24C-043 (6) 354 ELM ST BP-2021-0949
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-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: INTERIOR DEMOLITION BUILDING PERMIT
Permit# BP-2021-0949
Project# JS-2021-001628
Est.Cost: $18000.00
Fee: $126.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NIKOLAY GERASIMCHUK 063630
Lot Size(sq. ft.): 47044.80 Owner: Seventh-Day Adventist Church
Zoning: URB(100)/ Applicant: NIKOLAY GERASIMCHUK
AT: 354 ELM ST
Applicant Address: Phone: Insurance:
322 FRANK SMITH RD WC
LONGMEADOWMA01106 ISSUED ON:3/1/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:PARTAIL DEMO FOR MOLD REMEDIATION
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.
ir � . '
Certificate of Occupancy Signature: I • I
FeeType: Date Paid: Amount:
Building 3/1/2021 0:00:00 $126.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
rVE
The Commonwealth of Massachusetts
'FE8 2 6 ' Office of Public Safety and Inspections
Be(�o 22 Massachusetts State Building Code(780 CMR)
ing ermi't Application for any Building other than a One-or Two-Family Dwelling
N-PT Op „, (This Section For Official Use Only)
Bui dingPernu uP,t-c
tmtb ' 'ate Applied: Building Official:
SECTION 1:LOCATION
354 Elm Street Northampton, MA 01060 Seventh-Day Adventist Church
No.and Street City/Town _q j Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used 9th If New Construction check here 0 or check all that apply in the two rows below
Existing Building® Repair® Alteration 0 Addition 0 Demolition ® (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ® No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No El
Brief Description of Proposed Work: Partial demolition for mold remediation purposes for the entire
contents of the basement and partial (selective) removal of finishes and compromised assemblies
on the main level and choir loft. All surfaces to be cleaned and furnishing assessed for retention.
Conditions to be reviewed to determine scope of work moving forward to support occupancy following
demolition activities.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Assembly (A3) Proposed Use Group(s): Assembly (A3)
SECTION 4 BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) 2 4560 2 4560
Total Area(sq.ft)and Total Height(ft) 9120 3 8 9120 38
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 ® A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
I: Institutional I-I 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R Residential R-10 R-2❑ R-3 0 R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA CI IBD IIAO IIB ❑ IIIA ❑ IIIB ® IV VA VBD
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information Trench Permit: Debris Removal:Sewage Disposal: Licensed Dis sal Site 0
Public® Check if outside Flood Zone 0 Indicate municipal ElA trench will not be Po
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: •
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 9th Use Group(s): A3 Type of Construction: I IIB
Does the building contain an Sprinkler System?: NO Special Stipulations:continuous use for religious gatherings
Design Occupant Load per Floor and Assembly space: 200 (sanctuary) 100 (fellowship hall - basement)
SECTION 1 PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
S 1TNVRIV /VEW EAKILRNo PO ( ox!!d? Soccf l, 1&NeasleI. /)1f 0/56 (
Name(Print)�OrN�feke.E C t No.and Street City/Town Zip
sS c. So
Property Owner Contact Information:'S E. F F L /N T,/W A IT 6
PRoPE07 MA/6R 9'78-3i5 1153N/ 97&co2.- Y8V7 3L!NTH WAIT.Eica.soreory ow. OeG
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address City/Town State Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide (see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Lawrence Tuttle 413-283-2553 admin@architectural-insights.com 7141
Name(Registrant) Telephone No. e-mail address Registration Number
3 Converse Street Palmer MA 01069 ARCH 8/21
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
4:s Ct GA.c, � S WO ./Imo,
Coornnany Name
'h� 4(a 6�� o�or i.,c 6 GST D(o-c - Q ( ,U/2./
Name of Per Responsibl, or Cons cti License No. and Type if Appl' able
2 2 a v tC .'-F 10 h 4....2,�I 4':.cam /(`' o/%7
Street Address V -/Town State Zip
( 6-"7Z4 ti 32(I SA ) «V�� daLs coks-frcfrefJoi- 9-4-Nr; et e a- ►l - co.,=
7,Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11: ':k t 1ZS C:c 11 P1.` (M.G.L c.152§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$ .
3.Plumbing $ 14
-4 f,�
4.Mechanical (HVAC) $ Note:Minimum fee=$ . v (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (La (contact municipality)and write check number here 0 7
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest and e pains and penalties of perjury that all of the information contained in this
application
�is true and accura to the best o y w dge d un r tanding.
K \
PlNe,print and,Vname Title Telephone No. Date
Street Address City/Town State Zip Email Address
1 W 7/� X
Municipal Inspector to fill out this section upon application approval: ,� I � t �� �% '
Name Date
City of Northampton
`�ti:r.�srir
Massachusetts �c ,,A,,, o,
.:..
,.... 1 it.,--...lit
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building y a�
jf Northampton, MA 01060 S5p, 3r "•y0
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
C
la
) I
Location of Facility: cLA.. 5 e � (Q-+�-/�/�--
The debris will be transported by:
Name of Hauler: l . i')e_ / '
Signature of Applicant: Date: ,) /2 / /
A21
DATE(MMIDDlYYYY)
RD CERTIFICATE OF LIABILITY INSURANCE 02l26/Dr
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
NAME: Mike Pelletier
Rejean J.Remillard Ins Agency,Inc. IN C.No,Ext): 413-789-3070 ONE FAX
Ho): 413-786-0193
1040 Springfield Street E-MAIL
Feeding Hills,MA 01030 ADDRESS: Mike Pelletier
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: Main Street American Assurance
INSURED INSURER B: Liberty Mutual Ins Co
Anatolie Balaur INSURER C:
Allstates Construction INSURER D
26 Brainard Rd.
Wilbraham,MA 01096-1401 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 ADDLSUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE T $ 600,000
CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence)REN $ 600,000
ABED EXP(Any one person) $ 10,000
A Y Y MPT9213G 01/11/21 01/11/22 PERSONAL&ADV INJURY $ 600,000
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 1,000,000
X POLICY JERO LOC PRODUCTS-COMP/OP AGG $ 1,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
_ AUTOS ONLY _ AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
B OFFICER/MEMBERANY /EXCLUDEDXECUTIVEYYN N/A WC2-31S-618692-020 11/07/20 11/07/21 EL EACH ACCIDENT $ 100,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes.describe under 600,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
210MainSt
Northampton,MA 01060 °.• '
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
--. The Commonwealth of Massachusetts
. .w` Department of Industrial Accidents
'" log.-- l - 1 Congress Street,Suite 100
`•la' :as: Boston,MA 02114-2017
www.mass.gor/dia
11/Jokers'('ompeasation Insurance Affidavit: Builders/('ontractorsiElectricians/Plumbers.
'ID BE FILED WTItl'1'l1EPERMI'riIN(:Al! II )RI't1'.
Applicant Information Please Print Leetibly
Name tMosaics!.(tr}aniraUetrind►s•teittal): A(nI S CO i t gc-7—p u ccfk �r L k
Address: 6 A C!�� Zc _.� .. .
City/State/Zip:_ £(9 Phone#: (z/c3) 72 • -.3Z i
Arc you an employ er:'f heck the appropriate hut:
Type of project(required):
(.O I run a employer with employees Out!amain put-tine).' 7. (J New construction
7. l ant a sole peolrietora partnership and ha%e no mrployees wterking firs me in It. ®Ren ►de tug
any e'ateael .[No workers comp.insurance requitcel.]
9. lln►IIstun
3.1 am a hotecvw ner doing all work myself.No wutlers'cutup.insunatce required.]t
4.01 am a he ma oi
ler and will he hiring euntraetots to conduct all w ank on my peuperly'. 1 Will
10 J Building addition
emotive Mal all cunttactots tither have vaulters'compensation insurattec et are sale 11 Electrical repairs or additions
proprietor with ten employees.
12.0 Plumbing repairs or additions
S nr a general vomireleet anti I lave hired the sub-cvuttra tors listed on the attached sleet.
