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w DEP/,.R ME1JT OF DUILDFNC INSPECT)O1:S
212 Main Strect . 1funie;pal Duildinc
Northampton, Mass. 01000
WORlCER'S COMTENSATION 5NSUR4.NCE AF—TMr VIT
e116 7ier �/t'g ��o��� R_h!ov/e G,:919s
(Il CCIlSC[1 pc7 iI)}C t�)
\,qth a principal place oCbusioess/residence at
S f. L v c�/or,�/ 4I� 621056 Uh0ne ') 5'/3 SX7 2 00
do hereby certify, under the pains and penaltles of pcgury. hat
I 2= a-n employer providing the iollowine -workcr's cotnocnsc:jo,n cove 2ge for my
etuptovccs worming on this job.
s e�• _ �Ac �ordsl vz-3 io6
(L�sira Corer sv) (PC1 C-" N lCY r) (r;pir Tor, Dz�)
( )
[,am a sole proprietor, general coau-acror or homeowner (c c:e one) z-Dd hzve hired
Lhe conuactors listed below who have the following on Pokles-
(Name of Co^;-,c,o-1 (la2r�Itc: Cctnpi�lrT'cOc� '�`urn�c-) (r',�i;��on D�tc)
-- (N�� of CoaQZCto() _ (LZS-�-znc;. Ccm�aa�•iPolic� Nur,�i=cr) (t=��ir,:tion Dzte)
(Name of Coa=mo') ([crane Ccmpan}'Il'ol c� iv;l�txr) (E p r ooa Date)
(Name of Contractor) (Insurance Comczoy(Potiry Numbs) ���l<tion Date)
ocal eoc iI o cc�u.� tc mc'u�infort�v�oc pcvla:.ab to aL c -..c�;-�)
O i am a sole proprietor and bave no one working for me.
( ) I am a home owoer performing all the work myself.
NOTE:pica be ew-an IfiN"fie wbo caploy pczoux w w —.:e.,ao c r u•,orx cm .d..c:L:�of
C'3'mcee I -bier•.bc boc�-rcid�or ea QouacS x�pv.rec;i�tdeeo�e we C- --2?mc:d_--ni Le to
c loycs x�uitrs==r> ,'op Act GL15Z. S
t 1 C )),_pprlcifioc by.tlotarAa�(cr:t3 _a knit�-'7 c��dcYS trc
cal n,^ 0 ccloyx uau-r duo WoA-a,Co�/.eu_
1—&'—d d—>wpy oC Lbi,enlemcrl¢may bo(--&�d to tbo Dcgonmcru o r I.u:-i J'.—'usao'OQ o0 0([r.W�000 ror tS.
covct.o--c va-i5 c 1 O d-td Uu L Il tae Lo cm.trc`co uiYd.7 zoai oa 7 S A cf (C)I- t 5I on tad to the i.--,;o:Sai on cc=L=0�1 Qcailiin
00=1:�o(a(tnc a r LT to S I-}00 pp ar ya i. o(u p to ox ye.:r end a ail pe�J',i a�n be(oca;o(n Stn(W o'lc 0,
(L=of S 1 00.00.d_y LPJtC1 me
rcr dw..•.-iu,=--�.t u,c only
Pcrmlt Number ;
1�p Lot
Sipaa IaTI-scc Perm uc
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10, STRUCTURALIPEER REVIEW,(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No......❑
SECTION 11 --;OWNER AUTHORIZATION--TO BE_COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Toole ekin so l? /7/os�i7JQ L as Owner of the subject property
hereby authorize Q Gl /C AloU C O/ S I—I'Lic, f 10 G . _to act on
my be in all matters relf ork authorized by this building permit application.
Signature of Owner Date
I, RY/n671 �' �D�1/e CD/is7`/ uC"Ti0/7 -th e . asOwne uthorizedA en
hereby dec are 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.
Tirw o
Print Name
Signature of Ow en Date
SECTION 12 - CONSTRUCTIONSERVICES
10.1 Licensed Construction S'upervisLor: Not Applicable El
Name of License Holder : /1i ,7'/ e`' _ 066 R 2 /
License Number
s //er S ? vc►�/o
Address. � Expiration Date
yi - sy7 0
Signature Telephone
SECTION 13 WORKERS (M G
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida-
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... R No...... ❑
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 "PROFES$IONALDESIG.N AMID CONSTRUCTION S"Ef2V10ES ,FOR"BUILDINGS AND:STRUCTURES SUBJECT TO
CON"STRUCTtON CONTROL P,llRSaAN_ T0,780.CMR:116.{CO"NTAINING MORE'THAN.35;000"C F OFiENCLOSED.'SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number l
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
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
i
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3��General Contractor
/T4 G Not Applicable ❑
Corn-- panName:
Responsible In harge of Construction
5A'11e r S T �ycI/o,z4f d/05_z
Address
-��turSignae Telephone
Versionl.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L. c.40,§ 54) ( 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
El❑ Private Zone: Outside Flood Zone Municipal 14 On site disposal system ❑
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 96 9, 112 7 8 96 9, y2 7.8
Frontage 2(0 Se 2 6 5 0
Setbacks Front 102 102 ,
Side L: 88 R: 5'Z L: 88 R: y2
Rear /8' /a"
Building Height 6 y JC ' 6115
Bldg. Square Footage y02 96 % 1102,$6 1.
