10B-093 % 6 R/V1/
0
0
i RE.f31S ir7I.O!' rr },tlr1:
BUILDING & REMODELING LLC
Northampton Building Department February 12, 2013
Puchalski Municipal Building
212 Main Street
Northampton, MA 01060
I request that you grant a modification to waive the requirement for control construction for
the project at 1 Front Street, Unit #1 (Grove Hill Mansion) in Leeds because the work is of a
minor nature, will not affect health, accessibility, life and fire safety, or structural
requirements and is impractical in that the cost of control construction is considerable when
compared to the cost of the proposed work. Thank you for your consideration.
Sincerel ,
i �
Gary J. Chagnon
Chagnon Building & Remodeling LLC
•
co
6 3 u? u) o
° O p z 0 ( d.
� _1 z S r a
6 a0 _ D J W 0
Li U 0. r w Z cc
2 Q 5 O CO D d
Rs a w 3 0 cc _
x z w
a a co } z a r
r 0 D m �
U O
0) a R (/) m W 1
c
iu Q
o Z Z Z J O O I M
00 0 -- (7)
r a 0 : o
✓ 1 z I is W W
O r a I- u- Q Q
i
(r) a m
o Q¢ U W Z d
z CC 2 Z o
r 0 ■
F z o z f= o
o OO Or 0 0 0 s V ` � y CC ° z w h O O
\\"/
C O 0 Z U ~ Q ,,
Q Q (1 Z
a 0 Q w c a n O
o Q z w W \\
° z Z O > >
co
o ` .
- 2
crs a U R. �� a N W W a m I
Ta a 2 0. r x Z h
N N W Q 0. W N I- l
C N gr, r Z 2 71. J
a W ° ai
Q ti � '� E
ai c 2 • ,0 H Q a w (‘'• L'. Z
co 0 °- a a W cc I W > '� c
ti c o ° cc W m 0 ¢ Z F= w 0 a
c E a) c _ @ W a N W W Cr Z _
cc Q cic
o 0 E a v n I Z r OJ w p J w?
76 0 a) i
m v `° i S 0 0 ° r 0 > _ 1 ' 3
°a, m o a ° o ff J w i O
Y `,L r a O > h S O w
oc CO Q - r W r 0 I- w
Y z > = m Q w h I
Q a c c .c Q o w W z> r- W W
c W p O a > m Q W 1 W r Z V,
_ W in 0 co > rd 0 0 H 0 h a co—
- No W F- Q c 0)
TA Q Q m Q Z U N W Z Q �., � a 0 • 3 h 0 a) c 70 ro w u U CC W Z 1 t
' FoS
E h o 0 a o g„ Q r a Z a m 0 i O r W : 1 1
a) V - 4 z w Z J > a I > J
E h co l • a _ '° v f Q m 0 U < a CI) u> J a
O C C O J a 0 ix = o a ° ti5 N Z w
U Z cc' N c a> .7. Z >-10-±-
} (- h W= a p c
cn 0 3 0) m . °- w 55 0 w 0 i a a- F
a N m o w 0) 0 0 0 o a w 0. w U O j p `
O Z v n a ▪ Y o a m CC J r O Q W _ ^ \p ,
c u c a o o a W C7 a Q < w CC w I ¢ r m i"
Ci a E c a ¢
a p :7 E LL U Q w W ��
o c O m 2 ° m p 0 >- 3 0 m 0. a � I O < m r ~ W �- w ka m � ! zO a Q o o z N w _ r p h LL Y o p W Q a m s h U S r m E V Q a O W W= n O h c n > I �, a 0. a Z Z¢ � ( Q d > > >> W i c W � z w 1 o a `> E Z r r C O a Z t. 4 w o Eo m a Q 2 q ¢ ¢ O W I N Z E J o o m H C7 w c o i l C7 c. = 2 > > N L N =_ Z h U LLJ W F- z h U U Q a O p u w Z F- O Q W 1 c
LL O " F U O 0 a a m m O m U k = ti, m cL
x
' ' The Commonwealth of Massachusetts Print Form
� Department of Industrial Accidents
F 0 Office of Investigations
1 Congress Street, Suite 100
�t
t
u '' Boston, MA 02114 -2017
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): 01 tt c/✓ 13 "-i)/A fr , e ,ci/)C-&//4- ��C_
Address: l / S7 Ck t3 r, cy gcl-
City /State /Zip: / le I /( Phone #: 9/3- 4:95
Are you an employer? Check the appropriate box: Type of project (required):
1. Tam a employer with sP, 4. ❑ I am a general contractor and 1
employees (full and /or part-time).* have hired the sub contractors 6. n New construction
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling
ship and have no employees These sub contractors have 8. n Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.+
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3 . I am a homeowner doing all work officers have exercised their 1 1 . 0 Plumbing repairs or additions
[No workers' comp. myself. right of exemption per MGL
y [ r 1 and we have no P c. 152, 4 , 12.❑ Roof repairs
insurance required.] § O 13.0 Other
employees. [No workers'
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.
Contractors 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: / ,'vr'i FM I(_ � i,,. U/fLt 1�
Policy # or Self -ins. Lic. #: 000/ to 7d0_5" / Expiration Date: // / r / /5
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: C Date] c3/
/ 3
Phone #: /7 4 5 ..----- r 676-5
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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
•
Version 1 .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 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable LL'�
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
S ee jeIk
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 a
General Contractor `
Ci l hthti ' o �-p, t Pvt 1, I t_ y /- Not Applicable ❑
Company Name:
ic J cf//'CN0A -1
Responsible In Charge of Construction
/,5 c.2® PPJ-j-1 / �(/! i- 4 0/03
Address
�J yi3 �5
Sig . ure Telephone
Version!.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 er
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, re/I' M'N' U`rc S as Owner of the subject property
hereby authorize � y �J� . (iGT� /�/�" to
act on my behalf, in all matters relative to work authorized by this building permit application.
sec 5 5 ci:- a //3 �
Signature of Owner Date
A F y elv4 YJI✓ - , 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.
G y ��• c�t�cs oi,�
Print Name
Signature of O Of /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction (-17 - 46-A Supervisor: d / Not Applicable ❑
6z Name of License Holder : 64/2-y -y ` 60
J License Number
/ 54 ck t3 g1 de ► 1 ' I Ca X / /f/
Address Expi tion Date
4,f , 9i3 -- 9 : 6 7.
Signa ure Telephone
SECTION 13 - WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(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 0 No 0
Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: _ L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: AjDi2c55 f cctOQ ti�ME
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version I .7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
I E
Interior Alterations OS xisting Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. PE/16 ( // ,'ta/ NV/ 70,40 Cv41/ fi E14-5•1/
Of Proposed Work: /� ,p /� (►2 y /{j n �C/p L /y)(✓ s O �( �p �p,�?yy- //J(J ,p�,
/vCAi (�,AlexA,t , Cc;ux t'/ 11 r o ,° ✓L
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
7 t oY�xeci y az /(0
i�
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 0 1A 1 ❑
A -4 ❑ A -5 ❑ 1B 0
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑,., 4 ❑
R Residential WI
R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): 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)
15` 1st
2nd 2 nd
3rd 3rd
4"
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 12r Private ❑ Zone Outside Flood Zone❑ Municipal ' On site disposal system❑
•
Version1.7 Commercial Building Permit May 15, 2000
Department use only
of Northampton Status of Permit:
Building City Departmen Curb Cut/Driveway Permit
3 2 �`� 212 Main Street Sewer /Septic Availability
0 �czvoNS Room 100 Water/Well Availability
oFgW PT N MPp1060 Northampton, MA 01060 Two Sets of Structural Plans
v o �i phone 413-587-1240 Fax 413 587 -1272 Plot/Site Plans
N 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 - r T INF +' • ,iON
/ This section to be completed by office
1.1 Pro. -ii • .dress: �j
r Sr�re (/11.6 ( Map / B Lot /,3 Unit
16 EbS/ ,A- 01053 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Pe�t,A,/,` -c1 f in. 6ei / //7014/ 5/, z el 0 A-4A -44 / , /ee /'1.4
Name (Print) Current Mailing Address:
Vi3 - 3c3 03a
Signature Telephone
2.2 Authorized Agent: n
Cligy 3• Ct &JC' ?/ ,Ji f3 hl d IQc4 lI 4 /Y/
Name (Print) / Current Mailing Address:
61c3 ac?= T�"
Signature Telephone
SECTION 3 - ESTINATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /' 300 (a) Building Permit Fee
2. Electrical C 0100 4'.- (b) Estimated Total Cost of
Construction from (6)
3. Plumbing / ,5od Building Permit Fee
4. Mechanical (HVAC) orz
5. Fire Protection 33,0(96 4...----
6. Total = (1 + 2 + 3 + 4 + 5) Check Number • /b g 4192-
92
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0754
APPLICANT /CONTACT PERSON GARY J CHAGNON
ADDRESS/PHONE 91 STOCKBRIDGE ST HADLEY (413) 259 -6785
PROPERTY LOCATION 1 FLORENCE ST UNIT 1
MAP 10B PARCEL 093 000 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �/�
Fee Paid
Tvpeof Construction: REMODEL KITCHEN & DEMO INTERIOR WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060175
3 sets of Plans / Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 - Permit DPW Storm Water Management
De .
�-�
Sig . e of Buildi j ' icial 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 authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
1 FLORENCE ST UNIT 1 BP- 2013 -0754
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 093 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2013 -0754
Project # JS- 2013- 001301
Est. Cost: $33000.00
Fee: $198.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GARY J CHAGNON 060175
Lot Size(sq. ft.): Owner: GEIS PENNINGTON
Zoning: URA(100)/ Applicant: GARY J CHAGNON
AT: 1 FLORENCE ST UNIT 1
Applicant Address: Phone: Insurance:
91 STOCKBRIDGE ST (413) 259 -6785 WC
HADLEYMA01035 ISSUED ON :3/8/2013 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN & DEMO INTERIOR WALL
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 3/8/2013 0:00:00 $198.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner