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23D-107 (6) 548 ELM ST-CALVIN COOLIDGE NURSING HOME BP-2016-1415 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 23D- 107 CITY OF NORTHAMPTON Lot -001 Permit: Building Category: FIRE BUILDING PERMIT Permit$i BP-2016-1415 Project# JS-2016-002437 Est. Cost:$105000.00 Fee: $735.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group WKB CARPENTRY INC 96193 Lot Size(sq. ft.): 53143.20 Owner: 548 ELM STREET LLC C/O 548 ELM ST OPERATING CO RE TAX DEPT Zoning: URB(100)/WP(I)/ Applicant: WKB CARPENTRY INC AT: 548 ELM ST -CALVIN COOLIDGE NURSING HOME Applicant Address: Phone: Insurance: 91 PINEVALE ST (413) 525-2914 INDIAN ORCHARDMA01151 ISSUED ON:6/1/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:EMERGENCY SERVICE & REPAIRS DUE TO FIRE AND WATER DAMAGE - 24,538 Sq ft 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: O_ 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: FeeTvpe: Date Paid: Amount: Building 6/1/2016 0:00:00 5735.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner Versionl,?Commercial Haildin Permit May 15,2000 Department use only City of Northampton Statue of Permit: Butting Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 (Two Seta of Structural Plans phone 413-587-1240 Fax 413-587-1272 'PlottSite Flans 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 i-SITE INFORMATION 1.1 Property Address: This section to be completed by office 54c _ ,.. . 5 re N. I Map Lot Unit kr. 171.12171 (';(CYC Zone Overlay District Alm SI.District Ca District SECTION 2-PROPERTY OWNERSHIPIAUTHORLZED AGENT 2.1 Owner of Record Name tenet) Cucent Mailing Address: Ci it r Signature Telephoned 2.2 Authg[LLed Agent ("IAA; '.x ...Lt. ._.-‘ L I^tt,v t ) ;L;v' Neve Avert Current Maine Address: . 'Hl . ,a7 signature Telephone SECTION 4-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost;Dollars)to be Official Use Only completed by per 1appleant 1. Building 'y 51)-c �� J71?)2 ��� rz z _ _o d00 (a)Building Permit Fee irf t�9 2. Eledricei —7 A. {b}Estimated Total Cost of S(�r IiCTC� 'j �}c7�Q00 Constnrclion from s 3. Plumbing — �.f Fir Building Permit Feeft 000 Finksµ c� /7 , -735, v0 4. Mechanical(HVAC} 5.Fire Pt-Meatier -- 6. Total=(1 +2+3+4 it 5) (US-Ioad,Q 0 Check Number This Section For Official Use Only Buildng Permit Number Date sled Signature: Dui-ding Cam'niseener/Tnspector of eukdngs Date t'd 8688106E1b1 Ai uedieC emsA dZl:L091 LE Re VV Version 1.7 Commercial Building Permit May 15,2000 B. NORTHAMPTON ZONING I Existing Proposed F Required by Zoning This column io betilled in by eu:ld ng D panment Lot Size Frontage Setbacks Front Side L R: L: R' / Rear ) Building Height �\ Bldg. Square Footage Ye '\ Opeu Space Footage (Lor arc,.nines bide peseed parkin¢) k of Parking Spaces F:LI: puirme de tucaton) A. Has a Special Permit/Variance/Fin. ng ever been t§sued for/on the site? NO O DONT KNOW 0 Y\S IF YES, date issued: IF YES: Was the permit recon-. at the Registry of Deeds NO O D• T KNOW O Y O IF YES: enter Boo Page and/or Document# B. Does the site contain . brook, body of water or wetlands? N O DONT KNOW O YES O IF YES, has a perthit been or need to be obtained from the C nservaton Commission? Needs to be obtained O Obtained Q . Date Issued: C. Do any signs exist on the property? YES O NO Q IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended f r the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavat on,o f gig)ever 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES.then a Northamplon Storm Water Management Permit from the DPW is required. £'d 26881OCR lbl Alued)ep 8MM dd lZO 91 L£ARA Version IS Commercial Building Permit May15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs 0 Demolition Repairs 0 Additions ❑ Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use Other 0 Brief Description Eater a brief description here, £>ctefe -7 -P(IIcr <..:^.a r`F 1-1E._4,.,-c Of Proposed Work: I , .r,,,,:L.,SJ. 4:::,C Y ,,,c;,,.;_;4: tit_r^ e r.-(r..a2 SECTIONS-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A--" [] A-2 ❑ A-3 ❑ 1P, { 0 A-4 0 A-5 0 +.B 0 B Business 0 2A • 0 E Educational 0 28 0 F Factory 0 F-1 ❑ F-2 ❑ 2C 0 HHkill Hazard ❑ 3A ❑ I Institutional 0 -1 0 I.2 w I-3 ❑ 38i ❑ M Mercamae 0 4 ❑ R Residential 0 R-1 ❑ R-2 ❑ R-3 ❑ 5A 0 S Storage ❑ s-1 0 5-2 ❑ 58 0 U Utility ❑ Specify: M Mixed Use ❑ Specify. S Special Use ❑ Specify. OOI LETE THIS SECTION iP EXISTING BUILDING UNDERGOING RENOVATIONS,ADJF TIONS AND/OR CHANGE Se USE Existing use Group: Proposed Use Grown: Existing Hazard Index 780 CMR 30): . Proposed Hazard Index 780 CMR'34) SECTION G BUILDING HEIGHT AND AREA . BJILDING AREA EXISTING PROPOSED NEW CONS UCTION OFFICE USE ONLY Floor Area per Floor(st) 254 4 4' Tota'.Area(st) Total Proposed New Construction(s, Total Height(ft) Total -le ght ft 7.Water Supply(M.GL.c.40,5 54) 7,1 Flood Zone Information: i 7.3 Sewage Disposal System: Public ■ Private 0 i Zone Outside Flood Zane❑ Municipal ❑ On site dispose.system❑ Z,.d 96E9WEE lbI LdiuedieQB)1M dZCL09l l£LeN Version 1 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 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT __. __ _ _ _. _ _. _--,as Owner of the subject property S �N'LN1 hereby authorze _. _. _.__ ._..-. __.__. _ __ _.._ . .. . __ .'to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, L,r.e__._ aJ� as Owner,'Authorzed 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 paras and penalties of perjury._. 13_rufe /Q rau/zL n;Name / rrClnr CE'/ii l/70aI fes` Wanly.c Signature of Owner/Agent Dete SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable D Name of License Holder: L2Lt'__—le�r�u License Number It SLv /rig S• ifr ___ CS0167 _ Adores ,_� Expiration Date ' i 3 39[ 88o�j_ uce �� 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. F Signed Affidavit Attached Yes 1NJ No 0 Versions.7 Commercial Building Per„,it May 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) _ Ras at of(on Number Signature Telephone 9,2 Registered Professional Engineer(s): • Name Area of Responsibility Address Registration Number I Signature Telephone Expiration Date Name Area of Responsibility Add"ess Se,g stralion Number Signature Telephone ExpirationDate Name Area of Respons bility Adcress Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registradon Number Signature Telephone Expiration Date 9,3 General Contractor(trJ.1 j,O p „. (" -- __ _-.. Not ApP!icade ❑ Company Name _ E ...(p fr Responsible In CTharge of Construction I nk,4F'•- Addressaf Signature Telephone ie ccansrorr „/ f?../1 a ce Au e.;: �°'te=.� Office of Consumer A fairs d Business Kegulation ts41, 10 Park Plaza Suite 5170 • Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165445 Type: Supplement Card WKB CARPENTRY INC. Expiration 2117/2018 BRUCE TETRAUL7 91 PINEVALE ST. • — - INDIAN ORCHARD, MA 01151 Update Address and return card.Mark reason for change. Scat a aovrr L Address C Renewal 7 Employment r Lost Card rn.,r14'r,.l.nUd office of Consumer Affelrs&Business Regnlofion License or registration valid for individul use only w in oME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: -�Rn isitalion: Office of Consumer Affairs and Business Regulation iYsq 9 .155448. Type: ISPark Plaza-Suite 5179 Expiration: 211712012 Sipperneat Ca:c Boston,MA 02116 WKS CARPENTRY INC; BRUCE - 4AJt.T i1I 91 PINEVALE ST- ,\ v;...._.—_ 4 j�.bfer MAN ORCHARD,MA 01151 Undcrsvtretary Not valid without signature • igMassachusetts, Department of Puoi!a Safe: � Board of Building Regulalians and Standards Construction Saperrifer License:CS{0G6193 BRUCE L TETRAFYLT -- 115NOR'L7IBRANCH A% SPRINGELELU MA 01 Z mr.Y Exration oit*missl r 12(1912016 Cd 8699 LO££IbL Ai1uedreo BNM ddFLO9l L£AeIN City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 5-LA Fli i^,2 5r _ fit-y1 The debris will be transported by: _oft Upo s4c-Q-' The debris will be received by: l/edie j Qr Building permit number Name of Permit Applicant tA.)V D u& �t-y J ,''. ;:./) r�� '2 :f"n, �����'- r91vi��'! ,.- ��.L J ' d Date Signature of Permit Applicant 9'd B68810££117l Aaluedie0 BNM dZ :L091 l£'C N A✓oe CERTIFICATE OF LIABILITY INSURANCE 511/ mss' PRODUCER (413)53E-3311 FAX: (413)536-0900 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brochss xaaurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 725 Grattan Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 58 Chicopee MA 01021 INSURERS AFFORDINGCOVERAGE INAIC0 ._.— _.._.._. _— . ..— INSURER IYEw.eremNOrthland Insurance WXB Carpentry Inc INEuPERB.Commerce insurance Company ' LOLL .._ _. _._ 91 Piaevala sC 'INNPEaG AIM Mutual Insurance Co ,Gms •INEUPER P. SPri.um9f field MA 01151 'PORTER E. _—.. —_. COVERAGES THE SME WGTERO LISTED BELOW PAVE BEEN ISSUEDTOOTHINSURED MENTOABOVE FOR THE POLICY PER100 INDICATED.NOTINITHSTANDING ANY REQUIREMENT, EQUI NM TERM CONDITION OF ANY CONTRACT OR OTHER DOCUMENT T RESPECT TO ERHISTHIS C MAYBE ISSUED CR OL PESAI REEEURAN;EAFFORDED HAVBEEN EDESCRIBED HEREIN IS3L'BJECTOALL THE.TERMS,EXCLUSIONS AND CgND 6NS OMJGH POLICIES.AGGREGATE IIMIi56HOVINMAY HAVE BEEN REDUCED EN PAID CUMS R R! i{i _.__..._. —. a _. ' R '. �' . - !�9tNw(£ e %TwNwaER PCUCYEEi i RT :..YELP ffi�T'ONTV uLHtt GENERAL LAMM( i E.C.:OCCJEcenCE 5 1,00E1.000 tuAO Arc n "er i 50000 X CO VETO E c At I.an-i A 1 CLANS R XI Y_CORGS 259370 14/22/2016 i 4/22/2017 ME0EX.(VT vb p NNE) S S000 I I PERSONAL A ,URE I. 1 000,000 _ _ Eaa R cA-N 2,Boo,oeo CPLT'uf REGAL M APPLES EBB ( BECOMES COMF.EP ACC 2,000,+ODD. I IXC PE.EY. n • I:cc ( i `GTOND®ILEL!A LILY CiOMMED SINGLE:MT I— AM WFO _"corT: G R I_ ALL OVP.1.uTc1 p,10 so }5/16/2016 6116/2019 BtIALV BRAE ,s 20,000 : X scEICIALPALTO (Rummy £1 MISS 1 II IIPCO M RT la Jc Grv1EDALTOS i t %°PEPZ'DAMMCE 1 40.000 ; 100,Doe I P GARAGE:AR N AUTO0YjY•EF TOTIDEIT S I N imp •VIE I w r ... ACP/ONLYI =DC S %C SSIUVSRE4LaUABIUTY I I yAc ODOMBENC. _ S 10008 ni Cm....PDE I A_GREC C $ REMOTION E LcO nNSATON ! „ $ NDESPLOYERAtAILW r _111Vll_ PI ANT OFNI OR M EtECLTYE� I 100,0E0 wcm.RMryEBOExcu¢DAC400-.031111,2016A 01/03/2016 101/03/2017 EL d E P ENNECYCdL 100 000 WielleWEINSERzw I L- EL EbC SE PCLIC(M _I S _,$40,000 CMPR I I DESCRIPTIONOF DEPTET1GNS:LOa0.TONS+VEWCLES'EinLVSIepDOY OfDOMEYF}nPROV9aNS andr earpeesxy residential, interior, aiding and replacement vindavaws a. Killian Butler. the o.mmer is not covered by the .(Erten EMT policy above, XeaeaeSuaetta enBloyaea ob1R CERTIFICATE HOLDER CANCFI I ATIOEi_ 529-1433 J MOUE ANY OF THEABWEDESCRIEED POLICIES B£CAECELEOBEFORETHE! EIRATION Town of Easthampton DATE'HEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 OATS WRITTEN 50 Payson Ave MOTICETOTXECECTWCATE MtrFRNMIEOTOTHE LEFI,ROT BELPRE TODOS°MALL Easthampton, MA 01027 IMPOSE NO OBLIGATION ON LIABILITY OF ANY HIND UPON THE INSJRER.ITS AGENTS OR RTkGENIATIVES. AO'MC!ZED REPRESENTATIVE ,Je£frcy Bracht/313C C3 „r� ACORD 25(2009/01) 0158132009ACORN CORPORATION. AR rights reserved. INSCarenwa+'. The ACORD name and logo are registered marks of ACCRD L'd 86381Oti£LYL MUedJe3 HNM dLZ:LO9L L£�UW - The Commonwealth of Massachusetts '�'_ Department of industrial Accidents ',!