31B-286 (8) 129 MAIN ST BP-2017-0271
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:3IB-286 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: WATER DAMAGE BUILDING PERMIT
Permit# BP-2017-0271
Project k JS-2017-000141
Est. Cost: $4714.00
Fee:SI00.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THOMAS DOLAN 039281
Lot Size(sq, ft.,): 31755.24 Owner: FIRST CONGREGATIONAL,CHURCH OF NORTHAMPTON
Zoning: CB(1009 Applicant: THOMAS DOLAN
AT: 129 MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 297 (413)585-0612 O
CHESTERF IELDMA01012 ISSUED ON:8/31/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE DROP CEILING TILES & GRID WORK
FROM WATER DAMAGE WITH FIRE RATED TILE & GRIDS - 500SQ 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 if 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:
FeeTvpe: Date Paid: Amount:
Building $/00.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Version i7 Commercial Building Permit May 15. 2000
Department use only
REC"E /'=D City of Northampton Status of Permit:
G Gliding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability
AUG 3 12w Room 100 Water/Welt Availability
Nrrtthampton, MA 01060 Two Sets of Structural Plans
°E""o at r 'ie'c pic*/41 -587-1240 Fax 413-587-1272 Plot/Site Flans
3 I 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
This section to be completed try office
1.1 Property Address.
/c2Q //1[2n6 ,Y ,.�J _ ...__. Map Lot Unit
A/44/1�hw
„r44N /tl&, 0/060 Zone Overlay District
-- -- --- -- --- Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: i'-
\a Cals. zl b\oto0
Name(Print)� W¢: Current Mailing Address
���� 11ifs'. - S `-t- `139aS,Lnature �" X �a*"— Telephone
2.2 Authorized Agent —
.
Tho as 014ai 2.0. Oa( 6297_C4o41et,4,,/.d/".o'oz
Name(Print) Current Mailing Address
Signature ._._. Telephone - -. ..
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b .errnit a *hoard
1. (Building 1/47J/ 1 (a)Building Permit Fee
2. Electrical -O (b) Estimated Total Cost of
Constructioon from(6)
3. Plumbing Buitd(ng Permit Fee / 'jt
4 Mechanical(HVAC}
5. Fire Protection 1
& Total=(1 +2+3+4+5) 4'7/ 4> Check Number SIraq
This Section For Official Use Only
Banding Permit Number Date
Issued
Signatu - // ///!
B nm ion: nspe kr of Buildings f Date
Version( 3 Grum cefai Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE //''
Interior Alterations 0 Existing Wall Signs 0 DemotitionC� Repairs❑ Additions 0 Accessory Building❑
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use Other 0
Brief Description Enter a brief description here. Rep4ate ..tap 4'et itscc r.z el ^a L of Van-/*—
OfProposedWork: . - `, /AOM /vi-.en b!am a;e iv/AA flit., RA,led 7A. 18Atail
OO
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ 1A-1 0 A-2 0 A-3 0 1A 0
A-4 0 A-5 0 1E1 0
B Business 0 2A 0
E Educational 0 28 0
F Factory 0 F-1 ❑ F-2 0 2C ❑
H High Hazard 0 3A ❑
1 Institutional 0 I-1 ❑ 42 0 1-3 0 38 •
M Mercantile 0 e 4 ❑ 1
R Residandel ❑ R-1 0 R-2 0 R-3 ❑ 11 EA 0
S Storage ❑ S-1 0 S-2 ❑ SB 0
U Utility ❑ Specify.
M Mixed Use ❑ 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 34Y - : . Proposed Hazard Index 782 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
is
-275
Total Area(so Total Proposed New CoPetruchon(sf)
Total Height/ft) -
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zones Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone _ Outside Flood Zone Municipal 0 On site disposal system❑
Version! 7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zonmg
Thu cuhuon to be filled in by
Building Department
lint Size
Frontage
Setbacks Fronk
Side L R L: R
Rear _. ... .. .-..
Building Height
Bldgg. Square Footage % __.. ...
Open Space Footage , % _
part area minus bidM Se paved _.
parking)
a of Parking Spaces - "' ""
.......
Fill:
(volume&Lennon)
A. Hes a Speciat Permit/Variance/Finding ever been issued for/on the site?
NC Q DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property 7 YES Q NO Q
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 Q
IF YES,then a Northampton Stam Water Management Permit from the DPW is required.
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(ReotstreN)'.
-. Aegistrati0n Number .. _
Address
- Expiration Cate
Gtgnature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Rravaonsmiticf
Address Registration Number
Ignature Telephone Expiration Dale
Name __. __. _. __.. Area of Responsibility
Address RaytsiratiOn Number
Signature TTelephone Expiration Date
_.. __—
' Name Area or Reep005ibility
Address Registration Number
Signature Telephone Expiration F./ate
Name Area of Responsibility
.address i Registration Number
Stpnature Telephone Expiration Date _
9.3 General Contractor
T/h boL46). ad-I/LA.4/...a2.ate1071.9L Not Apprcabie ❑
Company Name'.
Responsible In Charge of Construction
20, 6& (99 c4,s ti fi //Iffy 0/0/2.
Adm.-es
A. . • - w5 C297.05-i/
Signature Telephone
Version1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes I) No 0
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. . . .. .as Owner of the subject property
_ _. _.. . .
hereby authorize . _. _.. .. .. to .
act on my behalf,to ail matters relative to work authorized by this building permit application.
Signature of Owner Date
I, oyL \‘‘)....\f— 70/1.1.- diel. _ ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application == and accurate,to the best of my knowledge
and belief. and (/ ..... .._7. _.. ..
Signed under^the pains penalties of perjury 1
Print Name
off'''. Q AM)�
a.
931E ,e
Signature of Owner/Agent Date
SECTION 12•CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Nal Applicable 0
Name of License Holder: /AD/1JAe ,eurn/ _ C.- d 339.0101
License Number
0. War aq-z ckestA,R071114. orot i9- 8-l7
AddressExp ration Date
/iJcYQ 4/13fr.of7-S/6V
Signature Telephone
SECTION 13•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c.152,§25C(5))
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 Afdavit Attached Ye: @fr No a
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office Investiaaltons
te ff of
1
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation insurance Affidavit: Builders,/Contractors;Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name (BusinesslOrgatazatioMndividual): tiltif Its, Sfajoo of1lihftAA
Address:
CitytStat�zsP: l a. /7J/o_ Phone 4:_ 3 —r0 -56
Are--you an employer? Check the appropriate box: Type of project(required):
1.ISS I am a employer with i 4, 0 I am a general contactor and I
employees(full and/or part-time).*
have hired the sub-contactors6. ❑New construction
2.❑ r am a sole proprietor or partner- listed on the.attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any y caP acI employees and have workers'
capacity. 9. 0 Building addition
reqworkers' comp.insurance comp.insnra corporation
required.] 5. ❑ We are a poratand its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
right of exemption per MGL
myself. [No workers' comp. 120 Roof repairs
Msvrance required) t C. t5_'-,§1(4),and we have no t-y-
9 .) employees. [No workers' 13.itQ Q`ner X re a.5 ...._
comp. insurance required.] )
:Any applicant that checks box gl must also fill out the section below shovnng their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
iirtiontracton that check this box must attached an additional sheet showing the name of the sub-contractors and start whether or not hose anodes have
employees. It the sub-contractors have employees,they must provide their workers'comppolicy number.
.I am an employer that is providing wonders'compensation insurance for my employees. Below is the policy and job site
information. /}
Insurance Company Name: /I. (r7 4t"`�LIOI./ .n5
Policy dor Self-ins.Lic.it 1L/4 Cs-
� 3) 36z/94' Expiration Date: ?--e94-'16
lob Site Address: /2 { /v' ilii tfr /4101,214.4 City/State/Zim:........... OW?
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 2518 of MGL o. 152 can lead to the imposition of criminal penalties ofa
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 o ju t
\ G hat the information provided above is true and correct.
Si%nature. e#74/1.--4,,,,........._. - § Date: J/ ?e/6
Phone PI L'/ .-ace- 6761 ....—
Official use only. Do trot 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 g: i
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: /94 4i.e,n rt _4,14--/..tem--
The debris will be transported by:
The debris will be received by: (/4/sy
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
TOM DOLAN GENERAL CONTRACTOR
PO BOX 297
CHESTERFIELD MA 01012
413-297-5164 (cell)
413-296-4303 (cell)
Fax 413-296-0150
August 31, 2016
Commissioner Hasbrouck
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction
for repairs to drop ceiling with new tiles and new grids with fire rated material at First
Churches, 129 Main 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 considered 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, section 107.1 allows for an exclusion from control construction for
this project."
Respectfully,
Thomas A.Dolan
Tom Dolan, Owner
Tom Dolan General Construction
PO Box 297
Chesterfield MA 01012