32C-165 (51) David Fortier Builders
32 Laurel St
Northampton Ma 01060
413-250-3399
Commissioner Hasbrouck Jan 26 2016
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the
Bathroom renovation project at 125a pleasant st 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 prescriptive requirements of 780 CMR.Thank you for your
consideration.
"Mass Amendments,section 107.1 allows for an exclusion from control construction for this project"
Respectfully,
u �
David Fortier
David Fortier Builders
32 Laurel St
Northampton Ma 01060
a The Commonwealth of'Massachusetts
x� Department of Industrial Accidents
— . r
r
Office of Investigations
600 Trashing ton Street
Boston, MA 02111
www.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeQibIy
Name (Bus iness/Organization/Indi vi dual):_ L— ( -lic.i At-, _
Address:City/State/Zip: tvA/ G« , t, Phone#: qO-- (A7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with-i 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp.insurance comp.insurance.4
required.] 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions
3.
❑ I am a homeowner doing ll work
Q officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
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 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: ki I v
Policy#or Self-ins. Lic.#: U)_G iS 'Z ` �`� 5 Expiration Date:
/�J Jr 0(vU
Job Site Address: t � �ti� ��` City/State/Zip:�D S�'(NR'� f-,-. 'l� �
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Sienature: Date: 11
Phone#: t(.(.1
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit;Zicense#
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#:
i
I
i
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 O No O
SECTION 11 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT dk
rr'me, _. G as Owner of the subject property
hereby authorize�'��) ( .t t C r _. _.. to
act on my behalf, in all matter tive to work orized by this building permit application.
Si ure of Owner Date
In1 .....
as-Qw"er/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 under the pains,and penalties.of perjury... _..
ea A
Print Na e, r-,.
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
....
Name of License Holder q2 , ....... ............... .
License Number
Address Expiration Date
k Q�� �. �IA u(fiL,o �{-t3—. 0 �i'�5 a
3�lll v
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
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 No 0
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. R: _.' L: ..., R:
Rear
Building Height
Bldg. Square Footage __
Open Space Footage °
/o
(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 Q YES Q
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 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 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.
Version 1.7 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):
Registration Number
Address _..
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
........__. .... ._ ... _
e.. _. t .��L� . dt S Not Applicable ❑
ta .. ,.._ ,. c w.,._ ..,, . w.. . ._...__.. .:., _..
Company Name:
Responsible In Charge of Construction
_ .......
Address—
Signature Q–T ' Telephone
I
Versionl.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 D� Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. QL✓1
p �F�pt(t. t# rtc i rl ".�j��i�r,�lutzS�c►tirsl
Of Proposed Work: ; 6UA� wi
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 E] A-2 ❑ A-3 ❑ 1A
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 ❑ 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 F-1 Specify: `;
_.. ._........ ..........
S Special Use ❑ 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)
_. _..... St
1 St
2nd
2nd ............ .....
_:..... _, rd .....
3
..d
3
4th
4th , _........_............
............._.............._........._....................._........._......................_
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 E]
I
Versionl.7 Commercial Building Permit May 15, 2000
r+ Department use only
V ity of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit -
JPN 12 Main Street Sewer/Septic Availability
0
Room 100 Water/Well Availability
E�0Ph,�ON Northampton, MA 01060 Two Sets of Structural Plans
° N0 phone 413-587-1240 Fax 413-587-1272 Plot/Site 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
/ _ + ...__...... ......
/�S l" 'CGL�{fl I Sf 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: /t
ca.7.S
Signature Telephone
2.2 Aut rized Agent:
._ _ ..
3� 1ur4L... ' !lf4h''rH#1�1�' q t1 40
Name(Print) /! ` ��� ` '�� Current Mailing Address:Signature Telephone
SECTION 3-ESTI ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. BuildingO (a) Building Permit Fee
_..._,
2. Electrical _ (b) Estimated Total Cost of
Construction from 6
3. Plumbing of 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-2016-0947
APPLICANT/CONTACT PERSON DAVID FORTIER
ADDRESS/PHONE 32 Laurel St NORTHAMPTON01060(413)586-8965
PROPERTY LOCATION 125A PLEASANT ST
MAP 32C PARCEL 165 001 ZONE CB(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: REPLACE SHEETROCK WALLS IN MEN'S&WOMEN'S ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
Demolition D
6Z
Signature of 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.
125A PLEASANT ST BP-2016-0947
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 32C- 165 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-2016-0947
Project# JS-2016-001604
Est. Cost: $19000.00
Fee: $133.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID FORTIER 008026
Lot Size(sq. ft.): 105415.20 Owner: MICKA JEREMIAH
Zoning: CB(100)/ Applicant: DAVID FORTIER
AT. 125A PLEASANT ST
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965 WC
NORTHAM PTONMA01 060 ISSUED ON:112812016 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SHEETROCK WALLS IN MEN'S &
WOMEN'S ROOM
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 1/28/2016 0:00:00 $133.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner