTION 11 .OWNER AUTHORIZATION -TO BE COMPLETED VuHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING P'ERM'IT Doug NIcVe, as Owner of the subject property hereby authorize .Seth Cracker _..,_._ to act on my behalf:T all matters lative to work authorized by this building permit application. 3117/X} Signature of Owner Gate L Seth Cracker as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are tare and accurate,to the best of my knowledge and belief. Signed under:he pains and„penalties of perjury. Seth Cracker Print N n e t' 3/17/20 Cate SECTION 12-CONSTRUCTION SERVICES 10.1 !lensed Construction Su ervisor; Not Applicable ❑ Name at License Holder William D, Crocker CS-067805 License Number 18C Stafford St Spr o-Neid IVIA 01104 4119d�0 Add,,ess Expiration date (413) 737-7803 Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L,c.152, 25C(6)) Workers Compensation Insurance affidavit roust 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 € Version l.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Doug McVey 1. as Owner of the subject property hereby authorize Seth Crocker o act on my behalf,,'qyall ma rs rklative to work authorized by this building permit application. 3/17/20 Signature of Owner Date I 'Seth Crocker 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 perjury. __ Seth Crocker _ Print Name 3/17/20 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: William D. Crocker CS-067805 License Number 186 Stafford St.,Springfield, MA 01104 4/19/20 Addrev. Expiration Date (413) 737-7803 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 Q No Q Version t.7 Commercial Building Permit Mav 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: 116 Pleasant St, Suite 3404, Easthampton, MA Not Applicable 0 ., . ...w..m�.�_.._ _ _.._. Name(Registrant) 063411, __. ... 116 Pleasant St, Suite 3404, Easthampton, MA Registration Number �.._ ._W..�._ _.__.. ..___. _ Address 09/31/2020 (413) 529-9434 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date ........ ...r Area of Responsibility I Address Registration Number ..,....._ _ - __.. ........ i r ; Signature Telephone Expiration Date Name Area of Responsibility z Address Registration Number .......,_.-......._._... . Signature Telephone Expiration Date F Name Area of Responsibility .—_-_.___..... __.... Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Crocker Building Company, Inc. Not Applicable ❑ Company Name: William Crocker Responsible In Charge of Construction 186'Stafford St., Springfield, MA 01104 Addres (413) 737-7803 Signature Telephone City, of Northampton 212 Main Street. Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of IVIGL 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 IVIGL c 111 , S 150A. Address of the work: L The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Ke Date Signature of Permit Applicant The Coininonwealth of Massachusetts Departntent of Industrial Accidents lip, I Congress Street,Suite 100 Boston, MA 02114-2017 tvww.mass.govldia Workers'Compensation insurance AfrtdavW Builders/Contractors/`Eit-etricians/P)utnbers. TO BE FILED NN ITH THE PERMITTING AtTRORITV. Ayglicam Information Elease Print Lezibh, 'Name (HiisinesVOrgaiiimiti(-n,'Individtmi):Crocker Building Company, Inc, Address:185 Stafford St. City'State.q ip:Springfield, MA 011 D4 Phone 4:(413)737-7803 Are vou an tmployer^Check the appropriate box: Type of project(re quiredy I at a employer with 20 employees(full and/or part-time), 7, C]New construction I am a sole proprietor or partnership,and have no employees working for me In 8. 2].Remodeling any ciipacil [No workers'romp o1sursoce requirciij 71 am a horrieowner doing all work myself No workers'comp,insurance iequjred,� 9. D Demolition I am a homeri-,viter and will be hiring contracton to conduct all on my properl� I wit] 10 E] Building addition ensure that all contractors either have workers'compensation insurance or are sole I LM Electrical repairs or additions promelors;with no employee,-, 12.Fj Plumbing repairs or additions I am a general contractot and I have hired the sub-contractors I isted or,the attached sheet Thm,Wb-camractors have emptoyces and have workers'comp.insurance-* 13.�Roof repairs *,Vc are a corporation ane.its officers have exercised their right of exemption per MGI, 14,[:]Other §1(4),and we have no employees.