39A-078 (6) I
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FIRST FLOOR
Commissioner Hasbrouck
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the minor
renovations at 518 Pleasant Street in Northampton 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.All work
will be completed within the prescriptive requirements of 780 CMR.Thank you for your consideration.
"Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
7
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The Commonwealth of Massachusetts
Department of frtdustrial Accidents
A — r Office of hives 1p ations
i-rt 600 Ul'ashingt n Street
_= Boston, MA 2111
-< www.nnass.g 7vldia
Workers' Compensation Insurance Affida-0t: I3 ilders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeQJbly
Name (Business/Organization/Individual):
Address: 7 S _
City/State/Zip: i Phc ne#: / 5 ��3 _t / C)
Are you n employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. I am a general ulb-co for and I 6. ❑New construction
employees (full and/or part-time).* have lured the sue-contractors
2.El I am a sole proprietor or partner- listed on the attached sheet. 7. E modeling
These sub-
ship and have no employees and have have
g. Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. 7 We are a corporation and its 10.0 Electrical repairs or additions
�. 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 12.7 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp.insurance egt,tred.]
*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 anew 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 thepolicy and job site
information.
Insurance Company Name: (_ —
�(j � 1_) 'y Gam- ' G` Ex/iration Date: �^
Policy#or Self-ins.Lic.#: P
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 c 1 under the pains an/d�penalties ofperjury that the in/ormation provided above is true and correct.
Sienature: �- `—° Date: Air
Phone#: - �l C, L
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit icense#
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#:
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Versionl.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
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize ' ;... �'wl�c i :'�. to
act on my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner Date
as OwnerL uthorize
CIA 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.._ _ a.� ........
i
r ' ��'JI..✓_ �� V .I ..'yf.1�........ ........... ..__.... ... ..__ ....
Per ame
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
......
Name of License Holder:
License Number
ess EE p tion Date
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit mus be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin g,rermit.
Signed Affidavit Attached Yes No 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICE -FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAININ MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
....., _.....:.. .....�,... ._..... , .....,._, :.,...._ .,__, Not Applicable ❑
Name(Registrant): _. ,.,..:
.._... .. ... __...__... ...._..__..
Registration Number
... ..
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
__._. _... _.... _.
Address Registration Number
Signature Tel phone 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 General Contractor
_.,_._�. ,.�.,..... , ..._,._._.,:..r. ._._.__. .....,...._, Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Signature / Telephone
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Version 1.7 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. w_..._... R. L R::.
Rear ......... _..m...,,
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 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 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
. - -
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Buildiing Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
t
Interior Alterations Existing Wall Signs ❑ Demolition❑ Repai s dditions '('1 Accessory Building❑
Exterior Alteration Existing Ground Sign❑ New Signs❑ Roofi g❑ Change of Use❑ Other ❑
_.:.., :.
Brief Description Enter a brief description here.
Of Proposed Work: � � j' �V-, X i
G' rte . 1 �° ._ r�l-r►c�—�
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly E] A-1 ❑ A-2 1:1 A-3 ❑ 1A 13
A-4 ❑ A-5 ❑ 1B ❑
B Business 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 1 2C ❑
H High Hazard ❑ 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 F-1 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)
1St
1St
2nd 2 nd
3rd :.
3rd
Oct,
4th
Total Area(sf) Total Proposed New Constructiion(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[—]
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Versionl.7 Commercial Building Permit May 15,2000
Department use only,
R CEO City of Northampton status of Permit:
Building Department Curb Cut/Driveway Permit -
,A� 206 212 Main Street Sewer/Septic Availability
ROOM 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
oFiguunir>GIKSPe�on 13-587-1240 Fax 413-587-1272 Plot/Site Plans
Wwm
Other Specify
APPLICATION TO CONSTRUCT, REPAIR,RENO',ATE, CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TW:7 FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
J1 i✓ �L� .S: A'f Tf cr Map Lot Unit
Zone Overlay District
.......... Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
n�i'r y1,
Signature u ? Telephone 413 • $'R
2.2 Authorized Agent:
Name(Print) Current Mailing Addressc�l /�
Signature Telephone a
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building C ; (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
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0910
APPLICANT/CONTACT PERSON ANDREW O'BRIEN
ADDRESS/PHONE 75 Clayton Rd. HOLYOKE01040-1543 (413)563-1902()
PROPERTY LOCATION 518 PLEASANT ST
MAP 39A PARCEL 078 001 ZONE GB(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
Typeof Construction: DIVIDE INTO 2 OFFICE SPACES&ADD DOORS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 047357
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Permit DPW Storm Water Management
D t' y
Sigr ici I 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.
518 PLEASANT ST BP-2016-0910
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,,ory: renovation BUILDING PERMIT
Permit# BP-2016-0910
Project# JS-2016-001546
Est. Cost: $3500.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ANDREW O'BRIEN 047357
Lot Size(sq. ft.): 48612.96 Owner: MCCOLGAN HARRY H&TULLY
zonin4: GB(100)/ Applicant: ANDREW O'BRIEN
AT. 518 PLEASANT ST
Applicant Address: Phone: Insurance:
75 Clayton Rd. (413) 563-1902 O Workers Compensation
HOLYOKEMA01040-1543 ISSUED ON.111912016 0:00:00
TO PERFORM THE FOLLOWING WORK.DIVIDE INTO 2 OFFICE SPACES &ADD DOORS
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 1/19/2016 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner