32C-067 u Orr-5 56}6-8 BP-2023-0790
2 CONZ ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-067-001 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-2023-0790 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 RENO ROOMS UNIT 56/58 Contractor: License:
Est. Cost: 12814 RAYMOND R HOULE CONST INC CS-066227
Const.Class: Exp.Date: 07/07/2025
Use Group: Owner: MAPLEWOOD SHOPS INC
Lot Size (sq.ft.)
Zoning: CB Applicant: RAYMOND R HOULE CONST INC
Applicant Address Phone: Insurance:
5 MILLER ST (413)547-2500 MCC-200-2000568-2022A
LUDLOW, MA 01056
ISSUED ON: 06/15/2023
TO PERFORM THE FOLLOWING WORK:
DIVIDE 1 ROOM INTO 2,ADD 2 DOORS & SINK
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:
•
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIVED
Versionl,7 Commercial Buildineermit May 15,2000
JUN 1 5 2023 Department use oMy.
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit '• ' s• ':. -
D PT OF BUILDING INSPECTIONS 212 Main Street Sewer/Septic Availability.
NORTHAMPTON•MA 01060
Room 100 W,aterNVell Availability •
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIot/Siits Plans
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
2 Conz St. U 'Y ` s ‘.61 d,- ‘ i Map 2. Lot CU is 7 Unit LU I
Northampton, MA 01060 1 Zone Ga Overlay District
i
1 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT { Q —,�'�
2.1 Owne .of Record: ✓Q 1► .02
p‘,...\,k....4
Name(Print) 4 \ a. Current Ma ling Address:\« i
`� -k6 tr; -' S i 0 1
Signature _ .�-� y f `L. Telephone
2,2 Authorized Agent:
Timothy S Pelletier 5 Miller St. Ludlow, MA 01056
Name(Print) Current Mailing Address:
1-413-547-2500
Signature Z�/ A E 71<7.--- Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I
$ 10,214.00 (a)Building Permit Fee
i
2. Electrical 1 (b)Estimated Total Cost of j
$ 1,500.00 i Construction from(6)
3. Plumbing $ 1,100.00 Building Permit Fee
4. Mechanical(HVAC)
/0e ` °
5.Fire Protection
6. Total=(1 +2+3+4+5) $12,814.00 Check Number 40- '/.3)?20
This Section For Official Use Only
Building Permit Number Date
3P zo23-o79 D Issued
Signs re:
,\,,,a2 3 or, /s/2,5/p3
Buildir Commlssionerllnspector of Bull. Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs ❑ Demolition❑ Repairs 0 Additions 0 Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign 0 New Signs❑ Roofing': Change of Use❑ Other L
Brief Description Enter a brief description here.
Of Proposed Work: Divide a room to create a smaller room, add a sink and 2 doors, as per attached plan. 1
SECTION 6-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 ID A-3 0 1A ❑
A-4 ❑ A-5 0 1 B 0
B Business Q 2A ❑
E Educational 0 28 0
F Factory ❑ F-1 0 F-2 0 2C 0
H High Hazard 0 3A ❑
I Institutional ❑ I-1 ❑ 1.2 ❑ 1-3 ❑ 3B ❑
M Mercantile 0 4 ❑
R Residential ❑ R-1 0 R-2 0 R-3 0 5A 0
S Storage 0 S-1 0 S-2 0 6B JO
U Utility ❑ Specify:
M Mixed Use 0 Specify:i
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: ( Business I Proposed Use Group: 1 Business
Existing Hazard Index 780 CMR 34):' '-; I 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)
1•t 1 100 r 1" 1 100
2n° 2� '
3rd I 3rd
4th 4s'
Total Area(sf) ; Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§64) 7.1 Flood Zone Information: 7,3 Sewage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.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 36,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
I Not Applicable ❑
Name(Registrant):
Registration Number
I
Address
1 Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(a):
Name Area of Responsibility
Address Registration Number
I
Signature Telephone Expiration Date
I I1 a
Name Area of Responsibility
I II i
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
I I �
Address Registration Number
II
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
I 1
Signature Telephone Expiration Date
9.3 General Contractor
Raymond R. Houle Construction Inc. Not Applicable O
Company Name:
Timothy S. Pelletier
Responsible In Charge of Construction
5 Miller St. Ludt w, MA 01056
:GO"—Address .
1-413-547-2500
Signature Telephone
Versionl.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 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APR IES FOR BUILDING PERMIT
I, VA,i{,2 � e tJJC S) i t/�C--- i,as Owner of the subject property
hereby au r;ze Raymond R. Houle Construction Inc. to
act o m beh-11'in al m tters relative to work authorized by this building permit application.
Vtu `d • er Date
Raymond R. Houle Construction Inc.
I, ,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.
I Timothy S. Pelletier I
Print Name
j7. ,
I
Signature of owne gene 0 Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:1 Timothy S. Pelletier 1 1066227
License Number
5 Miller St. Lu low, MA 01056 I 7 - 7 2v-
Address Exptrallon Dale
1-413-547-2500
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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
City of Northampton 212 Main Street, Northampton, MA 01060
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: 2 Conz St. Northampton, MA
The debris will be transported by: Raymond R. Houle Construction Inc
The debris will be received by: Manamara Waste Removal Wilbraham MA
Building permit number: Pending
Name of Permit Applicant Raymond R. Houle Construction Inc.
Date Signature of Permit Applicant
1 ..\.\ t ne c.omtnonwearrn of lvrassacnuserrs
Department of Industrial Accidents
1k7, Office of Investigations
'- 1l Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
‘.-: t,t�r www g
mass. ov/dia
�r
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly.
Name (Business/Organization/Individual):Raymond R. Houle Construction Inc
Address:5 Miller St.
City/State/Zip:Ludlow, MA 01056 Phone#:413-547-2500
Are you an employer? Check the appropriate box: Type of project(required):
1. 7I am a employer with 0 4. ❑ 1 am a general contractor and I 6. Nev❑ construction
employees(full and/or part-time).' have hired the sub-contractors
2,❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance,t
required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.)t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing atl work and then hire outside contractors must submit a new affidavit indicating such.
teontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:AIM Mutual Insurance ,_
Policy#or Self-ins. Lie. #:MCC-200-2000566-2022A Expiration Date:12/31/2023
Job Site Address: City/State/Zip:
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 thepair and penalties of perjury that the information provided above is true and correct.
Signature: ,�-��/1.t�-i/
-51k(� —_ Date: 7 ._ >
Phone#: 03' 5-y7--2-56%'0'
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: _ Permit/Liceltse#
Issuing Authority(check one):
10Board of Health 2❑Building Department 30City/Town Clerk 4.0Electrical Inspector 5E'lumbing
Inspector 600ther
Contact Person: P+e#: _.
.___-�......4) RAYMRHO-01 I
AN ELA
AG�RCP' DATE(MluoomYY)
41e`,� CERTIFICATE OF LIABILITY INSURANCE 12/22/2022
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 poilcy(les)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 Angela DiAugustino
Phillips Insurance Agency,Inc.
97 Center Street tar l),Ixt,;(413)594.5984 � ,NoJ:(413)b92-8499 _
Chlcopee,MA 01013 Miktsc angela@phillipsinsuranee.e0111
I
...---- INSURER(S)AFFORDING COVERAGE —_.... I NAIDR
INSURER A:Selective Insurance Co. _._...._ :12572
INSURED INSURER a:Massachusetts Employers Insurance Company
Raymond R.Houle Construction Inc INSURER C:__
.-------
6 Miller St . --
INSURER D: ................._.._.._. .._. ----- ._.
Ludlow,MA 01058 INSURERS!_
I INSURERS: i.
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 TOALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SuCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CUMMS.
INSSRt X S ADDLI UBR POUCY F POLICYEXP UAIRi
LTR TYP80FINSURANCE LINED WVDI POUCYNUMBER IlllArlDD IMArDD1YYYY]
COMMERCIAL GENERAL uABIUTY 1,�00,000
EQaqEr,1bA EE CtElRENCE I.__.—___
clAllbs�tkoE XI OCCUR S 2395590 11213112022 12/3112023 ��6I9E6 EpEaase�, 500,000
,
MED EXP(nri are parson) _ 16,000
PERSONAL 8ADV INJURY - 'I. 00,000
DgnASORtalo IANAPAUEs PER: I i GENERAL AGGREGATE $ 2,000,000
POLICY I X I j Pt"LOC I PRODUCTS•C tP/OP AGO 2,000,000
QTHER - J i (-5
A AUTOMOBILE UABtUTY s.COMBINED SINGLE LlMrr I 1f,000,000
I 1E4.E00M- 1_
ANY AUTO A9107499 I12/31/2022 12/31/2023 BODILY INJURY(Perpetsonl_i$ ...
AAkVRRi��O��S ONLY I A A�OpQSW�ULNNE��Dpp I BODILY IITN URY(Px acGdwflJl i
X AUTOS ONLY X �DTU7 ONLY I �PeOr accMant CE _
A X UMBRELLA LIAb I X!OCCUR I EACH OCCURRENCE 1$ 5,000,000
EXCESS LABarl CLAIMS-MADE S 2395590 12/31/2022 112/31/2023 i AGGREGATE $ 5,000,000
1 DEO I X I RETENTIONS 10,000 I S
B WyyOpRKERSCp�t PENSATION X H
-
ANDEMPLOYERS'LIASILITY ill I_ i .�. ...��e
MCC-200.2000566-2022A 12/31/2022 12/31/2023 1,000,000
QNY PROPRIET PARTN R/EXECUTIVE E.L.EACHACGDEIR.... ... $ -
FICER/M EM EXCLUDED? NIA
Mandatory in NH) El:DISEASE-EA EMPLOYEE$ 1,000,000
IS yes,deecrbeurxler 1,000,000
DESCRIPTION OF OPERATIONSbetav i I ' ELniseASE-POUCYLIMLT1 f(;
A Leased/Rented I S 2396680 12/31/2022 12/3112023 Limit 100,000
t I _ I
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Addl,IonaI Remark*Schedule,may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ATE THEREOF,
Proof of Coverage ACCORDANCE WITH TTHE POLICY PROVISIONSCE WILL BE DELIVERED IN
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) 11988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
•
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Re ulations and Standards
Cons IQqi T'$visor
CS-066227 �g� I*pires:07i/07/2025
TIMOTHY S
418 MOUNTAIN FLO 1I in'
WILBRAHAP#jAA' t 1
•
- itt
11'-3" 8'-0„
N
Approximate Proposed New
Existing Condition Condition
Scale 1/4"=1' Approx
Raymond R. Houle Construction Inc.
5 Miller St.
Ludlow, MA 01056
413-547-2500
Date: 05-12-2023 Proj #:
Drawing Title: New Blood Draw Room
Project: A Positive Place
Drawing Number Al