Ilse ec sue rt w-a+an►ttots have employees and have snorkels'cutup.inrarex.t 13.0ROUfrYpitirs
14.Q Ottet
h.D We are a cumin union and its officers have exercised their tight of exemption pet PM if.c. —152.If 1(4),and we have no employees.(tilt►waken'cutup.insurance required-j
Any oppin:ant that cheeks Ilex NI nmst also fill out the wvtion below showing their workers'compensation pollee nth.' it.
I Il.1110.,Vtnen who submit this affidavit itulicating 1hcy arc doing all work and ticn hire uubnk cetntlactuts must suhtuit a tea:dtidas et iudetatmg such.
1,11tr.r.feu that eir ek this but must ait:ec bed ale:nddil.otal sliest slenc In ilk:nave;Attu:sub-eetnitaeturs and state w billet et not those entities have
i.;':o)ccs. It the suh-c nnuaekus have employees,they must prosaic Moen wodcn'cutup.imt ny nunehet.
I a►t an emplop er that is providing workers'compensation insurance for my employees_ Below is the policy and job site
information.
Insurance Company Name: I► / a,(/, S I pp.,,,/ 4fflp ,' g1 Ass L( 'Leto CE,
Polley#or Self ins.Lic.#: (1)C — 3/ S - 6 f4), ' - o a O Expiration Date: /r IT 47. /
Job Site Address: 3 SY (L Y►-J S/ &0 t- ( h 0.re l i CitylStatolip: /' i 0/ '' 6 O
Attack a copy of the workers'compensation policy declaration page(showing the policy ana)ber and espirat- date).
Failure to secure coverage as required under MCA.c. 152.§25A is a criminal violation punishable by a tine up to$1.5011.00
and`or one-year imprisonment.us well us civil penalties in the Corm of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of tins statement may be tints aided to the Ot1'lce of Investigations of the DIA tier insurance
coveraee +crtfication.
!do hereby certify under the pains and penalties orperlurr that the in(i►rmation provided'alit re is Sre and correct_
Signature: Date: v< /e? �� /
Phone#: Co t( 3 3 ^ 9 o
(Vidal use onlr. Do not unite lit this area.to he completed by city or town official
('its or Town: Permit/License#
Issuing Authority(circle ones:
I.Board of health 2. Building Department 3.('il'e l ots n Clerk 4. Electrical Inspector 5. Plumbing Inspector
fi.Other
('ontact Person: Phone lt:
',mew Vj V.i. am v... V..Waawl VVia
e
Massachusetts
c
It.t ,,-//-'
>`i DEPARTMENT OF BUILDING INSPECTIONS
W . ,"i 212 Main Street • Municipal Building PD
--� Northampton, MA 01060 Jr,-lv x"\``
INSPECTOR
Louis Hasbrouck Fax: 413-587-1272 Chuck Miller
Building Commissioner Phone: 413-587-1240 Assistant Commissioner
CONSTRUCTION CONTROL DOCUMENT
(For professional Engineers/Architects responsible for Entire Project)
Project Title: Seventh-Day Adventist Church Date: 2/15/21
Project Location: 354 Elm Street Northampton, MA Map: Parcel: Zone:
Scope of Project:Interior demolition for mold remediation (full basement, partial main and choir loft
Nineth
In accordance with the-E-ig#th-edition Massachusetts State Building Code, 780 CMR Section 107.6:
I, Lawrence Tuttle Mass. Registration # 7141 ,
Being a registered professional Engineer/Architect hereby CERTIFIES that I have prepared or directly supervised
the preparation of all design plans, computations and specifications concerning:
[x] ENTIRE PROJECT
For the above named project and that to the best of my knowledge, such plans, computations and specifications
meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices
and all applicable Laws for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services to determine that
the above mentioned portions of the work proceed in accordance with the documents approved for the building
permit and shall be responsible for the following as specified in Section 10.7.6.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction documents as submitted for the building permit, and approval for the conformance
to the design concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
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, in general, if the work is being performed
In a matter consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, a progress report together with pertinent
comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory
completion and readiness of the project for occupancy.
•St O ARCN/r e' ik �,�
`� ��G
Signature and Seal of Registered rofessional Q.
�
.cp 4 .04410 ,..1',' •
15th D8 of February 20 21 ,/ 3•` 4' I:7/V
Y ',F�ITHOF 1.
(seal) '