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45 GLENDALE RD BP-2018-1362 GIS 4: COMMONWEALTH OF MASSACHUSETTS MV-.Block;42- 121 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categorv,ROOF BUILDING PERMIT ermit4 BP-2018-1362 Proiect4 JS-2018-002421 Es[ Cost:$8500.00 Fee $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WALTER MAREK III 055201 Lot Size(sp.f.): 17641.80 Owner: TOWNSEND DOUGLAS H&SHEILA A Zoning: Applicant: WALTER MAREK III AT. 45 GLENDALE RD AoplicantAddress: Phone: Insurance. 73 SOUTHAMPTON RD (413) 527-7667 O Workers Compensation WESTHAMPTON MA01 027 ISSUED ON:6/20/2018 0.00:00 TO PERFORM THE FOLLOWING WORKSTRIP & SHINGLE ROOF - 12 SQRS 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 FireplacetChimney: 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 6/20/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner R E (ZM r Department use only City of N rtha pton Status of Permit: JUN 1913"Wg spa ment Curb Cut/DrtvewayPermit 212 M in S eel Sewer/Septic Availability I OF SUILDI&yGN$ p�Tl(y��,g 1 WatedWell Availability \\ NOH THAMPTdQDlJPpIV�n1f1, 01060 Tvro Sets of Structural Plane phone 413- - ax 413-587-1272 PM/Ske Plans Other Specky APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FApMILY DWELLING SECTION I -SITE INFORMATION fo -)YZ 1.1 ProoeM Address: This section to be completed by officer I f\ Map Lot � L-/ Unit � S I� Zone Overlay DlatrtM rjar Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ND©cl- � - TelepL Signature 2.2 Aud d Agill Name(Pri ) Covert Mailing Address: u Iepi I,L Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed b "it applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+q+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Bulleing �Silftos Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column in be alkA in by Building Dcpasrmmst Lot Size Frontage Setbacks Front r' Side L R L: R: Rear Building Height Bldg.Square Footage �, / / r Open Space Footage (Lot urea minus bldg&paved parking) #of Parking Spaces Fill- vnlumu&Lacmion A. Has a Special Permit/Variance/Finding ever o\NO ite? NO O DONTKNOW O IF YES, date issued: IF YES: Was the permit recorded at the R "try of D NO O DONT KNOW IF YES: enter Book Pand/or Document# B. Does the site contain a brook, body of ater or wetlaDONT KNOW O YES O IF YES, has a permit been or n o he obtained fn Commission? Needs to be obtained OObtained Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: 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(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? VES O NO O IF YES,then a Northampton Stoml Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alleration(s) Roofing Or Doom O Accessory Bldg. ❑ Demolition ❑ New Signs [O] �/Decks [O ] Siding[0) Other[C3] � 1 Brief Description of Proposed I��11 >� J rlI VX 1 aS v Work: Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If New house and or addition to existing housing, complete the following: a. Use of building:One Family X Two Family Omer It. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? ) d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or W oodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction I. Is construction within 100 it.of wetlands?_Yes No. Is construction within 100 yr. floodplain_Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. SepticTank CitySewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �/M as Owner of the subject property herebya rize c,�ff kfe)l ` to act on my behalf,in all matters relative to work authorized by this Wilding rm{t application. Signature of Owner Date I. A a� Q� ,as Owner/Authorized Agent hereby declare that me statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed un t pains and pePalties of perjury. Pnnl Name ! � Signature of Owner/Agent Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructl n Su misor: Not Applicable ❑ Name of License Holder: C S J blSg0� License umb r Ur— h'1 i1 dl- Atldres Expiration Da ignature Telephone 9. d onae lah�ftt ConthaCtor Not A�licable rtK �Y�C. ll I I0O Company Name Registra'on N fiber Q q AdQQQ(res$1 ,/r 1 \�\ ) Expiration Dat Telephone�7 1) gqcl SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance of davit must be completed and submitted with this application. Failure to provide this afhdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes.......!KIC No...... ❑ City of Northampton i •°' Massachusetts A \ (� DRPAR29aUrT OF BUILDING DNSPROTZONS 212 IYio Street •Muoitipal Building i C° Northaepton, MA 01060 xW y `tee Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from constr ction work g performed at: L4 � Oa Je R� (Please print house number and street name) Is to be disposed of at: (Please printnam cation of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) J ) t I Jl�l lJrhj�r h'( Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the IocaUon where the debris will be disposed. City of Northampton Massachusetts Far / fr �. DBPARTNBNT OF Ba1LOZNG INSPBCTZONa 212 Win Street • Wainipel Building c° North, ton, M11 OlOfiO rah. �0 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC'). M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation,repair,modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owneroccupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by reeistered contractors. Note:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: R_- 1 � GRAS e- Est.Cost JR, Address of Work: Date of Permit Application: b 1 hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): —Job under$1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I heregy apply for a building permit as the agent of the owner: DatJ Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature �\ The Commonwealth ofMassachusens 11 Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2077 www.mass gov/dia N orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricions/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ' 1 Please Print Le 'bl NatilE (Rusan'sNOrgancom" lndividua�: W Address: City/State/Zip: �-l)t A -(JWa> Phone#: 1.1 Are you an employee!Ched thm i pproptlme box: Type of project(required): Idl...iloyer with errgloyccs(full suitor panaime).• 7. ❑New construction 2.�lam asole propriemr orpmmership and M1ave no employees working torment 8. Remodeling any capacity.[No women'comp.insurance ronti ed] 3Q lama hum .dmagall was myself Me wmkers'com1 Demolition p.inviesse repand.lt ❑ 4 I am a homeowner and will be hiring contramas to conduet all won,on my property. I will l0 Building addition w am met en cnudnamrs either have worlars compenmtied mango ce or am sole 11.[]Electrical repairs or additions progrieturs with no employees. 12.❑Plumbing repairs or additions &[]1 am a genal counselor and 1 have hired the sub-contractors hstint on the attached shat. 13 fgk of repairs These subconaactns have employees and have wome i'comp.msumdee 1 'L-1: 6 El We are a onf ord on end itaofficers have exemised their right of exemption pa MGL c. 14. Other 152,$1(4),add we have no employees.Mo wodcers'comp.insurance imanded.] :Any applicant Nat cheeks box 41 must also fill dui the section below ahowing their workers am emopeaion policy inf tion. Homeowners who submit this affidavit indicating they me doing all work end Nen him mande cdnhadors most submit a new affidavit indicating such, tContsctos that cheek this box must attached an additional shoot showing the nada of the subvommetom and state whether or not Nose entities have employees. Ifthe sub mo ctos have employees,they must pmvide Nev workers'comp.policy numbs. I am"employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name. Policy#or Self-ins.Licr#: w/�.,C�_ Expiration Date: Job Site Address: > U t. 1� City/State/Zip: ,8 Attach a copy of the workers'compensation policy declaration page(showing the policy number and er iratioo 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. 7 do hereby certify ander 11 pen Hes ofperjary Won the information provide -Qllb-Ir Iasis nue and correct Si nature: ['� Date: iti/ Y 1 [ X Of(cial 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(Fown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: o CERTIFICATE OF LIABILITY INSURANCE Ban�rmala°""Y" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFF9IMATIVELY OR NEGATIVELY AMEND,CITENO OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSITIUTE A CONTRACT BETWEEN THE ISSUING INSURERM,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CER71ROATE HOLDER. IMPORTANT: Hthe certificate holder Men ADDITIONAL INSURED,the poll6joleal must be andoraalL IfSUBROGATION IS WAIVED,subject to the items and cond#Wmoflhapollry,whin policies may requireaneMlmaement Astatmwd nthlscw#roca*do notc=Wrlghtstothe wrtlgwls holder In lieu of such s. mwNcen KS.K INSURANCE AGENCY,INC. rxoNe 413 527-7859 FA1[ 413 527-8310 203 Northampton St travissiaSOksk-Insumnce.com P.O.Box 597 Easthampton MA 01027 . PHENIX MUTUAL INS CO rwRED sessions.ASSOCIATED EMPLOYERS INSURANCE CO W.Marek Incorporated 73 Southampton Rd Westhampton MA 01027 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWRHSTANDINGANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACTOR OTHER DOC MENTT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COND71ONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- aTYPEQMWMNICE 9'F PgY.YE1V Lama X warERnsLaeearAE DAmLrrY 1.000,000 A cw.SlrnDE OOLCDR DUMSETO RFmEo 50.000 CPPU19447 11/01/2017 11/012018 $5,000 S1,000,000 LayT Ppt 20D0000 X POLx:r aAmo� �f LOc 1.000 ooa $ Auroewae tlseeln rnsmtllEo slxc�rAur f WHINANT NfTO BOgLY e4xEYRro•�1 s AUTO /ED Amos ED BOOLYINIURY(P�autlxi) f Xfwr Tm Avros Arms IED RInPERfYaVLWE f s usrom.usu accua FxDE66 ueAW No S •aDRxPA8w1@EMPIMMI xIPA., WF 1tIDEYPLOYFaa'WIdnY PNV PROPRIETORRARMERE)RTACNE 100.000 B o RCEFIE SER ExCLU ED? V Nu WCC-SOD5016290.2015A 02/702018 02/102019 arw 100000 pbwNary N rea rt ^tor-"mr Ey 500000 peaDprylpn DFOPER,(Tgna/1DC11TIDNa/YBeLII'B MDDRatal,AMtlmalhMV 8"Mub,mrr W aYadM tlmayv Y,epiaa GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION SIIWLD ANY OF THE ABCVE OE4CPE®PODCES BE CAHGHI.m BEFORE THE EXPIRATION GATE THEAECF, "Caps MILL INE D9N91FD N ACCOWMICEM THEPyLICYAtCYEmNa. Nnxq®P@RESENTATIVE 01980-2014 ACORD CORPORATION. AN rights raWread. ACORD 25(201101) The ACORD tape and logo am mglatsmd mads Of ACORD Massachusetts Departinent of Public Safety Board of Building Regulations and standards License:CS46520'i _ Construction supervisor WALTMLMAR66M 73 WUTHAWFION. . ' VANDIRMPfON /AW1 ' M� C — Expiration: Cofnmosioner eBR81201a 1 HIC Registration Registration 159488 Registrant W. MAREK INC. Name WALTER MAREK III Address 73 SOUTHAMPTON RD. City, State WESTHAMPTON, MA 01027 Zip Expiration 04/2912020 Date Complaints Details No complaints found for this registrant.