00 - CDH ED & Endo - Building Permit - For SubmissionCity of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ● Municipal Building
Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL &
MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS
1. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work (Digital & Hard copy).
3. Site Plan with location of proposed structure(s) and setbacks.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker’s Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CSL and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (if applicable).
8. Note any Conservation and/or Special Permit requirements (if applicable).
9. Driveway Permit (if applicable).
10. Proof of Water and Sewer entry fees paid (if applicable).
11. Trench Permit (if applicable).
12. Initial Construction Control Documents filled out and signed by the Registered Design
Professional in responsible charge.
13. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton
The Commonwealth of Massachusetts
Office of Public Safety and Inspections
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: ____________ Date Applied: ______________ Building Official: _______________________
SECTION 1: LOCATION
_________________________________________________________________ _________________________________________
No. and Street City /Town Zip Code Name of Building (if applicable)
________________ __________________
Assessors Map # Block # and/or Lot #
SECTION 2: PROPOSED WORK
Edition of MA State Code used _____ If New Construction check here or check all that apply in the two rows below
Existing Building Repair Alteration Addition Demolition (Please fill out and submit Appendix 2)
Change of Use Change of Occupancy Other Specify:___________________________________________
Are building plans and/or construction documents being supplied as part of this permit application? Yes No
Is an Independent Structural Engineering Peer Review required? Yes No
Brief Description of Proposed Work:__________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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): __________________________________________ Proposed Use Group(s):__________________________
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 A-2 Nightclub A-3 A-4 A-5 B: Business E: Educational
F: Factory F-1 F2 H: High Hazard H-1 H-2 H-3 H-4 H-5
I: Institutional I-1 I-2 I-3 I-4 M: Mercantile R: Residential R-1 R-2 R-3 R-4
S: Storage S-1 S-2 U: Utility Special Use and please describe below:
Special Use Description:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA IB IIA IIB IIIA IIIB IV VA VB
SECTION 7: SITE INFORMATION (refer to 780 CMR 105.3 for details on each item)
Water Supply:
Public
Private
Flood Zone Information:
Check if outside Flood Zone
or indentify Zone:__________
Sewage Disposal:
Indicate municipal
or on site system
Trench Permit:
A trench will not be
required or trench
permit is enclosed
Debris Removal:
Licensed Disposal Site
or specify:_____________
______________________
Railroad right-of-way:
Not Applicable
or Consent to Build enclosed
Hazards to Air Navigation:
Is Structure within airport approach area?
Yes or No
MA Historic Commission Review Process:
Is their review completed?
Yes 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: _________________________________________________________________
30 Locust St, Northampton MA, 01060 Cooley Dickinson Hospital
X X X X
X
X
X
X
X
The project includes the renovation of approx. 19,000 sq ft of the existing Emergency and
Endoscopy departments and the addition of approx. 14,000 sq ft on the Ground Floor.
Includes a new entrance, air handling unit, MEP and architectural upgrades.
2015
Hospital - Group I-2; Waiting Room - Group A-3 Use and Occupancy will be unchanged
X
X
X
6 67,143GSF 14,000GSF addition
402,861GSF 416,861GSF64.5ft 64.5ft
6
X
2015 I-2 & A-3 IB
Yes
185 Group I-2; 203 Group A-3; Total 388 OCC
X X X X
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
__________________________ ______________________________ ____________________________________________ ___________
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information:
_______________________________ _____-_____-___________ ____-_____-___________ _______________________________
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 .
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
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
_______________ _______________
Discipline Expiration Date
10.2 General Contractor
__________________________________________________________________________________________________________________
Company Name
_________________________________________ ____________________________________________________________
Name of Person Responsible for Construction License No. and Type if Applicable
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
____-____-_______________ _____-_____-_____________ ____________________________________________________
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 No
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials)
Total Construction Cost (from Item 6) = $_________________
Building Permit Fee = Total Construction Cost x ____ (Insert here
appropriate municipal factor) = $________.
Note: Minimum fee = $________ (contact municipality)
Enclose check payable to __________________________________
(contact municipality) and write check number here ______________
1. Building $
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Other) $
6. Total Cost $
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.
______________________________________________________ ____________________________ ____ -_____- ________ _________
Please print and sign name Title Telephone No. Date
____________________________________ _______________________ ______ _____________ ____________________________
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: ____________________________________ _____________
Name Date
Walsh Brothers, Inc
Robert Furbish CS-062625 EXP 5-24 CSL
X
Jessica Itzkowitz Project Manager 978 340 5668 11/3/23
210 Commercial St, Boston MA 02109 jitzkowitz@walshbrothers.com
617 878 4800 rfurbush@walshbrothers.com617-719-6919
32 Lowell St N. Billerica MA 01862
Walsh Brothers, Inc.210 Commercial St, Boston MA 02109
Martin Batt
8/31/24Arch
617-419-4662 mbatt@isgenuity.com 11098
500 Harrison Ave, Boston, MA 02118
30 Locust Street, Northampton, MA 01060Cooley Dickinson Hospital
1,500,000.00
1,000,000.00
2,500,000.00
6,900,000.00
150,000.00Fire Protection
12,050.000.00
12,050.000.00
The City of Northampton
$7 per $1000
84,350.00
n/a
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)
6 HVAC
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)
18 Workers Compensation Insurance
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
Please follow this link for construction control forms to be used by Registered Design Professionals.
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
See attached Initial Design Affidavits for all disciplines
X
X
X
Appendix 2
(For total demolition only)
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit application.
The building permit applicant attests under the pains and penalties of perjury that the following is
true and accurate.
Property Location
__________________________ ___________________________ ____________ _____________________________
No. and Street City /Town Zip Name of Building (if applicable)
_________________________ ________________________
Assessors Map # Block # and/or Lot #
For the above described property the following action was taken:
Water Shut Off? Yes No Provider notified and Release obtained? Yes No
Gas Shut Off? Yes No Provider notified and Release obtained? Yes No
Electricity Shut Off? Yes No Provider notified and Release obtained? Yes No
__________________ Yes No Provider notified and Release obtained? Yes No
Other (if applicable)
__________________ Yes No Provider notified and Release obtained? Yes No
Other (if applicable)
Cooley Dickinson Hospital30 Locust Street, Northampton, MA 01060
Lot 23B-046-001 OnlyNot Available
X
X
X
X
X
X