39-041 (28) 15 ATWOOD DR-DENTAL OFFICE BP-2021-1541
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39-041 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 P E RM I T
Permit# BP-2021-1541
Project# JS-2021-002563
Est.Cost: $250000.00
Fee: $400.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DEVELOPMENT ASSOCIATES 075752
Lot Size(sq.ft.): 217800.00 Owner: ATWOOD DRIVE LLC
Zoning:GB Applicant: DEVELOPMENT ASSOCIATES
AT: 15 ATWOOD DR - DENTAL OFFICE
Applicant Address: Phone: Insurance:
P O BOX 528 (413) 789-3720 WC
AGAWAMMA01001 ISSUED ON:6/29/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INTERIOR BUILD OUT - DENTAL OFFICE - 2884
SF
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. i I
Certificate of Occupancy Signaturi:` sr * Ti .
FeeType: Date Paid: Amount:
Building 6/29/2021 0:00:00 $400.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
gio V_
(c?"23 f3sc
The Commonwealth of Massach setts
Office of Public Safety and Inspectio s 2 Q
Massachusetts State Building Code(780 R)
Building Permit Application for any Building other than a(SA-el-• o-Family tYwel ng f
[� (This Section For Official Use Only)
Building Permit Number:Vr A - 157hate Applied: Building Official: Onrs
SECTION 1.LOCATION
No.and Street City/Town Zip Code Name of Building(if applicable)
15 Atwood Drive Northampton lobo
Assessors Map# Block#and/or Lot 039-041-001
SE OSED WORK
Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below
Existing Building® Repair❑ Alteration 0 Addition 0 Demolition 0 (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 EX No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No
Brief Description of Proposed Work:
Interior buildout of dental office-2,884 sf
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) ❑
Existing Use Group(s): B Proposed Use Group(s): B
SECTION 4 BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft)
Total Area(sq.ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5❑ B: Business lgt 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-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2 0 U: Utility 0 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA CI IB ❑ HA CI IIB ® IIIA ❑ IIIB ❑ IV 0 VA CI VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public N Check if outside Flood Zone 0 Indicate municipal
A trench will not be Licensed Disposal Site IN
required N or trench or specify:USA Hauling
Private 0 or indentify Zone: or on site system 0
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable IR Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No IR Yes 0 No t
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Northwood Development LLC 200 Silver St.,Suite 201 Agawam 01001
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Susan O'Leary Mulhern,Managing Member413_789 _ 7320 - _ esullivan@devassociates.com
Title cs1=� �((A• hone No.(business) Telephone No. (cell) e-mail address
If applicable,the property own hereby authorizes:
Travis P.Ward 200 Silver St.,Suite 201 Agawam MA 01001
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 O.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Development Associates
Company Name
Travis P.Ward CS-075752-Construction Supervisor
Name of Person Responsible for Construction License No. and Type if Applicable
200 Silver St.,Suite 201 Agawam MA 01001
Street Address ity/Town State Zip
413- 789_ 7320 413 _335 _ 7168 tward@devassociates.com
Telephone No.(business) I) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 C]
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 250,000.00
1.Building $ 250,000.00 Building Permit Fee=Tota o uction Cost x (Insert here
2.Electrical $ appropriate m nicipal r)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee= I contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 250,000.00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereb . •st under the pains and penalties of perjury that all of the information contained in this
application is true and accurate I e b: t of my knowledge and understanding.
Travis P.Ward Operations Manager 413 _ 789 _ 7320 6/24/21
Please print and sign name Title Telephone No. Date
200 Silver St.,Suite 201 Agawam MA 01001 tward@devassociates.com
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: (rC . .7 a
Name Date
City of Northampton
?��j M.io ..........s/CI•.
