31D-163 (7) City of Alort;hampton, Massachusetts
E Central Services
Memorial Hall,240 Main Street
Northampton,MA 01060
David Pomerantz (413)587-1238 Fax: (413)587-1248
Director of Central Services
To: Chuck Miller, Building Inspector
From: David Pomerantz
Date: July 3, 2014
Re: Building Permit Application-
City Hall Server Area Renovations
I request that you grant a modification to waive the requirement for controlled construction
for the above project in Northampton because the work is of a minor nature, and it will not
affect health, accessibility, life and fire safety, or structural requirements. Construction
control is impractical here since the cost of controlled construction is considerable when
compared to the cost of the proposed work.
Thank you.
-,. Tile C077z7nonweafzh of fassaclzusaLs
x. :._
. ,._:.,��--•F r_ - - Depar-7ine7zt
- — Qfjzce offizvestigado7zs
600l%i'ashin ow'Street
--_—_ Boson, M14 OZIII
u `= www.m ass.go v1dia.
Workers' Compensation Lnsurance Affida-vit: Builders/Contractors/Electriciaias/Plurnbers
A-DDlicant Information PIease Print Ledbly
N7ame(Business/Organizatiowbditadual):
City/State/Zip: Phone#:
Are you an employer? Check the appropriate bog: 'r1Pe of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full_and/or part-time).'` have hired the sub-contractors 6. ❑New construction
2-❑ I am a sole proprietor or partner-
5z on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
worlang for me in any capacity. employees and have workers' 9. F-1 Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5_ ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work DfBC rs have exercised their 11.E]Plumbing repairs or additions
Myself No workers' comp. right of exemption per MGL 12.E]Roof repairs
insurance required..] c. I52, §1(4),and we have no
employees. [No workers' 13-❑ ether
comp.insurance required.]
`Any applicant that checks box-1 must also fill out the section below showing their workers'compensation policy information.
?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 narm of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employes,they must provide their workers'comp.policy number.
I anh an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy t or Self-ins.Lic. t: Expiration Date:
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 Iead 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 WORD ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DL4 for insurance coverage verification_
I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct-
Signature: Date:
Phone 1.
Official use onZv. Do not write in this area, to be completed by city or town o.;TlciaL
City or Twvn: Permit/License it
Issuing Authority(circle one):
1.Board of Health >:B.ullding.Departme-ut 3..C;f�,7oFZZ Clerk '.Electrical Inspectbr 5.,P?rmbing In-.s.aector.
6. Other
Contact Pers on: Phone t
� a
• Ver8ionl-7 Commercial Buildin-Permit May-15,2000
SECTION fi 0-STRUCTURAL PEER°REVtEYir.(780.CMR 11;0.1'-)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER.AUTHORIZATIO.N -:70-05"COMPL'E I ED WHEN-
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize_.._______ ___..__._�___._...__ _____—T__w_ . _—,_ __ _.._.__ to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date -
GlAuthorized
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 a d en%alfiies of perjury.
APriintener/Age Date
SECT N 12 CON TR. CTlON.SERVICES
10.1 Licen r-nnstrlhctin Supervisor: Not Applicable ❑
Name of License Holder:..__ __-.
License Number
Address Expiration Date-
Signature Telephone
SECTION 13==WORKERS'COMP.ENSA:TION7INSURANCE AEEIDAVIT.M_G L.c.- :52
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,?000 . a
S. I O R'IA.NIP T O IN..Z O N-UN.G
Existing Proposed Required by Zoning
This cohnnn to be filled in by
Building Department
Lot Size
t -
Frontage
Setbacks Front '" T
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 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 �,j DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: y ��
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
c , Versionl.7.Commercial Building Permit May 15, 2.000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIOf�SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO t80 CmR.1:.16.(CONTAINING,MORE THAN 35,000 C.F..OF EN.C:LOSED SPACE) . .
9.1 Registered Architect-
Not Applicable ❑
Name(Registrant)_ �_-
---- Registration Number
Address
Expiration Date
Si nature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
f _
Address Registration Number
_ f
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 Y^
9.3 General Contractor
Not Applicable ❑
Company Name: t n
Responsible In Charge of Construction _ ^�
es
S at e Telephone -
Version 1.TCommercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35;00.0
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolltion❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ❑
Brief Description Enter a brief descn' on here. 1%- 1IA(. , `5J/ WALk- V S VN V)00 L I�{�LML_..._t
Of Proposed Work: ;Q`�NV°'`OTC wD S AQJ (AM �A�.✓< k- MU( T6-3
SECTION 5-USE GROUP AND CONSTRUCTION TYPE'
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ " 2B ❑
F Factory ❑ F-1 ❑. F-2 ❑ 2C l ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ 1 R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ 5peciry: ._._�_._.��.__�__�._____.._._._...-.r_._..__._:._________._,_,-_..__.------.
COMPLETE-THIS SECTION IF EXISTING B.UIL'D1Nt °U.NDERGO:ING-RENOVATIONS;ApDITIGNS ANDIOR CHAN-GF]WUSE
L sting Use Group: __..._ _..�. -_-_ —.. ____ _ __ _ Proposed Use Group:
sting Hazard Index 780 CMR 34):_ __ __,_--° Proposed Hazard Index 780 CMR 34):CTIO.N.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION 7 Q.FFICt °USE F�:N1a`
Floor Area per Floor(sf)
St
1 tit
2nd 2nd_ ---
rd 3 rd
m
4
_
4cn :.. -- -- -
Total Area (so Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
I
7. Mater Supply(M.G.L.'c.4D,§ 54) 7.1 Flood,Zone Information: 7.3 Sewage Disposal Systam:
Public ❑ Private"0 I Zone Outside Flood Zone❑ I Municipal ❑ On sits disposal system❑
Versionl-7 Co=nercial Building Permit May 15.2-000
r, r Depa-L use only
�, f I (�
City of Northampton Status o#Permit
i tY P
IJI Building Department cure Cuf/Dnveway Permrt - -
JUN 3 o Zo« 212 Main Street Sewer. ep..q. labiTty
_� ROOM 100 VSlater/Weil�vailability
E ec
tr;c, r n, ci. sin�pections Northampton, MA 01060 Tv�o Sets of 5tructuraa:Plans
t,,...
°` " 1,3-58741240 Fa-,413-587-1272 PIDtS:rte Flails
J.
Other SpecifijG.
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
21 �1Q�r',C - j------------ -_� Map S) Y Lot 1V 3 Unit
o :Zones _ Overlay District
Dist ipi CB'DistricY:
SECTION 2-;PROP.ERTY OWNERSHIPI AUTHORIZED.AGENT
2.1 Owner of Record:
- _.__
Name(Pnn U���D p Current Mailing Address:
Sionature Telephone
2.2 Authon e ent:
Name(Print) - -- -- - Current
Signature Telephone
SECTION 3-:EST(N(ATE°D=:CONS3RUCTION-COSTS- -
Item Estimated Cost(Dollars)to be Officiakiise Only
completed by ermit applicant -
1. Building (:a)`Building Perrnit_Fee
2. Electrical ,(6 `Esfiinated`Total4Cost of
-onstrucfion from (6) _
3. Plumbing-
4. Mechanical (HVAC)
5.Fire Protection
6. Total= (1 +2+3 +4+5) / Check Number
This Section�FbeOffdial Use-Onl
Building Permit Number bate.
Issued
Signature:
Building Commissionerhnspector of Buildings Date
File#BP-2015-0009
APPLICANT/CONTACT PERSON CITY OF NORTHAMPTON CENTRAL SERVICES
ADDRESS/PHONE Memorial Hall NORTHAMPTON (413)587-1260 Q
PROPERTY LOCATION 210 MAIN ST-BASEMENT WOMEN'S ROOM
MAP 3 1 D PARCEL 163 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 3/4 WALL W/DOOR IN OUTER ROOM OF WOMEN'S RESTROOM
New Construction
Non Structural interior renovations
Addition to Existing-
Accessory Structure
Building-Plans Included:
Owner/Statement or License 054510
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
A oved 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
Demo 't' y
7 �
Signature of Build ng O is al 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.
210 MAIN ST-BASEMENT WOMEN'S ROOM BP-2015-0009
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D- 163 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-0009
Project# JS-2015-000015
Est.Cost: $500.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CITY OF NORTHAMPTON CENTRAL SERVICES 054510
Lot Size(sq.ft.): 17380.44 Owner: NORTHAMPTON CITY OF CITY HALL
Zoning: CB(100)/ Applicant: CITY OF NORTHAMPTON CENTRAL SERVICES
AT. 210 MAIN ST - BASEMENT WOMEN'S ROOM
Applicant Address: Phone: Insurance:
Memorial Hall (413) 587-1260 ()
NORTHAMPTON MAO 1060 ISSUED ON.•71912014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 3/4 WALL W/DOOR IN OUTER
ROOM OF WOMEN'S RESTROOM
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 7/9/2014 0:00:00 $0.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner