31D-014 (4) City of Northampton
Building Dom,finent
Plan Review
Smith College 212 Main StMet
Northampton, MAo1o6o
23 West Street
Northampton MA 01063
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` SMITH COLLEGE
Facilities Management Department
Memorandum
DATE: April 1, 2015
TO: Louis Hasbrouck—Northampton Building Commissioner
FROM: Peter Gagnon- Capital Construction Director
RE: Lilly Hall Lactation Room Renovation
CC: file
Dear Commissioner Hasbrouck,
This letter is to request that you grant a modification to waive the requirement for control
construction for the above mentioned project. The work is minor in nature and will not
affect health, accessibility or life safety. For this project, it is impractical in that the cost
of control construction is considerable when compares to the cost of the proposed work.
The construction work and building modification includes the installation of a two non-
load bearing walls and doors. There are no structural modifications involved in this
project. The work also includes minor modifications to existing systems to accommodate
the new wall configuration. No reduction of individual system components will take
place.
I hope this satisfies the requirements for control construction in accordance with the
building code and that a building permit is issued to the contractor.
CC: Wischhof Construction
The Commonwealth of Massachusetts
T Department of Inditstrial Accidents
Office of Investigations
600 Washington Street
' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibly
Name (Business/Organization/Individual): /�r��Cr�%T7 l'�f� l JVST—i2L/c'770," —
Address:
City/State/Zip: L 1 0t Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with�_ 4. ❑ I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors Remodeling
2.El am a sole proprietor or partner- listed on the attached sheet. 7, ❑
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp.insurance.
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.F-1 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13 ❑ 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:
Policy#or Self-ins.Lic.#: V l 4�-- 9 2 L2 5 L Expiration Date:-'11S /G
Job Site Address: 1 �S s City/State/Zip: Al X✓1 /��
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 certi fy under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature:'` Date. �S
Phone#: `/
Of 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
J
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11);
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER:AUTHORIZATION-TO!BE COMPLETED.WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_ _..__. ..__.- _w __.. _ _... .____4___ __. -.,;,as Owner of the subject property
hereby authorize ....w: _ _,_.... ._ _-__._....... ,._. _....,_.. __ .,_.._. __ to
act on my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner Date
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 and r the pains and penalties of perjury ... �.
r _ _
Print Name
f nr�...'.41
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signat Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT
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
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 ❑
Name(Registrant):
_. w., .. _ M�u__, _ .._
_ � _._.._..._ ____� Registration Number
Address _ µ.
Expiration Date
Signature Telephone
9.2 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 Number
Signature Telephone I Expiration Date
9.3 General Contractor
`A//S C .__ �J!�1�.1.._.�<-/�-..j'�C?!�/, .___ , .__,_... i Not Applicable El
Company Name:
Responsible In Charge of Construction
_ ..:a_. -__ _
Address
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
S. NORTfIAMPTONZONING :.
Existing Proposed Required by Zoning .
This column tore filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L R'.._.___
Rear
Building Height
_._.__..... _._._..__..w
Bldg. Square Footage __._._ % __..
Open Space Footage _ %
- - (Lot area minus bldg&paved
#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 Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book _ Page _ µ and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued
C. Do any signs exist on the property? YES 0 NO Q
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 corstruction 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.
Version l.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing 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. _ C
Of Proposed Work:., Z GLr/ G(/ LcJ' Gf.'i y'/ 0,-)'Y 121
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 El 1A El
❑ A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - I� ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard El - - -- 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ 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,ADDITIONSAND/OR'CHANGE IN USE
Existing Use Group. Proposed Use Group. -------
Proposed Hazard Index 780 CMR 34)
Existing Hazard Index 780 CMR 34) •_._ .....-...-_ .._ °•-°• -----°
SECTION 6 BUILDING HEIGHT AND AREA
OFFICE USE ONLY
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf)
St
St
_. .... .... .. ....___.__ ..___ ...__. 2nd
2nd _.._.. ......_........
_ 3rd
3`d
4'h
4m .
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 ❑ Private ❑ Zone _ ,,_ Outside Flood Zone❑ Municipal ❑ On site disposal system❑
,1r .
Versionl.7 Commercial Building Permit May 15,2000
Department use,only
R I ZOIS City of Northampton Status of Permit
s Building Department CurbCut/Dnveway Permdb
212 Main Street Seweo8e.ptic AVallabitrty
- ;actions Room 100
Wate�/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot%Srte Plans
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 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
_... W._......._ w._..........
Map I Lot ' Unit
a 3 bfi�G'.� %s 7
Zone; Overlay District
'Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
.S�t/L/T/� ..4:.�'�Lr_C•r/�'___..�._..___--__.._.._...�.�� ...�..._�v��' �CG� i_ 5. ! ___.i1'c.�,c%Tff"rr�xrt.,r?I—�v
Name(Print) Current Mailing Address:
Signature `S � Telephone
2.2 Authorized Agent:
y�� vN�....__.�C� .sCi'�i`�C r4�-...�' /�'/�s'G>,'c��c'�'r�YG.�!�.._1��?GY�'!�► _.�
Name(Print) Current Mailing Address„_
Signature `�i.�e�/L Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS,
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _..:..:
t. ' J�J b
6. Total=0 +2+3+4+5) � � Check Number J]
This Section Foe Official Use Only
Building Permit Number Date
Issued
Signature:_
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0965
APPLICANT/CONTACT PERSON RAYMOND WISCHHOF
ADDRESS/PHONE 10 Blackberry Circle HOLYOKE01040(413)533-2520
PROPERTY LOCATION LILLY HALL-23 WEST ST
MAP 3 1 D PARCEL 014 001 ZONE EU(100)/URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL 2 NON BEARING WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 052126
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
em Delay
Sigr o ui di fficial 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.
LILLY HALL-23 WEST ST BP-2015-0965
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D-014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2015-0965
Project# JS-2015-001867
Est.Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RAYMOND WISCHHOF 052126
Lot Size(sq.It.): 14853.96 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: EU(100)/URC(100)/ Applicant: RAYMOND WISCHHOF
AT. LILLY HALL - 23 WEST ST
Applicant Address: Phone: Insurance:
10 Blackberry Circle (413) 533-2520 Workers Compensation
HOLYOKEMA01040 ISSUED ON.411512015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 2 NON BEARING WALLS
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 4/15/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner