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23B-011 (9) The Commonwealth of Massachusetts JAN - 3 2022 ,,,i .0, r, ay Office of Public Safety and Inspection's L Massachusetts State Building Code(780 CM ) nr I T of cu'.t�,+�,��� ,,T�o t Building Permit Application for any Building other than a Onii=or_T 1VFa>�itlny; , } Ns i (This Section For Official Use Only) Building Permit Number: gI`.1;2- S Date Applied: Building Official: SECTION 1: LOCATION 193 Locust St. Northampton 01060 Northamption Area Pediatrics No.and Street City/Town Zip Code Name of Building(if applicable) 23B 011-001 Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED 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 0 Repair 0 AIteration 0 Addition 0 Dem 'lion 0 (Please fill out and submit Appendix 2) Change of Use Cl Change of Occupancy 0 Other c .p • •Installatnn of temporary modular steel,pre-manufactured wheelchair rasp. Are building plans and/or construction documents being supplies :v.- o this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review requ Yes 0 No 0 Brief Description of Proposed Work:Installation of to ary odula tee',pre-m nufactg ed wheelchair ramp for Covid-19 access. % q ) N SECTION 3:COMPLETE THIS ECTION XISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing lding In s ' ation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Fl rs/Sto ' s( lude basement levels)&Area Per Floor(sq.ft) Total Area(s . t.) d 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 0 B: Business 0 E: Educational 0 F: Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 Cl I-3❑ I-4❑ M: Mercantile 0 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 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA D IB ❑ HA 0 IIBD IIIAD IHB 0 IV 0 VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: " Licensed Debris Removal: Disposal Site Public 0 Check if outside Flood Zone 2 Indicate municipal 0 A trench will not be Po CI required 0 or trench or specify:There will be Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 no debris Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 2 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 2 Yes 0 No 0 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: t_. ....- .._ ......__.._-. ..._ - .- • ---... ..._.. _. . . ._.._........ :;4 bi' n _ k.; n. ,7)bJ I �0 1: ..-- l�tl..: jl. i.., rtr{„'f , • • t . , •. Ef _ • ... _ .. _ I Att,1;11(•t IC. /h- f,-::J �1.t:s'11. - i , .>i i•:.rt7T',.fr ANorcA OCK(' SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 193 Locust St.Associates LLP 193 Locust St. Northampton 01060 Name(Print) No.and Street City/Town Zip Property Owner Contact Information David Steele,Managing Partner 413- - 8700 - ds@napeds.com Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Brian Jewett,Amramp VT&Western MA 76 Hartness Avenue, Unit 2 Springfield VT 05156 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 Id. Otherwise provide construction control terms(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 Amramp of Vermont& Western MA Company Name Justin B Gordon CS-112489 Ex 8/21/23 Name of Person Responsible for Construction License No. and Type if Applicable 84 Fitchburg Street Watertown MA 02472 Street Address City/Town State Zip 857-411t$378 - - justin.gordon@amramp.com Telephone No.(business) Telephone No.(cell) 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 13 No CI SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$2336.00 1.Building Installation $2336.00 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$I�'00 (contact municipality) 5.Mechanical (Other) $ Enclose check payable to Northampton 6.Total Cost $2336.00 (contact municipality)and write check number here 2166 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Brian Jewett Operations Manager $ -726 7327 ease print and sign me Title Telephone No. Date 76 Hartness Avenue, Unit 2 Springfield VT 05156 Brian.Jewett@Amramp.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts -�_` • Department of Industrial Accidents del 1 Congress Street,Suite 100 1:: Boston, MA 02114-2017 • ,. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Let ihlt Name(Husiness,'(rganization lndividuai): Graybeard LLC dba as Amramp of VT&Western MA__.___._____.