—ft ' Office of Investigations ..'e — 1 Congress Street,Suite 100 4.17-11-t_ ta>? r Boston, MA 0211 4-2 01 7 ' , 0 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors!Electricians!Plumbers Applicant Information Please Print Legibly Name (Bus:ness'Omanization'Lnddidual): [JO 4.13 00L,r - f\C ' _. ______ Address: q i Thi r,etic'de_. 3trr=n'W --------------.—__._.__ City/StateJLip I_ ,'ARYL Vii"- ails( Phone#: ; _►_2 R).0 `t ": I I gcct Areu an employer?Check the appropriate box: Type of project(required): 1.2 tJ' I am a employer with Q 4- 0 I as a general contactor and 1 — have hived the sub-contractors 6. ❑ Nieconstruction employees (full proprietor or partner- listed on the attached sheet. 7. L Remodeling ship and have no employees These sub-contractors have ( g. ❑Demolition workir for ine in an capacity, employees and have workers' g Y 2 7 1 9. ❑ Building addition [No workers' comp.insurance comp. inscmnoc.n regnired.J 5. Q We are a corporation and its + 10. ,eacorneal repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I 1 L Plumbing repairs or additions myself. [No workers' cora right of exemption per MGl, s+ P- �t :10 Roof repairs insurance recuued.j' 152,eel(.[,and have no employees. [No workers' J kers' 134Ottxra - comp.insurance required.} , J "Ari appliouahet checks box dl must aim till out the section below showing their workers'compensationpclicy Infonnatiol. 7 homeowners who submit tris affidavit indicating they ace doing all work and Men Biz oatside contractors must submit n new affidavit,Mlcatiag anat. :Cma<acto,s thet c iec*this box must attached an additional*cos showing Me name of the sub-com:ctors rad state whether or not Mose entities have employees, it Ne eine-ooatractors have smpioyets,:hey nnrst provide their sun:kms'comp,policy number. .1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t. Insurance Company Vvne. al. P-{U ryxp_�JG"VTSt,tt�n t^ `(-o yntrie,m -• - f Polley d or Se;f ns. Lic.p: t`= LI. , 4 OO - 10,.72,E 7 q . 7.0[SA Expiration Date: 01 Il Qii 1 ([_ til ' N. _ t - lobSiteaddress. . r i F_ �aVt �t 1 c'f�(,& City/Stae/Zip1''=_______ . Attach a copy of the'workers' compensation policy declaration page(showing the policy number and expiration date)" Failure to secure coverage as recurred under Section 25A o`MGL c. 152 can lead to fire 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 S350.00 a day against the violator. Be advised that a copy of this statement may be forwarded/o the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ins and penalties of perjury that the information provided above is true and correct. Sjmtarare_ f ,d ._ Dace: /4 /:: Phone 4: ` f "3 i 'Z,L) , , t_ __. __ IOfficial 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 Personr _ _ Phone x:_, I Muedie°8->w, dLL L09L bt/(?)31 831 8691/3109£LPL DATE 61(i( To City of Northampton Building Department Subject: Request for Waiver I request that your department/grant a modification to waive the requirement for control construction for the ,4e r7nr'Q'� r Dirk project at SLIir0-n Sl in far+k 0...co dIN because the work is of a minor nature,will not affect health, accessibility, life and fire safer ,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, Tail/ / �j/ ,rq SIGNATURE 71 j ,4/ ' /41,-, J'� NAME Foxe ! &4 U/T COMPANY or i? Gt�p f-tom ADDRESS 9a M i40 tic?,p/4 S /- • CITY,STATE,ZIP .�. Q. `vll 01!/5/