[No worker;'comp.tnsu,ance required,] *Anb applicant that checks h",41 must also fill out the section below showing their workers'compensation policy inforniatio,n fionwowntirs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a nowaffidavit indicating such, Contractors thin check this box must attached an additional sheet showing the name of the sub-comniaors and state whether or not those entities have employees. If the sub costractom have employees,they must provide their workers cramp,policy number. I am tin employer thal is providing workers'comiriensation insurance far W empkYees. BelowiSthe polic►y information. ,rend roto site Insurance Company Name:The Ohio Casualty Insurance Co,-Liberty Mutual Insurance ............. Policy ii or Self-ins,Lic. XWO(20) 57 69 93 99 Expiration Date:4/1/20 _296 Nonotuck St. Florence, MA Job Site Address, City"State'Zip: Attach a copy of the%4orkers'compensation policy declaration page(showing the poliev number and expiration date). Failure to secure coverage as required under MGL c. 152,§215A 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 ora 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 cerfif y under the pains acrd penalties of perjupy thar the informafion pro tided above is true and correct. Sig ,n bate: '7/ Phorw"-(413) 737-7803 Official use only. Do not write in this area,to be completed by cit} or town officiat City or Town. PermitIlLicense# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Cit-Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone Version L'Commercial Building il4—nit \,Ii\ lar_ C7epar men,use^-,nly City of Northampton iStatus cf Permit: Building Department lC rb Cut/Driveway Permi-, 212 Maid Street I Sewer'SepticAvailabiht, Room 100 Water/Well Availability Northampton, MA 01060 Two Sets cf S`ruc°urai Plans phone 413-587-1240 Fax 413-587-1272 i{ Io Site Plar> 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 SECTION 1 -SITE INFORMATION 1.1 Property Address This section to be completed by office y96 'Zonotuck Si. Map Lest Unit 1~loreace. MA Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Nonotui< V,il; --Lt_ _961vonott�ck St., Florence, MA I Name(Print; �. __...._ Current Mailing Address: (413) 519-0765 Signature Telephone 2.2 ALdhonzed Anent: Seth Crocker 186 Stafford St., Springfield, MIA 01104 Nerve(Print) Current Mailing Address (413) 737-7803 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by oer'mit applicant 1_ Building �� .�!{} � (a)Building Per-int r-e 2. Electrical 140,(lC ;�.l ltl (ul Estimated Total Cost of C;nstrUct*n from fi 3, Plumbing $50,000.00 Building Permit Fee 4. Mechanical{HVAC} 5. Fire Protection $65010,00 6. Total=(1 +2+ 3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature Building Commisslonerllnspector of Buildings ' Date ��� Version].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 Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other ❑ Brief Description i Of Proposed Work: Renovate lower level for MassachusettsAdaotive Technology Center SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A.-1 ❑ A-2 ❑ A-3 ❑ 1A 1 ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business El 2A ❑ E Educational ❑ 2B ( ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I I Institutional ❑ f-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 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 B Proposed Use Group: 13 Existing Hazard Index 780 CMR 341 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) 1s` 1 ` 8.85= 2" ,yrxl 3'a �.,�a 4*1 4m . Total Area(sp 8.854 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: j 7,3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Version 1.7 Commercial Building Permit May 15,2000 S. 7�ORTII Existing Proposed Required bN Zoning This column to be filled in by Building Department Lot Size ........... 'Frontage Setbacks Front .......... ...................... L: Rear Building Height _j Bldg.Square Footage Open Space Footage % i'Lot arra manus bldg&payed Parking) of'Parkin g Spaces Fill: (,volume&Wcal*w A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page and/o- Document#.-- B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES NO 0 IF YES, describe size, type and Location. D. Are there any proposed changes to or additions of signs-intended for the property ? YES NO IF YES, describe size, type and Location: E Will the construction activity disturb(clearing, grading,excavation,or filling)over I acre or is it part of a common plan that will disturb over 1 acre? YES tA NO IF YES.then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 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: 116 Pleasant St, Suite 311. Easthampton,MA Not Applicable El Name(Registrant) 66')4 116 Pleasant St. Suite 11. Easthainpton. MA Registration Number Address 529-9434 Expiration Da-e Signature Telephone �..9.,2 Registered Professional Engineer(s): Name —Tea Area of Responsibility Address F;-Istratlon Number Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature eleDhone Expirat,on Date Name k'I ea Address Registration Number Signature Expiration Date Name Area of Responsibi Address Registration Number slgnatur'-� Date~Telephone Eviration 9.3 General Contractor Crocker Building Company, inc. Company Name, Not Applicable 0 William Crocker Responsible In Charge of Construction 186 Stafford St- Springfield, IVIA 0",104 Address (413) 737-7803 Signature - Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Stru;tu•al Engineering;Stnucturai Peer Review Rewired Yes 0 No SECTION 11 -0 W-NER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i Doug (C ti'Cl' as Owner of the subject property hereby authorize Seth Crocker to act on my behalf,xrali matters relative to work authorized by this building permit application. 3/17/20 Signature of Owner Date ! Seth Crocker as OwnerfAuthorized 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 perjury. Seth Crocker Print Name 3/17/20 Signaiure of Cramer.Agent tate SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ ( Name at License Holder William D. Crocker CS-0$7$(}5 1 License Number 185 Stafford St. Springfield: MA 01104 4119!20 Address Expiration Date (413) 737-7$03 Signature: Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.'152,§25C(61) 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 0 Version 13 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. Doug McVey as Owner of the subject property hereby authorize Seth Crocker to act on my behaif„irgall 7rs rklative to work authorized by this building permit application. / yJ 3/17/20 Signature of Owner Date Seth Crocker 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 perjury, Seth Crocker Print Name 3/17/20 Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: William D. Crocker CS-067805 License Number 186 Stafford St., Springfield,MA 01104 4/19/20 Addre �-'-' Expiration Date (413) 737-7803 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 0 Version 1.7 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: 116 Pleasant St, Suite 3404, Easthampton, MA Not Applicable ❑ Name(Registrant): 6634 116 Pleasant St, Suite 3404, Easthampton, MA Registration Number Address 08/3 l 2020 (413) 529-9434 Expiration Date Signature Telephone 9.2 Registered Professional Engineer(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 Date Name Area of Responsibility Address Registration Number .......... _ Signature 9 Telephone Expiration Date 9.3 General Contractor Crocker Building Company, Inc. Not Applicable ❑ Company Name: William Crocker Responsible In Charge of Construction 166 Stafford St.,Springfield, NIA 01104 Addres -'" (413) 737-7803 Signature Telephone City of Northampton 2122 Main Street. Northampton, A�k 0 1060 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: 71 The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant ....... ICl/11 A4 L" -7,1( Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.govvdia NA'orkersCompensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING At"I'HORITV. A"licant Information Please Print Leeiblv Name Crocker Building Company, Inc. Address:186 Stafford St. citv'/State/Zip:Springfield, MA 01104 Phone 4;X413}737-78Q3 Are you an employer?Check the appropriate box- Type of project(required): I am a employei with 20. ___—employees(full and/or part-time).• 7. [3New construction I am?t sole proprietor or partnership and have ne employees working "or rte in acitv.IN(?vvork;ers'cornp.i'nsurance required 1 8. F,/J.Remodeling any czp I am a linmeowner&mg all work myself IN*workers'camp.insurame required.; 9. ❑Demolition 4101 tun a homeowner and wfll he hiring contractor to conduct all w=ork on my property ]will 10 Building addition ensure that all contractors either have workers'compensation insurance orare',Olt I I.M Electrical repairs or additions proprietors with no emplovees 12.[]Plumbing repairs or additions 5 1 am a general contractor and'I have hired the sub-contractors listed or,the attached sheet These sub-c€ntiwtors have tntptn les and have workers'comp insurance' 13.