32A-138 (109) .75
4TMAIN ST BP-2007-0572
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 138 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0572
Project# JS-2007-000838
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Kohl Construction
Lot Size(sq. ft.): 0.00 Owner: CHAMISA CORPORATION
Zoning:CB Applicant: KOHL DOUGLAS A//J��
:N sr sts `('t ia.
Applicant Address: Phone: Insurance:
31 Campus PIaza Road
HADLEYMA01035 ISSUED ON:11/20/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:Office Renovation
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: r House# Foundation:
/5/ini , Driveway Final:
Final: Final: Ff _
. r
z7�d
7 J Rough Frame: 0-f,/ (2(1c/66,6L6 co S
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: D k a -a.6-.0 7 .... 'y
THIS PERMIT MAY BE REVOKED BY TIS, CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL. Ty,t.
Certificate of Occupancy i' Signature:
FeeTvpe: Date 'aid: Amount:
Building 11/20/2006 0:00:00 $50.005171
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2007-0572
APPLICANT/CONTACT PERSON KOHL DOUGLAS A
ADDRESS/PHONE 31 Campus Plaza Road HADLEY
42s
PROPERTY LOCATION21-MAIN ST
MAP 32A PARCEL 138 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Bee Paid
Li/Building Permit Filled out q -it.
/ /t`ee Paid T .�O.ad 5j17 /
v Typeof Construction: Office Renovation
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFRMATION 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
9 9 /,126/d6
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.
Versionl_7 Commercial Buildin• Permit May 15,2000
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterANell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Spedfy
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
The Masonic Building Map Lot Unit
21-31 Main Street
Northampton,MA, 01060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Chamisa Corp. O 31 Campus Plaza Rd., Hadley, MA, 01035
Name(Print) ' Current Mailing Address:
r— ) (413)256-0321
Signature Pits j✓' • Telephone
2.2 Authorize• gent:
Douglas A. Kohl 31 Campus Plaza Rd.,Hadley, MA, 01035 g
Name(Print) Current Mailing Address:
(413) 256-0321
Signature Telephone
SECTION 3-ES ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building fey G , Doo / (a)Building Permit Fee
2. Electrical 1 I °Da / (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) 464000c--- Check Number4Sl 77 C4. o0
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
. Version1.7 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 Additions ❑ Accessory Building
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other 0
Brief Description Resurface all walls with new gypsum board and rewire all existing electric switches, outlets and
Of Proposed Work: ceiling fixtures. Refinish existing wood floors.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 0 A-3 ❑ 1A I 0
A-4 0 A-5 0 1B 0
B Business 0 2A 0
E Educational 0 28 1 0
F Factory 0 F-1 0 F-2 0 2C 0
H High Hazard 0 3A 0
I Institutional 0 1-1 ❑ 1-2 0 1-3 0 3B 0
M Mercantile 0 4 0
R Residential 0 R-1 0 R-2 0 R-3 0 5A 0
S Storage 0 S-1 0 S-2 0 5B 0
U Utility ❑ Specify:
M Mixed Use Specify: Offices, Studios, retail at ground floor.
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Mixed use. Proposed Use Group: Mixed use
Existing Hazard Index 780 CMR 34): 3 Proposed Hazard Index 780 CMR 34): 3
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
I" 9,000 1' 9,000
2nd 9,000 2" 9,000
3rd 9,000 3m 9,000
4th 9,000 4th 9,000
Total Area(sf) 36,000 Total Proposed New Construction(sf)
36,000
Total Height(ft) 60
Total Height ft 60
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone Outside Flood Zoneo Municipal 0 On site disposal system
Version1.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 9000 9000
Frontage
Setbacks Front 0 0
Side L: 0 R: 0 L:0 R:0
Rear 0 0
Building Height 60 60
Bldg,Square Footage
Open Space Footage
(Lot area minus bldg&paved 0 0
parking)
#of Parking Spaces
Fill:
NA
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location: Fitzwilly's : Painted on the west side of the building.
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO O
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 118(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable 0+
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 Expiration Date
9.3 General Contractor
Kohl Construction Inc Not Applicable 0
Company Name:
Douglas A. Kohl
Responsible In Charge of Construction
31 Campus Plaza Rd. , Hadley,M 01035
Address
C— (413)256-0321
Signature Telephone
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 e
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Douglas A. Kohl (Chamisa Corp. ) as Owner of the subject property
hereby authorize Douglas A. Kohl ( Kohl Construction Inc. ) to
act on my behalf,in all matters relative to work authorized by this building permit application.
G t 1/20/2006
Signature of n Date
Douglas A. Kohl ,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.
Douglas A. Kohl
Print Name
G i 11??� /1-cz
Signature of 0 er/ en[ Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Douglas A. Kohl 78892
Name of License Holder:
License Number
31 Campus Plaza Rd., Hadley, MA, 01035 10/25/2009
Address Expiration Date
(413)256-0321
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
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- The Commonwealth of Massachusetts
Department of IndustrialA ccidents
• H;l != Office of Investigations
' n'= 600 Washington Street
zo
• -''i: Boston, MA 02111
Aar% www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Kohl Construction, Inc.
Address: 31 Campus Plaza Road, Suite 3
City/State/Zip: Hadley, MA 01035 Phone#c 256-0321
Are you an employer?Check the appropriate box: Type of project(required):
I.Ri I am a employer with 25 4. E I am a general contractor and I 6 r 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 sheer. : 7. 1 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑' Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its
required.] officers have exercised their 0.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.9 Other„
*Any applicant that checks box#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.
teontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual Insurance Company
Policy#or Self-ins.Lic. #: WMZ 800287201 2006 Expiration Date: 02/10/07
Job Site Address: 21-31 Main Street City/State/Lip: Northampton, MA 01060
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 MCOL 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
f do hereby certify under the pa'n, • r pe Ides of;rjury that the information provided above is true and correct,
Si mat = =�„ � i41! Date: 11/20/06
Phone#: 256-0321
•
•
Official use only. Do not write in this area,to he completed by city or town official
+ City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington, Massachusetts
NCCI NO 26158
(800)876-2765
POLICY NO. )W M2 6002812012006
ITEM PRIOR NO. WMZ 800287201200$
1. The Insured KohA Construction Inc.
Mailing Address: 31 Campus Plaza Road Hadley MA 01035
an. SbNI Town or City CmMy Suto Lp Code
❑ Individual 0 Partnership ® Corporation ❑ Other FEIN 04-3247409
Other workplaces not shown above:
2. The poky period is trwn02t1012006 to 02162007 12:01 am.standard time at the insured's mailing address.
3. A. Workers Compensation insurance: Pad One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers LiatuTity insurance: Pad Two of the policy applies to work in each state listed in item 3k
The limits of our liability under Part Two are: Bodily Injury by Aaddent$ 500,000 each accident
Beaty injury by Disease $ 500,000 poficy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance.Coverage Replaced By endorsement WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications.Rates and Rating plans_
AVinformation required below is subject to verification and change by audit.
Classifications i—, Premium Basis Rates
Code Estimated Per SIIM E9tlmMM
Tool Annual of Mnual
No Rtmunera to R¢mne@dan Ptlmurn
INTRA 175698
SEE EXT tNSION OF INFORMATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 42,365.00
As indicated,Interim adjustments of premium shall be made: Deposit Premium $ 11,107.00
0 Annually ❑ Semi Annually 0 Quarterly ® Monthly
MA Assessment Chg.
$46,881199xx 4.4000% //n///� $2,063.00
This policy.including all endorsements,Is hereby countersigned by _ CLi)< // &^K-�a. 12112!2005
wtnonren Signature oats
GOV GOV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Renaissance Alliance Insurance
MA 5645 8 807 Alexander W Borawski Inc
WC 0000 of A(11-88) 981 Worcester Street
faess anpmyrc ,arc
ad nret Stile tbw
e ew,ai Cnc tC pemaSon insurance. Wellesley,MA 02482
used wed its penms.r on.