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24D-092 (18)
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: —6z/ 11)Oa;1-H r6 IVOPq011"19'7bAj The debris will be transported by: The debris will be received by: I&LOY AV& Building permit number: Name of Permit Applicant Wa 0/ Date Signature of Permit Applicant IQ D.A.SULLIVAN & SONS, INC. t, I :NI ►tAI t () rte I PAt I ciR LConstruction Manager ♦ Owner's Project Manager November 26, 2018 Building Commissioner's Office 212 Main Street Northampton, MA 01060 To Whom It May Concern: I request that you grant a modification to waive the requirement for control construction for the Exterior Renovations at 82 North Street in Northampton due to the fact that 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 considerable when compared to the cost of the proposed work. Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project." Respectfully, 1414 Mark Sullivan President D.A. Sullivan &Sons, Inc. 82 — 84 NORTH STREET, NORTHAMPTON, MA 01060-3289 , P: (413) 584-0310 ' www.DASULLIVAN.COM The Commonwealth of Massachusetts Department of Industrial Accidents > I Congress Street,Suite 100 < Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ley-iby Name (Business/Organization/Individual): 1),A IV oil r L� Address:_bl-�14M MCA,-) a City/State/Zip: OW Phone#: Al 4I_ Q 3 I U Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with__employees(full and/or part-time).* 7. New construction 2.LJ 1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.CJ 1 am a homeowner doing all work myself[No workers'comp.insurance required.]' 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I Lp Electrical repairs or additions proprietors with no employees. 12,F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROof repairs These sub-contractors have employees and have workers'comp.insurance. 6.f_1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill 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 state whether or not those entities have employees. If the sub-contractors 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: j nn Policy#or Self-ins.Lic.#: M C CZWZ0U0Qa 3 20 I bA Expiration Date: U Job Site Address: U 2-U 4 &A 04-1 �, City/State/Zip: apr'tb Gl.Y1'1 ,M N/ (�) U o Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un r the pains andpenaldes ofperjury that the information provided above is true and correct Signature: Date: Phone#: 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.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: 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 0 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 i 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 ❑ Name of License Holder:!Mark Sullivan License Number 82 North St.Northampton, NIA 01060 Address Expiration Date _(413) 584-0310 I f C 20 Signature Telephone SECTION 13-WOR '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 0 Version 1.7 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: l Not Applicable 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 t , 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 D. A. Sullivan& Sons Not Applicable ❑ Company Name: Mark Sullivan Responsible In Charge of Construction 82 North ST. Northampton, MA 01060 Address (413) 584-0310 54- Signature Telephone Versionl.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 Frontage Setbacks Front Side L: R: L:' R: Rear Building Height ; Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO @ DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the"istry of Deeds? NO 0 DONT KNOW 0 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 a IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained a Obtained 0 , Date Issued: C. Do any signs exist on the property? YES © NO IF YES, describe size, type and location: 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE I Interior Alterations Existing Wall Signs 0 Demolition 0 Repairs 0 Additions El Accessory Building El Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use 0 Other 0 Brief Description Construct small exercise room 144 SQ. FT. electrical,heating/cooling,ventilation, fire protection Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 0 A-2 0 A-3 0 1A ❑ 0 A-4 0 A-5 ri 1B ❑ B Business 2A ❑ E Educational ❑ 2B F Factory ❑ F-1 0 F-2 ❑ 2C ❑ H High Hazard 0 3A ❑ I Institutional 1-2 0 1-3 0 3B ❑ M Mercantile ❑ 4 ❑ R Residential ri R-1 ❑ R-2 ❑ R-3 ❑ 5A El S Storage 0 ST 0 S-2 ❑ 5B ❑ U utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use 0 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: B Proposed Use Group: �B Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA I OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor(sf) 1st 2 nd 2 nd 3 rd 3 rd 4 th 4 th Total Area(so Total Proposed New Construction(so Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: Sewage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone0 L3 _ Mu Versionl.7 Commercial Building 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 Water/Well Availability. Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 1 Plot(Site Plans r APPLICATION TO CONSTRUCT,REPAIR,RE VA E HE USE OR CC PANCY OF,OR DEMOLISH ANY BUILDING OTHER HAN A ONE OR TWO FAMILY WE ING SECTION 1 -SITE INFORMATION NOV 2 7 2018 1.1 Property Address: is s ction to be completed by office DEPT OF BUILDING INSPECTION NORTHAMPT N,MA01060ZIA 82 North St. Q . . of qd Unit Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: D. A. Sullivan & Sons 82 North St. Northampton, MA 01060 Name(Print) Current Mailing Address: (413) 584-0310 Signature Telephone 2.2 Authorized Aaent: Mark Sullivan 82 North St. Northampton, MA 01060 Name(Print) Current Mailing Address: 'l (413) 584-0310 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $3,000.00; (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of $1,000.00'; Construction from 6 $8,000.00 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection $4,000.00 00 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2019-0624 APPLICANT/CONTACT PERSON D A SULLIVAN&SONS INC ADDRESS/PHONE 82 NORTH ST NORTHAMPTON (413)584-0310 PROPERTY LOCATION 84 NORTH ST MAP 24D PARCEL 092 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: CONSTRUCT 144 SQ FT EXERCISE ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 053668 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF WMATION 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 Permit DPW Storm Water Management Demolition Delay it v)he 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. 84 NORTH ST BP-2019-0624 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block:24D-092 CITY OF NORTHAMPTON Lgt: -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-2019-0624 Proiect# JS-2019-001025 Est.Cost: $4000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: D A SULLIVAN & SONS INC 053667 Lot Size(sq.ft.): 21692.88 Ownfr. SIJLIVAN D A&SONS INC Zoning:URC(100)/ Applicant: D A SULLIVAN & SONS INC AT. 84 NORTH ST Applicant Address: Phone: Insurance: 82 NORTH ST (413) 584-0310 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:11/28/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 144 SQ FT EXERCISE ROOM 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 R joartinent 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: FeeTvae: Date Paid: Amount: Building 11/28/2018 0:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner