23B-046 BP-2023-1605
30 LOCUST ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23B-046-001 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-2023-1605 PERMISSION IS HEREBY GRANTED TO:
Project# 2023 CT SCAN AREA RENO Contractor: License:
Est. Cost: 62302 RAYMOND R HOULE CONST INC CS-066227
Const.Class: Exp.Date: 07/07/2025
Use Group: Owner: COOLEY DICKINSON HOSPITAL INC
Lot Size (sq.ft.)
Zoning: M/WP 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: 11/15/2023
TO PERFORM THE FOLLOWING WORK:
CREATE STRETCHER HOLDING &BREAK ROOM IN CT SCAN AREA ON GROUND FLOOR
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:
'fir sA
Fees Paid: $436.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
File #BP-2023-1605 Z N A
APPLICANT/CONTACT PERSON:RAYMOND R HOULE CONST INC (ALL )NTFRIo R ( '
5 MILLER ST LUDLOW, MA 01056-(413)547-2500
PROPERTY LOCATION 30 LOCUST ST
MAP:LOT 23B-046-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $436.00
Type of Construction: CREATE STRETCHER HOLDING &BREAK ROOM IN CT SCAN AREA ON
GROUND FLOOR
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
Driveway Grade%
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site.Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well,Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission P rmit DPW Storm Water Management
Demolition Delay
r
� � 11 3 93
Signs ture of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authori ties.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
The Commonwealth of Massachusetts
It), Office of Public Safety and Inspections
r 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 Z3~/ Date Applied: Building Official:
SECTION 1:LOCATION
30 Locust St. Northampton 01060 Conley fickinsnn Hospital9th
No.and Street City/Town Zip Code Name of Building(if applicable)
Z3P -04(0-00
Assessors Map# Block#and/or Lot #
SECTION 2:PROgOSED WORK
Edition of MA State Code used 9th If New Construction check here 0 or check all that apply in the two rows below
Existing Building Of Repair 0 Alteration di Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other IXSpecify: Create stretcher holding & a break rm
Are building plans and/or construction documents being supplied as part of this permit application? Yes XI No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 Noll
Brief Description of Proposed Work Create stretcher holding& a break rm in teh CT Scan area on the ground
floor
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) 0
Existing Use Group(s): 1-2 Proposed Use Group(s): 1-2
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) 210 sf 210sf
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 D
F: Factory F-1❑ F2 0 H: High Hazard H-1❑ H-2 0 H-3 0 H-4❑ H-5 0
I: Institutional I-1 0 I-2 DE I-3❑ 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3❑ R-4 0
S: Storage S-1❑ S-2 0 U: Utility 0 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAI I IBD HA IIB 0 MA CI IUB0 IV 0 VA 0 VBD
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:
A trenchwill not be Licensed Disposal Site id
Public It Check if outside Flood Zone Indicate municipal( requiredor trench or specify:
Private 0 or indentify Zone: or on site system❑ permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process:
Not Applicable/0 Is Structure within airport a proach area? Is their review completed?
or Consent to Build enclosed 0 Yes❑ or No tilt Yes 0 No ri
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 9th Use Group(s): 1-2 Type of Construction 1 A
Does the building contain an Sprinkler System?: yes Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Cooley Dickinson Hospital 30 Locust St. Northampton 01060
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Director of facilites 413 582 _ 2312 413 265. 8756 jkslater@mgb.org
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Raymond R. Houle Construction Inc. 5 Miller St Ludlow MA 01056
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 ii.
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
Raymond R. Houle Construction Inc
Company Name
Timothy S. Pelletier 066227
Name of Person Responsible for Construction License No. and Type if Applicable
5 Miller St Ludlow MA 01056
Street Address City/Town State Zip
413.547. 2500 413 _537_ 8657 tim@rayhoule.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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
06
1.Building $ 49,302.00 Building Permit Fee=Total Construction Cost x7 (Insert here
2.Electrical $ 4,500.00 appropriate municipal factor)=$ 3(t, .. b d
3.Plumbing $ 4,500.00
4.Mechanical (HVAC) $ 2,500.00 Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ 1,500.00 Enclose check payable to
6.Total Cost $ 62,302.00 (contact municipality)and write check number here" J 2_
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 b o y knowledge and understanding.