Open Space Footage % /J
(Lot area minus bldg&paved
aridn )
#of Parking Spaces 761 761
Fill: N,A N�A
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES X
IF YES, date issued: Der_ 13,, 200)
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book 6 SOy Page z 39 and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
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 lr NO
IF YES, describe size, type and location: VA), I's
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No_4
IF YES, describe size, type and location:
Versionl.7 Commercial Building Permit May 15,2000
=SECTION 4 �ONSIR11CriON ERVICESFOR�RO7ECTS LESS THAN 35,0 Q0
CUBIC FEET OF�L-0SED�P1Cf �'
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
_er ❑ ❑
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
❑ Accessory Building [ ] Repairs [ ]
BRIEF DESCRIPTION: 411cg ^ e_XiS7jg7 S eel Ce To oiloo,Te ouAeAv m7Y;re q to,ea
SECTIONS -_USE GROUP AND CONSTRUCTION TYPE _
USE GROUP (Check as applicable) CONSTRUCTION TYPE _
A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ 1A -iff-
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ I-1 ❑ I-2 I-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
i M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLE fE THIS SECTION iFDCiST3NG BUILDING UNDERGOING RENOVA3IONS,ADDITIONS ANDf OR-CHANGE IN USE
Existing Use Group: I-2 Proposed Use Group: l-2
Existing Hazard Index 780 CMR 34): 'y Proposed Hazard Index 780 CMR 34): y
SECTION 6 BUILDING,H`EIGHTAND-AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION �'� T ;OFFICE USEONLY v
Floor Area per Floor (sf) 3 sy ist
1st 2nd
'QTY``-afi•SVfi �'.^if` .q' t r'
2 nd 3rd
3 -3
3 � f "H i t k
4t'
pt
> r ,
z �
Total Area (sf) Total Proposed New Construction (sf) t
-------------------
Total Height(ft) ���
k�
N
Total Height ft ��
` Versionl.7 Commercial Building Permit May 15, 2000
City of Northampton
`Budding Departmenta �
212 Main Street
5-
Room 100
116rthampton, MA 01060 a _ '
'1^1 p one;413-�87-1240 Fax 413-587-1272
APPLICAT-7ON''TO'CONtSF# ULT REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION'1i SITE INFORMATION
1.1 Property Address: K P t
Thissecfio to be com letei3 fi office k
S� 3�—
+r--s: `!�'—�"C' °''TF��z",�y '�SaS'� Sz YwS.4.'�u `�+�, '}v,.rb..,$E �r,�,n '"F•`,'�'^^` ' ' :
O G� pi A/ yr�3Un�t € u
-30 4 CUS t STone � � t �yeray��sct, e� �4
x
ill',Str�15�7]t;t"- �: �' x-� � •"VB �,��� gr°��
.y
r.c. PROPERTY OW NERSHIPJAUT#10RIZEU AGENT
2.1 Owner of Record:
Cooley D1ckihsoh Hosaz;ro _3O1ocvst S loo. 160Z Da/
Name(P t) Current Mailing Address:
3113- 582 -z3/�
Signature Telephone
2.2 Authorized Agent:
711wo"'fiy S. Pellet-iee 5/I'),'lleh S7. Luc, /acv, /yIB O/O56
Name(Print) Current Mailing Address:
yi3- by7 2 500
Signature Telephone
SECTION33 ESTIMATED CONSTRUCTION COSTS T
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building a B
I D � 2 •�� -O uildmg Permit Fee
2. Electrical Fstimated;Total Cost of
:Construction from 6
3. Plumbing DO �� Bwlding Perm�tfee
4. Mechanical (HVAC)
5. Fire Protection
r
6. Total = (1 + 2 + 3 +4 + 5) Z $ 6 2. Oa Check Number � r
This Section for iicial Use.y
Building Permit.-Nu nil Ler ° -. Date issued: -
Signature:
Building Comm issioner%Inspectorof.Buildings Date
File#BP-2006-1340
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500()
PROPERTY LOCATION 30 LOCUST ST
MAP 23B PARCEL 046 001 ZONE M
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Tyneof Construction:_CREATE NEW OFFICE AREA 4TH FLR ICU-INTENSIFIST'S OFFICE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066227
3 sets of Plans/Plot Plan
THE FqLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�F9RMATION 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 Co on
Signature o 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 authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
30 LOCUST ST BP-2006-1340
GIs#: COMMONWEALTH OF MASSACHUSETTS
MaP:Block: 23B-046 CITY OF NORTHAMPTON
Lot: -001
Permit: BUlldlnq
Category BUILDING PERMIT
Permit# BP-2006-1340
Project# JS-2006-1977
Est. Cost: $28562.00
Fee: $101.00 PERMISSION IS HEREBY GRANTED TO:
Covst. Class: lA Contractor: License:
Use Group: 12 Raymond R. Houle Construction Inc 066227
Lot Size(sq. ft.): 667077.84 Owner: COOLEY DICKINSON HOSPITAL INC
Zoning:M Applicant: Raymond R. Houle Construction Inc
Applicant Address: Phone: Insuran-e:
5 MILLER ST (413) 547-2500 Workers
Compensation
LUDLOWMA01056 ISSUED ON.6/12/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:CREATE NEW OFFICE AREA 4TH FLR ICU -
INTENSIFIST'S OFFICE
POST THIS CARD SO IT IS VISIBLE FROM THE STREIF]'
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
wg Gl� Footings:
Ro,gh: �� �_{J j Lough: l House# Foundation:
�^V /��/U�� Driveway Final:
Final:1,, q Final: 7/�-CC
Rough 0 G��u /Nr%G1N�
g 51SP6Fr o
Gas: Fire Department Fireplace/Chimney:
rough: Oii: Insulation:
Final: Smoke: Final: oj� c,7(
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate -
Certificate of Occupancy -- Signature: _
FeeType: _ Date Paid: Amottut:
Building 6/12/2006 0:00:00 $101.0012460
212 Main Sheet,Phone(413)587-1240,I'ax: (413)587-1272
Building Commissioner-Anthony Patillo