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39A-020 (10) 118 CONZ ST BP-2017-0841 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 39A-020 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-2017-0841 Project# JS-2017-001407 Est.Cost: $5000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEITH DAVIGNON 30067 Lot Size(sq.ft.): 20473.20 Owner: GRETNA GREEN DEVELOPMENT CORP Zoning: GB(100)/ Applicant: KEITH DAVIGNON AT: 118 CONZ ST Applicant Address: Phone: Insurance: 225 CHAPMAN ST - 3RD FLOOR (401) 461-7771 PROVI DENCERI02905 ISSUED ON:2/10/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW BUILT-IN EXPRESS COUNTER TO BE LOCATED IN MAIN LOBBY. NEW DOOR OPENING CONNECTING THE SECURE EMPLOYEE WORKROOM TO THE SECURE SIDE OF NEW COUNTER 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 2/10/2017 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0841 APPLICANT/CONTACT PERSON KEITH DAVIGNON ADDRESS/PHONE 225 CHAPMAN ST-3RD FLOOR PROVIDENCE (401)461-7771 PROPERTY LOCATION 118 CONZ ST MAP 39A PARCEL 020 001 ZONE GB(1001/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid c±iBuilding,Permit Filled out Fee Paid Typeof Construction: NEW BUILT-IN S COUNTER TO BE LOCATED IN MAIN LOBBY.NEW DOOR OPENING CONNECTING THE SECURE EMPLOYEE WORKROOM TO THE SECURE SIDE OF NEW COUNTER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 30067 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 gn . rfg" tial l Si at di Date * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Versionl.7 Commercial Budding Permit May 15,2000 'Department use only' City of Northampton Status of Perms Building Departti C Department Curb Permit i _ / 212 Main Street Syerl5epficAvedabHity, pj Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of5hucwral Plans /phone 413-587-1240 Fax 413-587-1272 PIot(Slte Plans AP CATIO O 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 118 Conz Street Map Lot Unit Zone Overlay District - -- -- - - - - - --- - ------ Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Gretna Green Development Corp 270 Exchange Street-Chicopee,MA 01013 Name(Pont) K✓ Ofitai/A paNrCurrent Mailing Address' (413) 746-5500 hitt Signature Telephone 1//3 177' '7V/. 2.2 Authorized Allen . New EnglandTreatmentrr�� ��������.����'''Access,,AInc (Tenant) tt 5 Forge Parkway -Franklin,MA 02038 Name(Print) YN{V Iv r�LL�Y/ 0� OBJ tr'Y'+^S Current �^ ' I• - Cu 5Mailing (508)590-1414 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $5,000.00 (a)Building Permit Fee 2. Electrical - - - - (b)Estimated Total Cost of Construction from(6) _-. .. .. _._ _. 3. Plumbing Building Permit Fee 6. Mechanical(HVAC) 5. Fire Protection - - - - 6. Total=(1 +2+3+4+5) Check Number _m7..sta. iOr0 This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commluuonwnnspector of aufldhgs Date 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 0 Existing Wall Signs 0 Demolition❑ Repairs 0 Additions 0 Accessory Building Exterior Alteration 0 Existing Ground Sign❑ New Signs 0 Roofing 0 Change of Use❑ Other❑ Brief Description New built-in express counter to be located in the main lobby. Additionally,a new door opening Of Proposed Work: will be provided connecting the secure employee workroom to the secure side of the new counter. SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 0 A-2 ❑ A-3 ❑ 1A I ❑ A-4 0 A-5 ❑ 1BI ❑ B Business ❑ 2A 1 0 E Educational ❑ 28 I 0 F Factory 0 F-1 ❑ F-2 D 2CI ❑ H High Hazard ❑ 3A ❑ I Institutional 0 1-1 0 I-2 ❑ 1-3 0 3B � ❑ M Mercantile 0 4 ❑ R Residential ❑ N-1 ElR-2 0 R-3 ❑ 5A ❑ S Storage ❑ S-i 0 S-2 0 58 I 0 U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use E3specify: - -- - COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Mercantile _.— _ Proposed Use Group: Mercantile I Existing Hazard Index 780 CMR 34y __.. 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) 1" 6,753 1„ 3' - 3`° __ _ Total Area(sf) 6,753 Total Proposed New Construction(sf) Total Height(0) -- 24 Total Height ft 7.Water Supply(M.G.L.c.40,§54) LI Floop Zoom Information: T.3 Sewage Disposal System: Public 0 Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This colmnn to be fined in by Building Depamnent Lot Size 29,895.sf(0.69 Acres 29,895 sf(0,69 Acres Frontage 58932'...... ,589.32' __.. _. _. _ Setbacks Front 1 1 3' ',. .3'J Side L N/A R:.N/A LN/A R N/A. Rear 92' 9.2'_. _.... Building Height (24' + 24' +: Bldg.Square Footage 6 75 j % 6.751 - Open Space Footage (Ict areaminus brag&payed 30.8 30.8 parking) k of Parking Spaces 40 _ 40_ Fill: N/A _... - N/A (volume&Location) -- - - -- — — - A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW O YES 0 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 O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Cj Obtained O , Date Issued: _C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: Monument sign at main entrance to parking lot D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO Q IF YES,then a Northampton Storm 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: Keith Davignon,Vision 3 • hitects Not Applicable 0 Name(Registrant) 30067 225 Chapman Stre i -Providence,RI 02905 Re9atratiat Number. Address / •. MR - -: p K J(401)461-7771 E piratim Date •Signature Telephone 'I)M @Listo773azl_C'/Y- 9.2 Ref/late •• Professional Engineer(s): N/A Name Area of Responsibility _.. Address Registration Number Signature Telephone Expiration Date Name Area of Respon5JNllty Address Registration Number Signature Telephone Eyhation Date Name flea of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsbili1y Address Registration Number Signature Telephone Expiration Date 9.3 General Contactor Unknown Not Applicable ❑ Company Name. Responsible In Charge of Construction Address Sgnature Telepane 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 (3 No O SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject properly herebyauthonze,_ - - _. _ 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 under the pains and penalties of perjury. Print Name _ Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor Not Applicable 0 22 _ Name of License Holder _ 62.26:,_ ii/96-7-412,172L/ (4 i 2 (_.7 2_ License Number N44,2_ )4/24_ 04u, s8‘z 0714 `,/-7117 Addre Expiration Date � it 1175 475--6-7 03 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 O No O The Commonwealth of Massachusetts �_= Department of Industrial Accidents n E.-Ws P Office of Investigations E =RBI_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 , " at—we.' www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information q Please Print Legibly Name (Business/Organization/Individual): g05 I/re-tm{ni, Address: 1/ /445/4 cT/o96 City/State/Zip: witLil 25&L !%s- Re_ Phone #: 171/3-'c75 --571S Are you an employer?Check the appropriate box: Type of project(required): I.❑ f am a employer with 4. ❑ I am a general contractor and I nployees(full and/or part-time).* have hired the sub-contractors 6. 2. construction 2.U✓ I am a sole proprietor or partner- listed on the attached sheet. 7. Vi rcemodeling Jn ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ID Building addition [No workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.D Roof repairs insurance required.]'' c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] 'Any applicant that checks box 1/1 must also till 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 stale whether or not those entities have employees. If the subcontractors 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. l.ic. #: Expiration Date: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceerrttify under the pains and penalties of perjury that the information provided above is true and correct f Signature: /" n— Date: 2'7/O1/47 Phone#: Zi/3 'S7-- 70$ Official 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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: Ile (il! Z 9r LeinirrigizFN The debris will be transported by: ;-;€t 9—' The debris will be received by: VII LLE.7 ZGG/x-#- Building permit number: Name of Permit Applicant J'Jnr �i7 iii /O7/ 7 Date Signature of Permit Applicant Information and Instructions Massaciusits Genera Lays dhapta 152 require all erployers to provide workers compensation for their employees Pursuant to this statute,an employee is defined as"...every palm in the service of another under ay contrat of hire, ecpre s or lopped,or or written." An employer isddi and es"ai individual, patnadlip,association, corporation or otter legal entity,or aly two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not mote than three apartments and who resides therein,or theoccupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or en the grounds or building purte na t thereto shalI not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)iso state that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL.chapter 152,§25C(7)state"Neither the marimwesth nor ay of its politica subdivisions aria I enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presorted to the contrasting authority." Applicants Please fill out the workers' compensation dfidavit completely, by dtatcirg the boxes that apply to your situation aid,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the mantes or partners,ae rot required to nary workers cortpeis#ion irsnraice If an LLC at LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents Should you have my questions regarding the law or if you ae required to obtain awakes' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if rimy) and tilde"Job ate Address' the mplicait should write'al locations in (city or town)." A copy of the affidasit that has been offiddly stamped or mated by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Depatrrenr s address,telephone aid fa<number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 7-2013 www.mass.govidia 225 Chapman Street 401461 7771 Providence.RI fax 401.461.7772 02905-4592 email:v3©vision3architects.corn TRANSMITTAL zProject: NETA- Northampton — Express VISION Counter Architects Project No.: 16062a Company: City of Northampton 212 Main Street, Room 100 Northampton, MA 01060 Attn.: Chuck Miller Assistant Building Commissioner Date: January 4th, 2017 From: Ali Otterbein Architectural Designer Of: Vision 3 Architects 225 Chapman Street Providence, RI 02905 Re: Permit Drawing, Permit Application & Check for Permit We are sending you attached via DROP-OFF the following: Copies Date No. Description 1 12.08.16 Issued for Permit Drawing 1 Building Permit Application I 12.23.16 Check for Permit Application Remarks: Please see Issued for Permit drawing sets as requested. Copies to: File j Signed: (LL's, Ail Otterbein Architectural Designer