___._. Address: 76 Hartness Avenue, Unit 2 City/State/Zip: Springfield VT 05156 Phone#: (844) 726-7327 .Arc yaw an rmpkryPr?Check the appn,prultc hot: Type of project(required): I aI am a employer with 2___employees(full and Or pars-tiai) 7. 0 New construction 20 I am a sole pcupnctur or partnership and hate nu employees working fur me in K. 0 Remodeling any e-apacity.[.Nu workers'comp.insurance required.) 9. ❑ Demolition 30 I am a hum:mum:I dying all suck myself.[No workers'cutup.insurance required.)• 4.0 I am a homeowner and NAill be hiring contractors to conduct all work on my property. 1 will I O 0 Building addition mutt that all contracturs calm line workers'compensation insurance or ue sole I I.o Electrical repairs or additions prupnetors with nu employees. 12_0 Plumbing repairs or additions 50 I am a ka7a^ral contractor and 1 hat a hind the sob-cuntractors listed un the attached.sheet Ttxac sub-euracwn w hate employees and hate urkers'comp insurance. 13.nRtxyfrepairs nt 6.0 We are a corporation and its otficcn hate excttixd their nght of exemption per MUL c 14. Otlictlnstallatlon of modular steel, pre-manufactured 152,y 1I41.and we hasc no employees.[No V.urken'comp.insurance required.] Wheelchair ramp. 'Any applicant that cheeks box al must also fill out the section below shun Mg their w urkcrs'compensation policy information. t Homeowners who submit dos atrda.it indicating they are doing all work and then hire outside contraetun must subnut a new afftdax it indicating such :Contractors that cheek this box moo attached an additional sheet show Mg the name of the sub contractors and state whether or not thug entities hale ;NO ryeca. If the sub-contractors base employees.they must proaidc their workers'cramp.policy number. 1 um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ Hartford Underwriters Insurance Co. Policy#or Self-ins.Lic.#: 6S60UB-7H84311-7-22 Expiration Date: 1/6/23 Job Site Address: 193 Locust St. City/State/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 tine up to S1,500.00 and or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er the pal d penalties of perjury that the information provided above is true and correct Signature, Brian Jewett Date: -3X/?-Q.7.---/ Phonct: (844)726-7327 x1 Official use only. Do not write in this area,to be completed by city or town official 1 City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Insitt•rrur 6.Other Contact Person: Phone#: J - . . . • • •i. -; •,' :• : • • ' . . . . . . - . . . • Ir1 II . . `:".• . • . • . , • VDAC jnF,dli I AD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S6OUB-7H84311-7-22) RENEWAL OF (6S60UB-7H84311-7-21) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY A STOCK COMPANY NCCI CO CODE: 10456 1. INSURED: PRODUCER: GRAYBEARD LLC DBA LAWRENCE & WHEELER INC AMRAMP VT & WESTERN MA PO BOX 546 76 HARTNESS AVENUE UNIT # 2 CHESTER VT 05143-0546 SPRINGFIELD VT 05156 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 01-06-22 to 01-06-23 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA MINIME .11111 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in 0 item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee " C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B 0 0 D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 12-06-21 AS ST ASSIGN: MA OFFICE: RMD HTFD 05G PRODUCER: LAWRENCE & WHEELER INC 75XLB 008702 Side View: C am' Imp 800-649-5215 30" RISE / 30' RAMP / Job Name: — " RISE/ 'RAMP Northampton © 0 Area O Q © 0 O Pediatrics/ L-6 L 24 ■, ---- © O BTp Northampton, --14 , L MA 18" i 30" ■11,'EEM ' 20" L-10 -10 ---Aminh--_ TOTAL 30" \ • • ��, L 24 L-14 L 14 10 —� L-10 L-10 RISE / 22" 23 —— 13 12 Location: = - Amramp f-.- 5' ---+— 5' —..-I-.— 5' I 8 I 5' --I— 5' --..-I- 5' —Hf 5' — } — 5' -] 2' H- Western MA + VT Requested: Top View: Brian J. 1 LOOP RAIL Phone: 12' 32" 7'-11" I • ••••-..-----•: 413-325-1457 ♦ •• •• ••• •••• !•••••�'�!�•••••!!!!!♦ •444•I••♦••• •••!.•••!!. •••!•!••.•• 36 !!►••►.•►O•••.• . ❖!❖!•4 m Fax: !•!❖!• *S:4•+4%4* 5CC36 • ,...!'•'•'•• ••;•►•,��►• •:❖'•°Q'•'❖:❖:•4 i�i'iii•••••Oiii ELEV. = 0 ••i'i'i•• i;ii;i;14.14. i o bate: •.•_A•_AA•A♦AAAA 1�.�.��.�.���.�ti�� 12 27-21 wee..."..... . - •• - Zip••••••••••••!•. ��• •• ;itIf;iit 5CC36 : t 5CC36: i • • NOTES Drawn By: •!••••• '•••••••' 1- Rev A Mike •••!•••. ow... .❖.•.o� 2. 4R3T Stair •••••111 !••• .•••• i•!•• Checked B •••• !!!!. !•• !•••. y: ..... ..... 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