25A-190 (45) BP-2022-0707
54 INDUSTRIAL DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25A-190-00I CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0707 PERMISSIONIS HEREBY GRANTED TO:
Project# 2022 BUS WASH Contractor: License:
Est. Cost: 805000 UNIVERSAL ELECTRIC CO, INC 104921
Const.Class: Exp.Date:03/10/2024
Use Group: Owner: PIONEER VALLEY TRANSIT AUTHORITY
Lot Size (sq.ft.)
Zoning: GI Applicant: UNIVERSAL ELECTRIC CO, INC
Applicant Address Phone: Insurance:
79 Wayside Avenue (413)788-9473 WCP2300581
WEST SPRI NGFI ELD, MA 01089
ISSUED ON:06/27/2022
TO PERFORM THE FOLLOWING WORK:
INSTALL NEW BUS WASH AT PVTA
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I
12.017(
Fees Paid: S5,635.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachu'setth
Office of Public Safety and Inspections i
9 J(/N
Massachusetts State Building Code(780 CMR)
3
Building Permit Application for any Building other than a Orik-orn amily Dweffl ig
OR -
j (This Section For Official Use Only) 3 '�O�TNa 1//)1N,
Building Permit Number: Date Applied: Building Official: 1�„„ T! ys
/
SECTION 1:LOCATION
5 / s r i a/ Priv t, ,Ga�fd1levy oloc,o f"/ rer VA hif T.,ri1 4q4 6 4
No.and Street City/Town Zip Code Name of Bdilding(if applicable)
e2S-79 f 90
Assessors Map# Block#and/or Lot #
SECTION 2 PROPOSED WORK
Edition of MA State Code used y If New Construction check here ❑or check all that apply in the two rows below
Existing Buildin0( Repair 0 AlterationX_ Addition 0 Demolition ❑ (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other %Specify:gvs toast LAU raft
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,%
Brief Description of Proposed Work ti'a/ tic euc' c cl j G r( . v t .
Loyl„i 4cfti relcce�.,c�f' plu,.,6, rrpLvi , a• �! ck;tiAi j•.,,c.,it(
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): I3, S —1 Proposed Use Group(s): a, S-I
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ,s+ 78�
l t,CkzZ. ,.,_ /,4;5
Total Area(sq.ft.)and Total Height(ft) }; Yto a3
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4❑ A-5 0 B: Business E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 ❑ 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 0 R: Residential R-10 R-2 0 R-3 0 R-4 0
S: Storage S-ig S-2❑ U: Utility❑ Special Use 0 and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB ❑ ILA ❑ IIB)8( IIIA ❑ IIIB ❑ IV 0 VA 0 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 Check if outside Flood Zone Indicate municipal
A trench will not be Licensed Disposal Site
requiredfor trench or specify:
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, Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No, Yes 0 No ❑
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
pv TA 2808 AL., S4. S 'Q 1d, /�tA 0/l0 7
Name(Print) No.and Street City/Tomah Zip
P erty Owner Contact Information:
roSex'.,cira clQ4.1 1113 -73Z - zLlf y!3- 6Sy- 7065- srkeli 0,v7,1,• Govl l
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 C.
Otherwise provide construction control forms(see section 107 in the code)as required.
10.1RegistereQQd Professional// Responsible for Construction Control (the professional coordinating document/submittals)
SA (t" &c,J4iiJ 95'7 - (S'o3 s7 rcet�l(w/.�K75i ✓nic.cool93'///6
Name(Registrant) Telephone No. e-mail address Registration Number
Oh( Fr�-..,,i,1 Cer,.-f-er metro'., )14,4_ OzIi I �},r,L.,+e�fi zz
Street Address City/Town State Zip Discipline piration Date
10.2 General Contractor
tt41 L eiffAl )ri 1- (b./ -1.."".r •
Company Name
.S'te1I &i L/Jes,4L,5-K,' CS-toyciZ1 — Cons-trvA,,,, Surervisbr.
Name of Person Responsible for Construction License No. and Type if Applicable
79 Ida f,de Ave- (esf Sk'il A/d A44 QIoJ
Street Address City own State Zip
yr3 7.4': q if 7 3 II 13 -Gf7 - P/L '3 IMAJCLokr^10 @Ulcna . 40401
• 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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor pp
and Materials) Total Construction Cost(from Item 6)=$ b0S?01)
1.Building $ /6) 000 1 7A0,"
i Building Permit Fee=Total Construction Cost x (Inse erp )
2.Electrical $ /(rp, COO appropriate municipal factor)=$ • s
,
3.Plumbing $ 30100c,
4.Mechanical (HVAC) $ �q pp D Note:Minimum fee=$/7 (contact muni ' ,/
5.Mechanical (Other) $ l/ o O oc) Enclose check payable to
6.Total Cost $ 0 S 000 (contact municipality)and write check number here _
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 owledge and understanding.
:Af/<l / /2, D # 4 r c
t ec WI -" 9y7?—(/Øz
Please print and sip name Title Telephone No. Date
7I ida .64 /k/ t ,/'r/ti Non dott 4,4.w 6)vec int• cei.ii
Street Address City/Town State Zip Email Address
iALd
Municipal Inspector to fill out this section upon application approval: � C ` ' 6 'l f
NameDa e
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
2 Foundation ✓
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters) 1/
6 HVAC t/
7 Electrical ✓
8 Plumbing(include local connections)
9 Gas(Natural,Propane,Medical or other) ✓
10 Surveyed Site Plan(Utilities,Wetland,etc.)
11 Specifications 1/
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) ✓
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify) 1/
*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
c-letthayl Pe/l.rci ���- 383- 6 So 3 Sitv4.,o 4t)60 Sfv,k�.w,,� 95/l1G /
Name(Registrant) Telephone No. e-mail address Registration Number
6,-ter '.3as'fakk i4,4 02l!( /644'af
Street Address City/Town State Zip Discipline Expira'on 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.
City of Northampton
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1` Massachusetts il.....
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DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Jy. D�
' Northampton, MA 01060 syhj��
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: LSR et, Frees ► •. Co, 1,-.c .
The debris will be transported by:
_NameofHauler: )OS& L 1. rQ�-�tA,.6„ C.0 L ) j)^c_
Signature of Applicant: / Date:
/2-/2-0zz
The Commonwealth of Massachusetts
==, 1, Department of Industrial Accidents
_del_ 1 Congress Street, Suite 100
-_ Boston,MA 02114-2017
U' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: Universal Electric Co., Inc.
Address:79 Wayside Avenue
City/State/Zip:West Springfield, MA 01089 _ Phone#:413-788-9473
Are you an employer?Check the appropriate box: Business Type(required):
1.17 I am a employer with 100 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. El Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing
no employees. [No workers'comp.insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers, Electrical Contractor
with no employees. [No workers' comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Patrons Mutual Insurance Co. of CT
Insurer's Address:769 Hebron Avenue
City/State/Zip: Glastonbury, CT 06033
Policy#or Self-ins.Lic.#WCP230051 Expiration Date: 12/03/2022
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 c. 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 certify, under the pains and penalties of perjury that the information provided above is true and correct
Signature: 7.20te Date:
Phone#: 413-788-9473
Official use only. 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.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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). 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 Department's address,telephone and fax number:
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form Revised 02-23-15