" Massachusetts
.' of . , c•
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ON.•, ;D
y T Northampton, MA 01060 S"n- -40
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:
Location of Facility:
The debris will be transported by:
Name of Hauler: USA Hauling
Signature of Applicant: f Date: 6/24/21
sc The Commonwealth of Massachusetts
l. Deparunent of Industrial Accidents
v r11 I Congress Street,Suite 100
111= Boston, MA 02114-2017
�c;�fis www.mass.goWdia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesihly
Name(Business:Organization/individual): Development Associates
Address: 200 Silver Street,Suite 201,P. O. Box 528
City/State/Zip: Agawam,MA 01001 Phone#: 413-789-3720
Are'on an employer?Cheek the appropriate box:
Type of project(required):
1.1X1 I ant a employer with 4 cmplu)res(full andlor part•tirn.).• 7. ®New construction
2.0 1 am a wile proprietor or parincnhip and have nu employees working fur me in 8. 0 Remodeling
any cif i:rty.[No workers'rump.insurance required.]
9. ❑ Demolition
30 I am a homeowner doing all wort myself.[No workers'corm.irnurancc required.]'
10[] Building addition
4.0I am a hum-owner and will be hiring contractors to conduit all wink on my property. I will
ensure that all contractors either have wvukcrs'compensation insurance or are auk 1 I.❑ Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
S01 am a general contractor and 1 have hin:d the wb-cunLractum listed un the attached sheet_ 3.n RoUf repairs
These sub-contractors haw employees and love workers'coup.uiaunrnecr
6.0 We are a corporation and its.officers have exercised their right of exemption per MGL c.
14.D O[her
132,§1(4),and we haw no employees.[No workers'comp.insurance required.]
'Any applicant that checks box PI mint also till out the section below showing their workers'compensation policy information_
t homeowners who submit this affidavit hulicating they are doing all work and then hire outside contractors must submit a new.•affidavit Milk-aims such.
tCuntracturs that cheek this box roust attached an additional sheet showing the name of the sub-euntractors and state whether or not those ctinitic:r have
einpluyec. lithe sub-contractors have employees.they ritual provide their workers'cvrrnp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: Great American Insurance Company of NY
Policy#or Self-ins.Lie. 4: WC1130018 05 Expiration Date: 04/13/22
Job Site Address: 15 Atwood Drive Cityi5tate/Zip:Northampton,MA 01060
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 SI,500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of th' statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby calf r r penalties ofperJury that the Information provided above Is true and correct.
Signature: Date: 6/24/21
Phone 4: 413-789-3720
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License ft
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Citvil'own Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural X
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC X
7 Electrical
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR) X
18 Workers Compensation Insurance X
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Charles W. Roberts,AIA (413) 259-1630 CRoberts@kuhnriddle.com 10107
Name(Registrant) Telephone No. e-mail address Registration Number
28 Amity St. Amherst MA 01020 Architectural 08/31/21
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
Initial Construction Control Document
} 7v To be submitted with the building permit application by a
Registered Design Professional
r for work per the ninth edition of the
.. � Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Refresh Valley Dental Date:June 24th,2021
Property Address: 15 Atwood Drive,Suite 203,Northampton,MA
Project: Check (x) one or both as applicable: X New construction Existing Construction
Project description:This project is a 2,884 SF fit-out of existing open space on the second floor of a recently constructed
and occupied building. The project will include new doors and partition walls as well as new floor,wall,and ceiling
finishes. New HVAC work,as well as modifications to the existing sprinkler system will be part of this work. (MEP/FP
drawings,specifications,and code compliance documents are to be submitted under separate cover). The new office
space,and the entire building,will be fully sprinklered.
I,Charles W. Roberts,MA Registration Number: 10107 Expiration date: 08/31/21 , am a registered design professional,
and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerningl:
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 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 D... _.24`t ,4
Jile
Enter in the space to the right a"wet" or electronic signature and seal: ;' ? Ad ,it^
e.
Phone number:413-259-1630 Email: Croberts@kuhnriddle.com 9 No.10107 1 [[{
AkiliE s 3T v `r
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 direc su. rvised. If'other'is
chosen,provide a description.
Version 01 01 2018