©Roof repairs 6Q l are a cogwai ion anC its officersnave exerc!,,eetirrightore xempt(on[No workers' M G I er 14.ether p 52, 1(4),and we have no employees -)rkers'comp.insurance *Am applicant that checks box#1 must also fill out the section below sbowing their workers'compensation policy information. Hmnewwrimuho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors than check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have emplevecs If III,-sub-contractors have employees,they must provide their workers'comp policy number. I am an etnplctyer that is providing workers'compensation insurance for my employees. Below is the policy and jolt site information. Insurance Company Name:The Ohio Casualty Insurance Co-Liberty Mutual Insurance ..........-_11--................-_.11111111__.'-..______1-.......... Policy 4 or Self-ins.Lic.;4:XWO(20) 57 69 93 99 Expiration Date:4/1/20 Job Site Address,296 Nonotuck St. City/State!zip:Florence, MA Attach 8 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 ora STOP)VORK 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 hereoy certify under the pains and penalties offierjuty that the information provided above is true and correct. S_iLriature. '7 Phone 0:(413)737-7803 Date: Official use only. Do not write in this area,to be completed ky cit),or town offlciaL City or Town; Permit/License# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk C Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CROCBUI-01 CHRISTINE ACORO CERTIFICATE OF LIABILITY INSURANCE DATE/17/2 AT D/YYYY) �-� 3//17/217/2 020 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. If 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 Christine Sullivan NAME: Phillips Insurance Agency,Inc. PHONE 97 Center Street (A/C,No,E :(413)5945984 FAX xtiic,No):(413)592-8499 Chicopee,MA 01013 n oARILESs:Christine@phillipsinsurance.com INSURERS AFFORDING COVERAGE NAIC S INSURER A:West American Insurance Co. 44393 INSURED INSURER B:Ohio Security Insurance Co 24082 Crocker Building Co INSURER C:Ohio Casualty 24074 Mr.Seth Crocker 186 Stafford St INSURER D Springfield,MA 01104 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBIR ED POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAMS-MADE �X OCCUR BKA57699399 4/1/2020 4/1/2021 DAMAGE T RENT 0.eD $ 300,000 PREMISES MED EXP(Any oneperson) 51000 PERSONAL&ADV INJURY $ 1,0001000 GEN'LAGGRE -GATE� LIMIT APPLESPER: - GENERAL AGGREGATE 2,0001000 POLICY J LOC PRODUCTS-COMP/OP AGG 21000/000 OTHER B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000 X ANY AUTO BAS57699399 4/1/2020 4/1/2021 BODILY INJURY Per person) OWNED SCHEDULED AUTOS ONLY AUTOSBODILYBODILY INJURY Per accident ATOS ONLY AUTO ONLDY (AD co. acEoR.I DAMAGE $ C X UMMIEL-A LIAB X OCCUR EACH OCCURRENCE 10,000,000 EXCESS LWB CLAIMS-MADE US057699399 411/2020 4/1/2021 AGGREGATE 10'000'000 DED I X I RETENTIONS 10,000 C WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY XTATUTE ER YIN 057699399 411/2020 4/1/2021 1,000,000 ANY PROPRIETOR/ IEXECUTIVE a N/A E.L.EACH ACCIDENTEXCLUDE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 11000/000 If as,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E:L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Renovation at 296 Nonotuck St Florence,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit Of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City P ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE `?..., ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Initial Construction Control Document W To be submitted with the building permit application by a R Registered Design Professional for work per the 9'edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title:Nonotuck Mill—Adaptive Technology Center Date:3/26/2020 Property Address: 296 Nonotuck Street(Ground Floor Rear)—Florence,MA,01062 Project: Check(x)one or both as applicable: New construction x Existing Construction Project description: An open, non-combustible space within the Nonotuck Mill complex is being converted from a warehouse space to a new location for the MA Department of Disability Services "Adaptive Technology Center". This shop-type facility is being relocated from Industrial Drive in Northampton. I Siegfried Porth MA Registration Number: 6634 Expiration date: 8/31/2020 , 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 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: N R Ari Phone number: 1-413-529-9434 Email: siegfriedp25@gmail.com f. NOTE: OUR OFFICE IS CURRENTLY CLOSED DURING THE CORONA f I PANDEMIC, PLEASE USE EMAIL FOR NOW.THANK YOU. I 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 06 11 2013