23B-046 (79) DIETZ&COMPANY APCHITFSM,INC.
TRANSMITTAL
TO: Tim Pelletier DATE: December 8,2004
Raymond Houle Construction,Inc.
187 East Street
South Hadley,MA 01075
CC: RE: ED Radiology Renovations
File Northampton,MA
20427
FROM: )ebb F.Dennis AIA
® ATTACHED,via pickup by recipient
❑ FAXED,number of pages not including this page:
COPIES DATE CSI No. DESCRIPTION
3 12/08/2004 Building Permit Set
17 Hampden Street
Springfield,MA 01 103
telephone
(413)733-6798
REMARKS facsimile
(413)732-4385
12/08/04 Building Permit Drawings e-mail
office @dietzarch.com
shop drawings logged by:
v.\20427-ed radiology renovation-cdh\06-construction documents\pro]ea team\gencontr-constmgr12004-
I I-12_trn[buildingpermlt].doc
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Before the X-Ray unit is used in radiography,a comprehensive radiation survey shall be
made to determine the adequacy of the shielding barriers. The determination of adequacy of
lead barriers(as specified in this report)and its certification shall be the responsibility of the
installer. The project manager shall obtain a written certification from the contractor
before occupancy and use. A shielding barrier radiation survey will be acceptable.
Cumulative exposure dose determinations shall be made for all locations adjacent to the
protective barriers. If the cumulative exposures are in excess of MPD levels then additional
shielding or controls shall be provided for protection of environs occupying these locations.
The use of this X-Ray facility shall be permitted only after the entire facility and its
surrounding areas are determined to be safe by physical radiation survey using clinical
operating technique factors used in radiographic examinations. The facility physician shall
develop and implement appropriate radiation safety and quality control procedures to meet
licensing requirements of DPH regulations 105 CMR 120.000.
This report is complete and valid only when written acceptance is granted by the person
aduunistrationally responsible for requesting this consultation by affixing his/her signature
in the space given in this report. A copy shall be sent to the consultant and Radiation
Control Office,Department of Public Health,90 Washington Street,Dorchester,MA.02121.
The facility shall register the x-ray unit with the Radiation Control Office(DPH)before
clinical use.
6. ACCEPTANCE OF REPORT:
I hereby acknowledge the receipt of this report and accept the recommendations given in this
report. I shall take appropriate actions to implement all the recommendations in this report.
A copy of this report will be given to Medical Director of the facility for follow up and
implementation of various requirements for compliance.
Nancy King,Manager
Department of Radiology
Cooley Dickinson Hospital
Northampton,MA 01060
REPORT BY: Suresh M.Brahmavar,Ph.D. Date:
Medical Physicist/Radiation Safety Officer
Cooley Dickinson Hospital
DPH/RCP #650056
SMB/mek
RADIATION SHIELDING CALCULATIONS FOR X-RAY FACILITY
DATE October 14,2004
Nancy King
Manager,Department of Radiology
Cooley Dickinson Hospital
30 Locust Street
Northampton,MA 01060
At your request I am preparing this radiation shielding report for the proposed x-ray installation as
shown in drawing#1. The protection barrier specifications are based on the data and information
made available to me by you at this time.
1. LOCATION:
Department of Radiology Present DPH/RCP Registration#02340
Emergency Room
Replacement of X-Ray Unit
2. LAYOUTS:
Drawing#1 dated 5-28-2004
3. X-RAY UNIT: Phillips Digital Dignost VM)125kV/500 mA
4. BARRIER THICKNESS:
The data summarized on the following pages are based on the information given to me by
Nancy King. Table 1 refers to shielding barriers for X-Ray installation. The physical
layout in Drawing#1 is for X-Ray facility. The present barriers of this X-Ray Room meet
the required standards of radiation protection.
5. RECOMMENDATIONS:
The barrier thickness values for X-Ray room are given in Table I. The barriers with lead
glass shall have lead protection equivalent to 1/16 inch of lead. The audio and visual
communication shall be provided between operator of X-Ray unit and patient during
radiography. Electrical interlocks that terminate X-Ray exposure or light indicators shall be
provided on entrance door of the X-Ray room. All barriers shall extend from the floor up to
a minimum of seven(7)feet. The operators of the X-Ray unit shall be trained radiographers
and the use of this X-Ray facility shall be under the control of a physician.
