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23B-014 (2) BP-2023-0116 125 LOCUST ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-014-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-0116 PERMISSION IS HEREBY GRANTED TO: Project# ERV 2023 Contractor: License: ADAMS PLUMBING &HEATING Est. Cost: 149000 INC CS021742 Const.Class: Exp.Date: 07/03/2023 NORTHAMPTON CITY OF BOARD OF PUBLIC Use Group: Owner: WORKS Lot Size (sq.ft.) Zoning: OI Applicant: ADAMS PLUMBING &HEATING INC Applicant Address Phone: Insurance: PO BOX 126 (413)743-2308 MCC-200-2000025-2021A ADAMS, MA 01220 ISSUED ON: 02/01/2023 TO PERFORM THE FOLLOWING WORK: INSTALL ERV 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: toJit,4).AAA. Y ' I Fees Paid: $ 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner fa S t- tJ 4- ra-"V1-1 I L ••••t.., The Commonwealth of Massachusetts 4 U Office of Public Safety and Inspections `' ' /Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Tvi$ Dwelling (This Section For Official Use Only) ''-".; nFCTi,.,j �r/ Building Permit Number. = 3- Illy Date Applied: Building Official: SECTION 1:LOCATION 125 Locust Street Northampton 01060 Peter McNulty DPW A,dmin Bldg No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2 PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building® Repair 0 Alteration ® Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: Install new energy recovery ventilator. Energy recovery ventilator will be mounted on the ground outside of the building. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft) and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5❑ B: Business 0 E: Educational 0 F: Factory F-1 0 F2❑ H: High Hazard H-1 ❑ H-2 0 H-3 0 H-4 0 H-5❑ I: Institutional I-1 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility❑ Special Use❑and please describe below: Special Use Description SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB ❑ HA IIB ❑ IIIA ❑ MB ❑ IV VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public L$ Check if outside Flood Zone INIndicate municipal ER A trench will not be Licensed Disposal Site 0 Private❑ or indentif Zone: required®or trench or specify: yor on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: sforic C, mmission Review Process: Not Applicable a Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 124 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: ___ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner City of Northampton 212 Main Street Northampton 01060 Name(Print) No.and Street City/Town Zip Property Owner Contact Information Katie Deppen, Facilities PM 413 _587 _ 1020 757.270 _8441 kdeppen@northamptomna.gov Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this buildingpermit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 17. Otherwise provide;..>structi.n ,.,ifirl t.u:n>,(see section 107 in the code)as required 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) William Towsley 413. 525. 3170 bill@towsleyassociates.com 35337 Name(Registrant) Tele hone No. e-mail address Re 'stration Number 32 Knlood Dr. East Longmeadow MA HV 06/30/2024 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Adams Plumbing&Heating, Inc. Company Name Jeffry Daignault CS-021742 Name of Person Responsible for Construction License No. and Type if Applicable 43 Printworks Drive Adams MA 01220 Street Address City/Town State Zip 413_ 743 2308 - - a.moresi@adamsphinc.com Telephone No. (business) Telephone No.(cell) e-mail address SECTION 11:WORKER5 COMPENSATION INSTJANCE AFFIDAVIT (M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 13 No O — SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor 149,000.00 and Materials) Total Construction Cost(from Item 6)=$_ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ 5,800.00 appropriate municipal factor)=$ 3.Plumbing $ te1 4.Mechanical (HVAC) $ 105,400.00 Note:Minimum fee=$ c tuiicipi0 5.Mechanical (Other) SM $ 37,800.00 Enclose check payable to 6.Total Cost $ 149,000.00 (contact municipality)and write check umber here _ - SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and ac ra to t t of my knowledge and understanding. Jeffr y E.Dai vault c Construction Superivsor 413.743 _2308 1/31/2023 Please print and sign na Title Telephone No. Date 43 Printworks Drive Adams MA 01220 a.moresi@adamsphinc.com Street Address City/Town State Zip Email Address 11 Municipal Inspector to fill out this section upon application approval: 2 I Name Date ► a A_. if Commonwealth of Massachusetts Commonwealth of Massachusetts Division of Occupational Licensure go- Department of Fire Services i BU-026385 PipefittuekittlrestP�6tl�esI Master 4, Oil Burner Technician Certificate PMU-000353 fy Elcpires:07/03/2024 ,• JEFFREY E DAIGNAtLT j ' -- JEFFREY E DAIGNAULT 1 ASHFORD NGTS .''., 1 AASHFORD HEWS ADAMS MA C1220 4» ADAMS MA 01226 1 ':v"'1 V-7> s ExpiralTion Date cc-nr,,,, 11 State Fire Marshal 07/0 /2023 Iltr Commonwealth of Massachusetts Commonwealth of Massachusetts Division of Professional Licensure .� j Division of Po Board of Building Regulationsrofessinal Licensure and Stan�ards Spqnitls•}a linttnctor Consti�u�"t�i��iS•pervisor i SC-001368 w� 4' E pires: 07/03/2023 CS-021742 isores:07103I2023 JEFFREY E DAIGNAULT JEFFREY E DAIGNAULT 1 ASHFORD HGTS 1 ASHFORD 1:GTS ADAMS MA 0.