23A-291 (13) /
From:
To
Louis Hasbrouck
Building Commissioner
City of Northampton
212Main Street
Northampton, MAO1060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, 1 request that you
grant a modification to waive the requirement for construction control of the project at
because the work isofaminor nature,will not affect structural elements, health,accessibility,life or fire
safety, and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,
EXHIBIT A
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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint 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 more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states 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)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or 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 any questions regarding the law or if you are required to obtain a workers'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 necessary). A copy of the affidavit that has been officially stamped or marked 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
< Boston,MA 02114-2017
v ' www mass govldia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FRED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:
Address: P.0. zox I ill 5 S Proa a r ort r4 mer
City/State/Ziplamn-_,_N,Q p1053 Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail .
or part-time).* 6. F]Restaurant/Bar/Eating Establishment
2Z I am a sole proprietor or partnership and have no 7, Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]* 11. Health Care
4.[] We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 1 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box M.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: `7?��at�at�rlS
Insurer's Address: a,
City/State/Zip:
Policy#or Self-ins.Lic.# P JUS —d 18C 304 y 7 Expiration Date: 6 Z b—,ZD I
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 WORD 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 cerci/fy,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: /^ sem, Date:2-"&¢,-x b.A, 070.7
Phone#: -Y1.3 .�ftL oos
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):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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: 190 h1opgMck <rgAwr nO&S"ct�► HA
The debris will be transported by: in jut ja' 4..)It"
The debris will be received by:
Building permit number:
Name of Permit Applicant WVJt0m 7- 1ls2omsNA
2• or►
Date Signature of Permit Applicant
' 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 No
SECTION 11 OWNER AUTHORIZATION TO BE COMPLETED:-WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize �Iij�A+ � � to
act on my behalf,in all matters relative to work authorized by this building permit application. � �
Z . IU�u@+r-cRKR- Z 0/
Signature of Owner Date
1, as IftmadAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Si ned under the sins andenalties of�ee uryL
tA
Print Name
,di ,� 2 �
Signature ofQwped gent Date
SECTION 12 CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
2 15P-0Za
Signature 101, 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
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 1'16(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)'
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
F— 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 Re istration 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
to O Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
° pr Version 1.7 Commercial Building Permit May 15,2000
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage E: �
Setbacks Front "
Side L: R: L= R:=
Rear
Building Height
Bldg. Square Footage 0110
Open Space Footage %
(Lot area minus bldg&paved N�
parking)
#of Parking Spaces
Fill:
volume&Location _ _ c
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q) DONT KNOW 0 YES
IF YES, date issued: � I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter BookI== Page= and/or Document# .
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Art
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
P : The Project is
off"12;
Construction of sound walls. Remove existing drywall. After door opening
to accept T-O"x 6'-8"pwhung gasketed sound door. Insulate stud wall
cavities with 3'r4"Roxul cover with W'sound board. InstallW nesilent
sound channel horizontally over sound board. Install W drywall attached
to sound channel.
(See attached drawing for sound wail.)
Install 1 —3'-t"x 2'-0" Marvin aluminum clad awning window in east wall
64"from floor through concrete block wall.
Includes x"x 4"x 4" steel angle to support concrete blocks above
window, alterations to framing, patching drywall and finish trim to match
existing ranch casing on door and window.
Office 1:
Install 1 —T-6"x 2'-0" Marvin aluminum clad awning window in east wall
5'-6"from floor through concrete block wall.
Includes W'x 4"x 4"steel angle to support concrete blocks above
window, alterations to framing, patching drywall and finish trim to match
existing rand casing.
Offing 03: (Sound Booth Room)
Alter framing to accept 3'-0"x 6'-8" pre-hung gasketed sound door. Install
and trim door to match existing trim.
RmiaoWn Area and Waiting Rwrn:
Remove existing wood framed single glazed glass IV-0"x 10'-0"window.
Replace with aluminum 4SIT thermally broken framing with bronze
anodized finish.
Glass—1'" bronze tinwi/Low E insulated glass
Panels—Top 12"x 45'x4"insulated solid panel bronze
The work listed above includes all materials and labor to perform this work as
well as protecting the carpet and office equipment, dust protection.
Re-installation of baseboards, prime all new drywall both walls and patches.
Polyurethane the two new doors, installation of locksets(provided by client),
clean up and removal of construction debris. The quotation includes the price of
a dumpster, cost of plans and Building Permit.
Proposal does not include finish painting of walls or trim.
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❑ Additions ❑ Accessory' Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing[] Change of Use❑ Other❑
Brief Description Entera brief description here. Z+�aTpII Tw+ +►,,.,�..�%� +�e.•es/R> pcts �'"'4a �6=d�"1O�-O`
Of Proposed Work:
{o—& fAM'►ft6(.TAW-)'& CvL^v.Wft AI&&aIa�r�1+Abi"abiwnn 3'r&&9 'F�bwt� .wIN�. I~1AJ9W.WW
Gu+ss :•..wc R e
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
❑ A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi h Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ I-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 513 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
77=
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
tF10E�dM
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
Floor Area per Floor(sf)
S
w
St
St
,s
nd x� S
nd 2 X � s�� Y s a
2 �' �
rd
rd
th m a a M
�• - �-- 4s���$ �
4th
F �
Total Area(sf) Total Proposed New Constructions `
Total Height(ft)
E ��
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❑
- Versionl.7 Commercial Buildin Pennit Ma 15 2000
I Ezu
-- -- --- City of Northampton
Buil ing Department
NOV - 5 2018 2 2 Main Street
Room 100
FPT of can rnr;Gi Ti rth mpton, MA 01060
r�o,�rf]AtiPf.ip' i 6i;M-58 -1240 Fax413-587-1272
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 Prooertv Address: Tht 0`14 e c ExtPfe dbYaffice y 4
MO N o tv oTLL c is s-w-v-t E T 5 Map
Zon
Eltt $t D€strrct C13 p( rN
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SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
U �
Name(Print) Current Mailing Address:
r T/ zZ
Signature)( Telephone
2.2 Authorized A-gent:
• I.EEb �--��
Name(Print) Current Mailinq Address:
�/3 58� .4005
Signature
Telephone
SECTION 3-ESTI ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use ONy
completed by permit applicant
1. Building 19� (a)Building Permit Fee
2. Electrical (b)i Estimated Total Cost of
Construction from 6
3. Plumbing1777`��
Building Permit Fee
4. Mechanical (HVAC) d bg �r•-
5. Fire Protection
6. Total= 0 +2+3+4+5) &0 . ob Check Number
This Section For OlficlW Use Only.
Building Permit NumberDate
Issued
Signature:
Building Commissioner/Inspeetorof Buildings Date
File#BP-2019-0552
APPLICANT/CONTACT PERSON WILLIAM TUROMSHA
ADDRESS/PHONE P 0 Box 141 LEEDS (413)5864005
PROPERTY LOCATION 190 NONOTUCX_ST
MAP 23A PARCEL 291 000 ZONE Gl(IC,40)/
THIS SECTION FOR OfTIC.I.A.,USE ONLY:
(. *_
PERMIT APPLICATION __ 'CKLIST
ENCL ED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid "�
Buiidiniz Permit Filled out
Fee Paid
Typeof Construction: INSTALL 2 AWNINGWE1ND!jj1_111_
New Construction
Non Structural interior renovations
Addition to Existing
AccessoryStructure
Building Plans Included:
Owner/Statement or License 000515
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�FWMATION PRESENTED:
Ap
A_
!:�_ proved 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 REQUAREDUNDE)k'
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 Delay
11 6 t8
SignatureofBuilding 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.
190 NONOTUCK ST BP-2019-0552
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map--Block:23A-291 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: window replaced BUILDING PERMIT.
Permit# BP-2019-0552
Proi ct# JS-2019-000896
Est.Cost.$19300.00
Fee: $135.10 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor. License:
Use Group: WILLIAM TUROMSHA 000515
Lot Size(sg.ft.): Owner: FRITZ NICOLE
Zoning:GI(100)1 Applicant: WILLIAM TUROMSHA
AT: 190 NONOTUCK ST
Applicant Address: Phone: Insurance:
P 0 Box 141 (413)586-4005
LEEDSMA01053 ISSUED ON.-111612018 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2 AWNING WINDOWS
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: M 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:
Feellee: Date Paid: Amount:
Building 11/6/2018 0:00:00 $135.10
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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