All accepted normal procedures of radiation safety shall be followed. Radiation protection
and radiation monitoring devices shall be provided for the use of the personnel in this
facility. All recommendations given in NCRP reports#48,49 and#51 should be followed
for installation and use of this X-Ray unit. The compliance requirements of new 105 CMR
120 and DPH shall be implemented. The X-Ray unit shall meet the guidelines of the HEW
and the Department of Health,Radiation Control Office,Commonwealth of Massachusetts,
Boston,MA.
COOLEY DICKINSON HOSPITAL
,A/L. DARTMOUTH-HITCHCOCK ALLIANCE
October 15, 2004
Robert Walker, Director
Radiation Control Program
Dept. of Public Health
Dorchester, MA 02121
RE: Replacement of X-Ray Unit in ED
Cooley Dickinson Hospital,Northampton,MA
DPH/RCP Registration #02340
Dear Mr. Walker:
The decision has been made to replace the present x-ray unit(Shimadzu) in the
Emergency Room with a new Digital Diagnostic VM x-ray unit(Phillips). The shielding report
prepared by Dr. S. Brahmavar (Medical Physicist/RSO) is enclosed. This is a replacement unit in
our present x-ray room with RCP registration#02340. Our total number of x-ray tubes will
remain the same.
All the recommendations given in the physicist's report will be implemented before using
the new x-ray unit in patient studies. The schedule to install this new unit is in the next ten
weeks.
I would appreciate your approval letter as soon as possible.
Thank you.
Sincerely,
Suresh M. Brahmavar, Ph.D.
Medical Physicist/Radiation Safety Officer
Cooley Dickinson Hospital
DPH/RCP # 650056
SMB/cmr
cc: Jeb Dennis
Enc: 4
CDH Radiology * 30 Locust Street* Northampton,MA 01061-5001 * Phone(413)582-2655 * Fax(413)582-2665
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.Chester, MA 02121
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❑Registered ,. ❑Return Receipt for Merdtandlse
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4. Restricted Delivery?(Extra Fee) ❑Yes
,rticiNumber 7003 1680y0001 1898 7746
Transfer fer f ft rom se►vfce IebeQ
=orm 3811, 1 ' Dorhestic Return Receipt 102595-02-M-1540
it ti tIt 1 {.,. t + 1 t
Cooley Dickinson Hospital,Northampton, MA
DPH/RCP Registration#02340
Dear Mr. Walker:
The decision has been made to replace the present x-ray unit (Shimadzu) in the
Emergency Room with a new Digital Diagnostic VM x-ray unit(Phillips). The shielding report
prepared by Dr. S. Brahmavar(Medical Physicist/RSO) is enclosed. This is a replacement unit in
our present x-ray room with RCP registration#02340. Our total number of x-ray tubes will
remain the same.
All the recommendations given in the physicist's report will be implemented before using
the new x-ray unit in patient studies. The schedule to install this new unit is in the next ten
weeks.
I would appreciate your approval letter as soon as possible.
Thank you.
Sincere
Z '
Q Suresh M. Brahmavar, Ph.D.
W4 Medical Physicist/Radiation Safety Officer
f1 Cooley Dickinson Hospital
DPH/RCP # 650056
SN1B/cmr
cc: 1eb Dennis
Enc: 4
-CDH Radiology * 30 Locust Street * Northampton,MA 01061-5001 * Phone(413)582-2655 * Fax(413)582-2665
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DEPARTMENT OF BUILDING INSPECTIONS i=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 4
CONSTRUCTION CONTROL DOCUMENT
(for professional Engineers/Architects responsible for Entire Project)
Cooley Dickinson Hospital
Project Title: Fn Radi nl ogy Date: 12-8-04
Project Location: 30 Locust St . Map: Parcel: Zone:
ScopeofProject: Renovation of Emergency_ Radiology Room
In accordance with the sixth edition Massachusetts State Building Code, 780 CMR SECTION 116.0.