� '/4( President 413-537-8657 11-09-2023
Timothy S. Pelletier V ,, f►
Please print and sign name Title Telephone No. Date
5 Miller St Ludlow MA 01056 tim@rayhoule.com
Street Address City/Town State Zip Email Address
i'
Municipal Inspector to fill out this section upon application approval: r- ; r- • ,1,1 Y k J l I I/s/e a s
Name Da
City of Northampton __
! `5 Si
Massachusetts ��,? - ;�a
} N 7�
;t'l DEPARTMENT OF BUILDING INSPECTIONS IS. !�°
212 Main Street • Municipal Building ti C'
Northampton, MA 01060 'rs'..`••-^�'�0
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: a dumpster
Location of Facility: USA Hauling disposal site
The debris will be transported by: USA Hauling
USA Hauling
Name of Hauler:
Signature of Applicant: ,� Date: 11-09-2023
l
�..,,N RAYMRHO-01 ANGELA
'4��EY CERTIFICATE OF LIABILITY INSURANCE DA;My�D 2)
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 pollcy(ies)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 c E.CT Angela DiAugustino
Phillips insurance Agency,Inc. HNE
97 Center Street (A//CC,No,Ea*(413)594-5984 FAX Nol:(413)592-8499
Chicopee,MA 01013 a Ess:angeia@philapslnsurance.com
INSURER'S)AFFORDING COVERAGE_ NAIC#
INSURER A:Selectjve Insurance Co. 12572
INSURED INSURER E Massachusetts Employers Insurance Com n
Raymond R.Houle Construction Inc INSURER C
5 Miller St
INSURER D•
Ludlow,MA 01056
INSURER E:
INSURER F:
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 TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE 'ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
RNSR. -_..._1NSD WVD IMM.D➢IYYY`O.umfee1YYY1
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE I ^J OCCUR is 2396590 12/31/2022 12/31/2023 ;;y,frc, ( ENTE new ,s 0,0
00
MED EXP(Any one_par_enn s 16,-00
PERSONAL S Aov INJURY $ 1,000,000
.S
GEN AGGREGATE LIMIT APPLIES I II 1 GENERAL AGGREGATE _t.'$
2,000,000
POLICY L1 Pa _- LOC PRODUCTS $
2,000,000
OTHER. -- ' R
A AUTOMOBILE LWeiLiTY I COMBINED
gocid DLSINGLE MIT = 1,000,000
AUTOS ONLY 12/3112022 12/31/2023 BODILY INJURY)Per peon) -_——" --ANY AUTO 910749E
OWNED SCHEDULED
AUTO X AUUTNOSyy�Ep BBCOOILY II]NJUDRgY1!!�er accident)j$
X AUTOS ONLY X AUTOv ONLY (Par�Owawc). . _...,E_._..-.__.._I$ — -
I
S
A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE S 2395590 12/31/2022 12/31/2023 AGGREGATE $ 5,000,000
DED X RETENTIONS 10,000 $
B WORKERS COMPENSATION X I STATUTE OTH-
ER AND EMPLOYERS LIABILITY MCC-200-2000566-2022A 12/31/2022 12/31/2023 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT _I$
QEFICCER EXCLUDED? N N/A. - 1,000,000
(ei NH) - E.L.DISEASE-NA EMPLOYEE $
Nyes desaibeorder 1,000,000
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $
A Leased/Rented i IS 2395590 12/31/2022 12/31/2023 Limit ; 100,000
I1 I I
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mom space is'squired)
CERTIFICATE HOLDER _ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
9 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE/
ACORD 26(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
i ne c,ummonweaan of iviassacnuserrs
�—-- Department of Industrial Accidents
13_ —.ger Office of Investigations
_' =3I0
_ Lafayette City Center
;: 2 Avenue de Lafayette, Boston,MA 02111-1750
4 www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/lndiv,dual):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.ELI am a employer with ' 0 4. ❑ I am a general contractor and I 6. ❑New 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
workingfor me in anycapacity. employees and have workers'
P tY 9. 0 Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 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 all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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. Lic.#: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 thepai s andpenalties of perjury that the information provided above is true and correct.
- s -- /
Signature: ����i�L(f Date: �!�a i)''2-3
Phone#: ///J J r7 0..5d 0'
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
1DBoard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 59Plumbing
Inspector 6.0Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building RegulationsR and Standards
]
Consti {5visor
CS-066227 —rim"`` llcplres:07/07/2025
TIMOTHY S efi ,�y "
418 MOUNTIVN
WILBRAHA 41A
Commi:sioncr
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Q Raymond R Houle Construction Inc.
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, „ Ludlow, MA 01056
i 413-547-2500
Date: 09-19-2023 Proj #:
CT SCAN BUILDING - / Drawing Title: Existing Conditions Plan
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CT Scan areal renovations
Office_
Drawing Number A-100
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iI �- 0 5 Miller St.
- Ludlow, MA 01056
i 413-547-2500
Date: 09-19-2023 Proj #:
CT SCAN BUILDING i ----- Drawing Title: Demolition Plan
! \ Project: CT Scan areal renovations
—. Office[ --
� J Drawing Number A-101
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Break i - 5 Miller St.
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O � 3 413-547-2500
CT SCAN BUILDING I Date: 09-19-2023 Proj #:
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Drawing Title: Floor Plan
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Drawing Number A-102
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