�20 - ADAMS MA 01220 ..., i;t��SS`1:1L1Z�, i ` -- -- Commissioner , o„ p yYS,,;p,,; Commissioner Ou4c, 1. ',-,-Wit L,a n J Commonwealth of Massachusetts Commonwealth of Massachusetts IP Division of Professional Licensure ipt, Division of Professional Licensure HqvisiA•YA6i1r er RefrigerBtPOt1'Technician t HE-119t EJt,,pires:07/03/2023 RT-002530 Expires:07 03/2023 JEFFREY E LAIGNAt3LT ' 7 JEFFREY E DAIGNAULT ' - 1 ASHFORD I1GTS 1 ASHFORD HGTS ADAMS MA O4220 ; ADAMS MA 01220 �C C.oIW1 issionel ,;',:«j:;; ,' .,, 1,,;' Commissioner cic 4 /'. )1ZI,7df_a_. City of Northampton Massachusetts ,. DEPARTMENT OF BUILDING INSPECTIONS . '1;::‘ 111:.:0 Or* 212 Main Street a Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. Net .gyp !, cA--I I , The debris will be disposed of in: Location of Facility: The debris will be transported by: Name of Hauler: Signature of Applicant: Date: The Commonwealth of Massachusetts ►[--th a Department of Industrial Accidents �1= 1 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 Lezibh Name (Business/Organimtionilndividual):Adams Plumbing& Heating, Inc. Address: PO Box 126, 43 Printworks Drive — City/State/Zip:Adams, MA 01220 — Phone#:413-743-2308 Are you an employer?Check the appropriate box: Type of project(required): 1.12 I am a employer with 80 employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]+ 9. El Demolition Q Building addition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs,or additions pmprietors with no employees. 12.D Plumbing repairs or additions 5.0 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. 14.['Other HVAC 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. --- 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. 1.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 sbeet 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: Massachusetts Employers Insurance Co., Inc. Policy#or Self-ins.Lic. #: MCC-200-2000025-2023A Expiration Date: 1/1/2024 Job Site Address: 125 Locust Street City/State/Zip: Northampton MA01060 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: j jj k t + Date: //3"_//91- Phone#:413-743-2308 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 6.Other Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Massachusetts Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 58713 POLICY NO. MCC-200-2000025-2023A PRIOR NO. MCC-200-2000025-2022A ITEM 1 The Insured: Adams Plumbing & Heating Inc. DBA: Mailing address: P 0 Box 126 FEIN:**-***2575 Adams, MA 01220-0000 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 01/01/2023 to 01/01/2024 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B 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. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual 01 Annual Remuneration Remuneration Premium • INTRA 000124512 INTER 911837307 SEE CLASS CODE SCHEDULE Minimum Premium $416 Total Estimated Annual Premium $126,667 GOV GOV Deposit Premium $13,347 STATE CLASS MA 5183 State Assessments/Surcharges $162,739.00 x 4.1800% $6,802 This policy, includingall endorsements, is herebycountersigned by ' `—"''� 9 � `" � — 12/07/2022 Authorized ignature Date Service Office: MountainOne Insurance Agency Inc 330 Whitney Avenue 85 Main Street, Suite 100 Holyoke MA 01040 2789 North Adams, MA 01247 WC 00 00 01 A (7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. +y.\ Initial Construction Control Document To be submitted with the building permit application bv-a 1,kk >> Registered Design Professional for work per the ninth edition of the Massachusetts State Building Code, 780 G.NfR, Section 207 Project Title: Date: i/3 fagz,7 3 N+_.bv✓,ciJriecsi7Yo a ,S y 3-r**/ .A�61 (5a t.D, itiC Property Address: l S L c>c u s7 5 r- NU/2i'70frtP ry N MA Project: Check(x)one or both as applicable: New construction Existing Construction Project description: wf�c,,.i row,scoy f 3 3 7 /3a/2 I NIA Registration Number: • Expiration date: ,am a registered design professoonml, and I hare prepared or directly supervised the preparation of all design plans,computations and specifications concerningt: Architectural Structural Mechanical .� Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (80 CMR), and accepted engineering practices for the proposed project I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable_ 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code_ Nothing in this document relieves the contractor of its responsibility regarding the provisions o 7:0 CMR 107_ �Ka When required by the building official.I shall submit field/progress reports(see item 3 i . .:., . tent comments,in a form acceptable to the building official. o WILLIAM A. c(i) g TOWSLEY Upon completion of the work, I shall submit to the building official a`Final Constru ;tilts CPKAWINIWitu 35337 �� STE E� Enter in the space to the right a"wet" or / � OI 1t� electronic signature and seal: (/f�' //SGizj Phone number: ,135-58 Z Email:0/14 GT-a tiv5L+0' .At',4c-/ow S 'C1�mot' Building Official Use Only Building Official Name: Permit No.: Date: Note I.Indicate with an project deign plans,computatinrts and specificat oru that you prepared or directly super _d_If'other'is chosen,provide a description. Version 01 01 201S Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required l Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(mat require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) • 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) - r *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Wi iliaN,T 5, ` ,����� ��pfts. 35331 �v t 'i�3 -3 3S' 5 ' 7 G s.tc rr tc,s. <c? Registration Number Name(Registrant) Telephone p No. !/ w e-mail addresse� f c�PC �U I i vvt d ii' F. km/t 11,(�(f/Oi v �A rat 2t E�.t.._ .1//3t^/ /Z- - Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address Cite/Town State Zip Name(Registrant) Telephone No. e-mail address Registration Number Street Address Cih/Town State Zip - Discipline Expiration Date Please follow this link for,nsiruction control forms to be used by Registered Design Professionals.