1 Kerry L. Dietz , Principal Mass. Registration Number 5264
Being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly
supervised the preparation of all design plans, computations and specifications concerning:
X1 Entire Project
for the above named project and that to the best of my knowledge, such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable
engineering practices and all applicable laws for the proposed project.
Furthermore,I understand and AGREE that I shall perform the necessary professional services to
determine that the above mentioned portions of the work proceed in accordance with the documents
approved for the building permit and shall be responsible for the following as specified in section 116.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction documents as submitted for the building permit, and approval for the
conformance to the design concept.
2. Review and approval of the quality control procedures for all code-required controlled
materials.
3. Be present at intervals appropriate to the stage of constriction to become generally familiar
with the progress and quality of the work and to determine, in general, if the work is being
performed in a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, a progress report together with
pertinent comments. Upon completion of the work, I shall submit to the building official a final report as
to the satisfactory completion and readiness of the project for occupancy.
3q
CSs) z
Signature and Seal of registered rofessional:
�a
Fax 413-587-1272 -phone 413-587-1240
J '
~" Gih) II �Cl"f���t111jJiQ11 —=–
^* D p/.-R-Mchri O' DUILD"-No INS? C-110p,S
a
Zi2 Main Strcct ' Mun•acipal Bu[ldinc
Northcmpton, Mass. 01000
«`OI ',1Z'S CO'u'ENSA'17ON
!, _ Ra_y_mond•_R._Houle Construction Inc. ___-_ _._ _._ _•,
+vl[jJ z pfLicipall plate of busieess/residcnce at:
187 East St. South Hadely, MA 01075 (Done:) 413-532-9243
(5uc--t/ci c}(sutcrri p)
do hereby ccr-ify, under ulic pPLIIs and penalties of pulury, u`ta!
I cr an employer providing t!te fof!o:vi.�e % orl;c�s calnocassuon cove---c nor cn5
clupiovc:cs wor:�ng on'1<iis Job.
Arch Insurance Company IRWC100737 12/31/04
I.= a soic proor'iCior, g'CCe:21 GOna-aczor Or (cL"c:e one) 27a b2vc hired
cite comsat o:s steal below wb.o hIve tht follo%V'L 2 workeds C-Omp sa;nn pokles:
�: C aR arc Col�p��}y�cur, "ua=� ) ( >:ptracea Dmc)
-- (ti m c of Ca a. zc-,0 – (�s�zac Cow?aa�i?ol�c, �I�ccr) (Lxpir.:don Due)
(u c of Coa an,or)
of Con 7aCtar) ��surzaw CanPZ�flPolicy N L.Z ) Da:-).
(,-.,.�:5'i�xxl c`.ca it c c�:1•w c..:..'u�is'x-�oc�ui�a�to.1!occ�to.^.) ,
z sole proprietor zed ve no ooe wo rig for me.
ovvDer per 0 g a' r✓,e work czys°.1-F.
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veto.. �Cix-:%�"' :Lji-_LO ate_:'�:.b_`.'.�--:x�icc 2S.�cr}.!G I S?c:lc?L uc ^- ::ice ofc�i::1
cry �o or, t_x or,,to S I.SCo.00 �tior��x"�o(u? a rs y c';J ix� c��c rorn or.S!�W a c C-1—
a(SIOG.CY
For dc7�•'s-•=''u.c on!y
1'C:Za1t 1`l l'�bG
Si o:Li IPc=uc a,Ce _.... A
Versionl.7 Commercial Building Per, it May 15,2000
SECTIOk:10 STRUCTURAL.PEER REVIEW(780 CMR 110:11)
Independent Structural Engineering Structural Peer Review Required Yes......❑ No. 12
SECTION II'-':OWNER,AUTHORIZATION-TO BE COMPLETED WHEN
OY{NERS 'AGENT OP CONTRACTOR`APPLIES FOR-BUILDING PERMIT
(),4 1-7 SV
as Owner or. the subject
he-eby authorize Raymond R. Houle Construction Inc. t_ z_ `
m}' beh f, in all ma` e.s rel aLlVag to work aithorized by this building permit application.
2-1 VC,
Signature of Owner Date
I, Timothy S. Pelletier as Owner/Authorized A
h eo declare that the statements and inforrna:ion on L a
the foregoing application are true and accurate, to the best o my
kn_A,ledge and belief.
S! -,ed under the pains and penalties of perjury.
Timothy S. Pelletier
Na
c ,y
p C%
Sig-ature of Ov _r/Agent Date
SECTION 12 - .ONSTRUCTION_SERVI'CES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Na--,e of License Holder: Timothy S. Pelletier 066227
License Number
187 East t.South Hadley, MA 01075 07-07-2005
Expiration Date
413-532-9243
g-ab re Telephone
SECTION 13 -WORKERS' COMPENSATION INSURANCE AFFIDAVIT
_ .. _. _
Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this _�-,c_
wi' 'esu!t in the denial of the issuance of the building permit.
S _'z Aidayit Attached Yes....... X No...... ❑ -
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9 PROFESSIONAL DESIGN.AND CONSTRUCTION SERVICES - FOR.BUILDINGS AND STRUCTURES SUBJECTTO 11 CONSTRUCTION CONTROL P1IRSUANT T0780.CMR.136'{CONTASNING MORE THAN 35;000_C,F. OF-.'ENCLOSEDSPACEj
9.1 Registered Architect:
Not Applicable O
Name(Registrant):
Registration Number
Address
Expiration Date `
Signature Telephone 4
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
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address
Registration Num er
b...
1
I
&g:,a'ure Telephone Expiration Date
9.3 General Contractor
I
Raymond R. Houle Construction Inc. Not Applicable ❑ j
_ompa-y Name
Timothy S. Pelletier
=s_�-_-s pie In Charge or Construotion
I
187 East I
A�. ess
413-532-9243
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:
Public)M Private ❑ 1 Zone: Outside Flood Zone WX Municipal 0 On site disposal system ❑
8. NORTHAMPTON ZONLNG
Existing Proposed Required by Zoaing
This column to be filled in by
Building Depa.-tment
Lot Size 969,4 7.8 969427.8
Frontage 2,658- 2,658-
Setbacks Front
102 102'
Side L: 9,91 R: 421 L: RR, R: 42'
Rear 18' 18'
Building Height
64.5' 64.5'
Bldg. Square Footage %
402,861 402,861
Open Space Footage %
(Lot area minus bldg&paved 40.6 40.6
arldng)
r of Parking Spaces 761 761
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES XX
IF YES, date issued: December 13,2001
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES XX
IF YES: enter Book 6504 Page 239 and/or Document 1#
B. Does the site contain a brook, body of water or wetlands? NO XX 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 XX NO
IF YES, describe size, type and location: Various Locations on Site
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No, XX_
IF YES, describe size, type and location:
Versiocl.7 Commercial Building Permit May 15, 2000
S1 CTIOTV 4 �ONS�RUG�iONaERVICfSF0k1 O7ECTS LESS THAN 35,fl00
CUBIC-FEET OF NC D-SPACES, -F`
Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ Roofing ❑
k ❑ ❑
Exterior Alterations DemolitionO New Signs [ ] Change of Use [ ) Other [ ]
p Accessory Building [ Repairs [ ]
B?_IE= DESCRIP'T'ION: k rec"VI Z 4 It fix- f x�stivG 944
FSECFION 5 -.USE GROUP AND'CONSTRUCTION T1fPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A 11ssembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A IX
A-4 ❑ A-5 ❑ 1B ❑
B Blsiness ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C I ❑
�HKQI Hazard ❑ 3A nsttutional ❑ I-1 ❑ I2 I-3 ❑ 33 ❑
M Mercantile I ❑ L 4 I ❑
R Pesidendal ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage 1 ❑ S-1 ❑ S-2 ❑ 5B ❑
U Ut:!ity ❑ Specify:
I M M xed Use ❑ Specify:
S Special Use ❑ Specify:
=.COM°LETE:7NIS SECTION IF EX STING BUILDING UNDERGOING ftclvOVA330N5,f.DDI7I0NS ANDJOR CHANGE IN USE
Ex;stir,g Use Group: 1-2 Proposed Use Group: I-2
Exis r.g Hazard index 780 CMR 34): 4 Proposed Hazard Index 780 CMR 34): 4
SECTION 6.BUILDING HEIGHT^AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTP.0 t IONS_-_` - ��x _
Flocr;-.,-e3 per Fioor(sr `. Y _
2"d � �- r .L _ A
3t
A/TV17*rf /v
ZCJ Total Prorose� s r (S;,)
Total Heg ;t f
Versionl.7 Co=ercial Building Permit play 15, 2000
- -% n`eTttaisen
City of Northampton `
Building Department
- 212 Main Street a i1
Room 100
j 1-,`Northampton, MA 01060 Fa a
phone 4 3-587-1240 Fax 413-587-1272 _
A>,PiI TION TO CONSTRU , REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDINC
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION A- SITEZNFORMATION
_ --- ` ; Th�ssecfiotoe_compieteajr office �'
1.1 Property Address:
�-- �.� e. '.-to.- •�i. Yom'- --•° -� � '^`�z�.?,.--
Cooley Dickinson Hospital F`Map ° `$ llart
Zones verlay Drsfiict '. `~
30 Locust St. a_ �� ,+z s z �. -� Y
--C'n.
SECTION:Z=PROP-ERTY..OWNERSHIPIAUTHORIZED AGENT -
2.1 Owner of Record:
Cooley Dickinson Hospital. 30 Locust St.
Name (Print Cu, ent Mailing Address:
413-582-2313
Signature Telephone
2.2 Authorized Agent:
Raymond R. Houle Construction Inc. 1.87 East St. South Hadley, MA 01075
Na.'re(Print) Cur-,ent Mailing Address:
413-532-9243
Signal are Telephone
SECTION 3-7ESTIMATED CONSTRUCTION COSTS ,
Item Estimated Cost(Dollar) to be Official Use Only
completed by permit aoolicant `
1. Building �, t r® (a)Building Permit_Fee
2. Ele--,Tieal b e,G, -{b)Estimated:Total Cost of
// 0 .00 Gonstniction from'-i-(6)'-
3. Plumbing I , , Building Permit fee_
6 �.
4. htechanical (HVAC) d �, L,cr _
3. Fire Protecton
Tot✓! _ (1 + 2 + 3 + 4 + 5) Z? 3 2 `p ` Check Number I .—�
This Section For Official Use Only
5uilding P i umber -- I Date Issued:
Aa
Signa. re:
Building Commissioner/Inspector of Buildings Dat°
File#BP-2005-0665 '
APPLICANT/CONTACT PERSON Raymond R.Houle Construction Inc
ADDRESS/PHONE 187 East St SOUTH HADLEY (413)532-9243
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
Building Permit Filled out _
Fee Paid
Typeof Construction: RENOVATION 6F EMERGENCY RADIOLOGY ROOM
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INrF ATION 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
J�ft 1;7-
Signature of Buildi Officia 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-2005-0665
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 23B-046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build•Ina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0665
Project# 35-2005-0891 " D
Est. Cost: $27324.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin 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
AT. 30 LOCUST ST
Applicant Address: Phone: Insurance:
187 East St (413) 532-9243 Workers Compensation
SOUTH HADLEYMA01075 ISSUED ON.12114104 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATION OF EMERGENCY RADIOLOGY ROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of R'iring D.P.W. Building Inspector
Underground: Service: Meter:
/ / 1 Footings:
�/ ��
Rough: ����5 �t,;'� Rough: // House# Foundation:
Driveway Final:
Final:,y+ ��' ��ti�f� inal:
Rough Frame:
OK
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: � � Final:
THIS PERMIT MAY BE REVOKED BY THE C�Vff OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy- '� �'`3 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 12/14/04 0:00:00 10007 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo