13-088 BP-2021-1977
26 STONEWALL DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
13-088-001 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-2021-1977 PERMISSION IS HEREBY GRANTED TO:
Project# 2021 BATHROOM Contractor: License:
Est. Cost: 30000 LEARY BUILDING COMPANY 104806
Const.Class: Exp.Date:02/17/2022
Use Group: Owner: ROSS PAUL C
Lot Size (sq.ft.) •
Zoning: RI/RR/SR Applicant: LEARY BUILDING COMPANY
Applicant Address Phone: Insurance:
13 GLENDALE WOODS (413)336-2611
SOUTHAMPTON, MA 01073
ISSUED ON:10/06/2021
TO PERFORM THE FOLLOWING WORK:
living room to bedroom and bath
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: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: ler4 9
• (PI 4°1
Fees Paid: $195.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
RE-Cy
QED
§ . .a,, ,,A,, The Commonwealth ofMassachu -tts SEP I I
2i ' i ' 'IC 'ALITY
1Mlassaclh ts State B ui g Co, 80 c ' E
./ PT OF
Bedding P.ermit'App1ication To Construct,Repair,lien 'On j ,... 'eerie,'! rr. 2011
One-or Two-Family Dwelling °^' ";1 n,oc601"Ns
This Section,For Official Use Only --J
.B.uzitung ermii " 1 ._
7 l�u��her: (J�"a��"1 7 Dale Apiliieti:
5j 1/1/ ID-b-Zbz? I
P lding OicitA(Print Name l Signature Date
SECTION.1:'SITE-INFORMATION
LI Property Address,: 1.2 AssessorsMap&Parcel Numbers
1(i S1ONEWALt. ( - /3 c.)p g
1.1a is lids an accepted street'? yes no 1 t"""" "" I
1.3 Zoninentbrmationz 1.4 Property Dimension:
Zoning District Proposed Use Lott Area(sgk,It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Ittar Yard
Required Provided Requited Provided. Required Provided:
1
,1 ater'Sampiy:OWL c..44;:I54) 1.7 .F:lood lane Inf: catM n: 111 Sewage Disposal System:
Zone: Outside Flo Zone? Municipal disposal system Public 1:3 'Private 0 Check if yes❑ 0 On site di. osal s tem 0
SECTION 2: PROPERTY OWNERSHIPI
, f Rtcorrl:
hii )CS 1(o S:�rXL4nac. 6r4. / lllooiwtMi' v, bt,A Gicc,-L
Name(I-lint)
City,Siaie,Zii
/1i)VS- S.S1 VIToLA & Cont. f
No.and Street eleplmme Ernail=Address
SECTION 3:DESCRIPTION OF PROPOSED WORK.(check all that apply)
New Construction l Existing 13nikling la Owner-Occupied la Repairs(s) D r Alteration(s) Addition
Demolition. 0 'Accessory Bldg 0 Number of Units ' Oar D Specify:
1 411JL,i,L/.;,Jt.a.l.1ld.W V1 14tJUJWA Work':
. )(
1 Jua,N' Livi�+c.. �otA. (N7J (Sbtlooiu Y I Abe Ki—Lt eoAA, i.'li SPF.0 I
1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:Item Official Use Only
(Law and Materials) _
{ 1.•Brnldinw I 30 1. Building Permit Fee:'S —Indicate how'f is determined:
i Standard t rv' Application fit ition Fee 2.Electrical [$ r E Total Protect Cost(Item 6)x muItigiier x
3.Plumbing ' S. 2. Other Fees:
4. Mechanical (SAC) S — List:
5. Mechanical. (Fire
Suppression) Total All F
Check NoA Check Amount:qq6 Cash Amount:
1 6. suite;rro,eci ',„i. Paid 0 C.ri P aid in Full °zttstanding Balance Due:
0
Q
SECTION 5: CONSTRUCTION SERVICES
SI C'am:atraetieta Supervisor Lieemie(CSL),
• /OLIS0(0
/r n1 Lustre Number ExpiradruuDatc
Name of CSL Wider
List CR.Twe(see below). U
13 t r-EAoALe L.1ooA S De
, No:and Street , Type
Description
Sov i HAµp-rod-1 �1/� Ow "� I 1. Unrestricted(Buildings up to 35,000 cu.ii.)
R. Restricted 1442 Family Dwelling
City/Town,State,LIP VI Masonry
RC Roan Covering
•IWS Window and Siding
SF SOli¢1 Fasel'1ing Appliances
K13 33t,- Zcott (i .af,• tt,C1tAgt. eti. ' I ' Insulation _
one E = address tD !Demolition
e 2 Registered Ho...a r..,nre,ve .nnt Conan ntn..(MC) 1
.�.r w6mw.t. Home.flay.v....u..u. t.vu.,o.,.v. laaa..� / f. ��
Law
lta.6t/ll�. I)JC H 2 Reg I V(O 3-1/Registration Number Eap ixatian.Data
HIC •,,, y Name or kIK'/Regtistra t Name
iS CJooAS bi
No.and Street \ E�iail address
So.TiMMPioN , MA` OI0„ C✓33� UghCity/Town,State,ZIP ✓ Telephone
SECTION 6:,WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. § 25C(6))
Workers Compensation Insurance affidavit it must be completed and submitted with this application. Failure to provide
this affidavit Wild resialtin the denial ofltbe l :,. :,'.-Akfttheluilding‘pennit.
Signed Affidavit Attached? Yes No ❑
'SECTION'7a;,OWNER_M THORIZAT NTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR Bti DING PERMIT
I,as Owner of the stibiect'property;hereby authorize Qke G �,vi Oil I L�
to act on my behalf,in all matters relative to work authorized by this buildin per tit appli ion.
q- 2&• 7I
Pri Name(Electronic Sire) Dare
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pa. s and o alties of per jury that all of the information
contained in this application is true and c to e b f my kno edge and understanding.
q-7�2i
Pri. fOwner'.s.or Au orized gents ame(Ele rii 'Si at a Date
TES:
1.. An Owner who obtains a Wing permit to do hi own work,or art owner who hires an unregistered contractor
knot registered in the Home improvement Contractor(WC)Qarow.am),wial.nor have;access to the arbitration
nri ram nr miaranh,4 inrl iinflPr 1(4 f;r P.1 a7 A flther imnnrtant infnrmatinn nn tha 4f(f"'Prncrram ran fi iinri at
www.mas ,govivca Information on the Construction Supervisor License can be found at www.itiass,gov;dps
2. When substantial work is pkuuteg4 provide the in,£o>ruoticns be"ow:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks.or perch
Gross liviug.area(sq. it) Blabitablero m count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
Type of heatittg system Number of decks/porches
:ypc of cooling systclll LllVlWbLL VtlVll
3. '"Total Project'Square,Footage"maybe substituted for"Total Project Cost"
164;.\...
The Conunonwealgt of Aiksseteltusetts.,
. i- , -----' De.parintent of IndtostrialAceitients
I Congress Street,Suite ISO
&won,.MA 0211416117
1,
WWW.mask:At:Via
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Workers"Compensathm Insurance Affidavit:BuildersiContractorvElectransfPlumbert.-
-11)RE FILED WITH THE PERNIFITING AUTHORIFV.
ArbehirklItillferle**14/0 'Meow Print ,Legiltlx
M aine(BosiscssOrgantrationttridividnal): L.
Address: IS ‘l.eivom.4 (,).),, I it
— -- - .
CitYiStaterrIP: StsiWtm.ProA)+111.4_919313 Phone;4:, los 35(0.-16,1 1 , , _ _
i
Are von au employer?Cheek the appropriate box:IC I inn a enevlov!er war% ,,,_ _,empimates tlitil aultor partAnney, [I, Type of project(required):
T. '--1 New construction i
, - i.....,
2,171 I am al sole provrattor oc partairrahap and have no enaptimores working fee are ini : '' g-., .`.."1 Remodeling
any capacity.No wotters'clamp.instnance regional]
' 9: D Demolition.
30/ara a bornorovier doing a work myself,No workers*comp,morninee rotarook)4
to,D Build-le/addition
4.0 I am a linmeownia and will he hiring croonactorstrt tAltidad all work on my property. I will
' t IC Electricat re/waft,ore or additions
moire that all conteactont either hove*totem'compernatied inserance oe sole
f 12.1j Pltunbma repairs or additions
5.10 4 mai a gxmerat contractor and I lam:hared the sub,cotstractors hated.on the anactual sheet
.?, : 3.71 Roof repairs.
These sub-conuactors haw enerployees and have workers'comp.traurance.;
we are:a corporation aid its officers have exercised their right of exemption per'WM.c. I 4 )thet (3•0)I&KR (otiveRtat
•, .1-44)..iitien.clitnearo emplayenc.'No worker,'corn?.reworateereostoed.1
''''hey otpoti‘ltei Rue%Meek%box a1 name also bll oat the iwstaietal,ehos idiowingtheer*ottani`tatrioanation poit4 astforarabon..
t Homeowners who submit this affidavit irwheating they ate doing all work and then hire outside contractors mon%ikon a new affidavit tadioning sock
.4erantratarna tint eirael.thw boa roma attaziond an allitional shot;ithimang the name of the solx-eartrackant and iazae wile:dna or not those anlitivl..have
employee. if it.S.maly-4.tnfitaiEus,IffilVti triltpiv,t-gc,-,iltv.f anal pluv:iti.iiMir 1.r0illt.VSN WIttft.puim,Sittli/VC.1
OTI...,........,....M1F4.,...K.M.11.1.1,....,
I am as employer dart&providing ovrkers'compensation invralnwe for not employees. Bekaa is the policy and jobsire
information.
Insurance Company Name:
Policy#or Self-tn .Lie.4: Expiration Date:
Job Site Address: City:Statelip:_________________
Attach a copy of the Is orkers."compensation policy declaration page( htn the policy number and expiration date).
fader stsztre oomerape as tequila surater lvIGL c.152,§25A is a cantinal violation punishable by a tine up to SI,500.00
and/or one-yeor tropri:sotunent,as well as civil penalties in the form of a STOP WORK ORDER and a forte of up to$250.00 a
day against theviotator.A copy of that statemem may be.forwarded ito the Office of liotesttgations of the I)1A for insurance
*clove:ape vertfication.
I do'hereby c a I .,,,,7 nd en o 0 • airy that Ike itfortsmitlim provided above is true and correct
Signature: i ill Date: 9 -z - zi
Phone ) ;ta-/a
office.
. use only. Do not write in ibis neon,*robe completed by city or town official
City or Town:.
PennitiLiousse#
Issuing Atatbority(circle one):
!. itn..rt er th"qth Ir.r•"Ralf:"ner"r!Ment 3.ritITFaltts flee, 4 riertrir.qlmnettAr 'it.Pintegil,",PI—Ltc-r 1,
----...
1 6.Other
1. (*comet-Person: Phone#:
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FORM 153 The Commonwealth of Massachusetts Dok use oirgy
Department of Industrial Accidents
Office of investigations - Dept. 153 1 I
I Congress Street,Suite Me,Boston. Massachusetts 02114-ZI117
=71W lettp://wwwartass-gotildia briestISWO ID az
,
Za",+- AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, s C1(4) by adding the following paragraph:
-This chapter shall be elective for.an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation.Notwithstanding section 46„these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to cam(out the
purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C.-
'ettratant TO .(iL
c
152, if4)as anieriaita, 'WAY.thr iaittei-sigiwt453flioers of
Leary Building,Inc. 1039 East Mountain Road,Westfield,MA 01085
(Name of Corporation and Address)
each holding at least 25%of the issued and oulstandina stock in said corporation. do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation pOlicy covering the undersigned corporate officer(s)or director(s), VWe the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L.c. 152 for
any injuries that may be sustained while in the employ of the above-named corporation.
Further,1/we the undersigned do understand that., should the above-named corporation kite or have in
its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s),,said
corporation is required to obtain workers' compensation coverage for the employee(s)as prescribed by
M.G.L. c. 152, §25A.
I/We the undersigned have read and understand the statements and obligations as delineated atxwe and
I/we have checked the appropriate box below my/our name(s)indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L. C. 152.
Signed ondee the Pains and Pennkies of perjury:
Thr.,,...4.try A. Leafy.President 07/1542014
Signature Print Name&Title Date hiainktrUyyyyt,
ZI wish to exercise my right of exemption or 0 I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(atineddiNnyy)
0 1 wish to exercise my right of exemption or CI I wish NOT to exercise my right of exemption
Signature Print Name&.Title Date(rnmAdiihyyyy)
I wish to exercise my right of exemption or D wish NOT to exercise my right of exemption
Signature Print Name&Tide Date tinin'tidAyyyy)
0 I wish to exercise my right of exemption or wish NOT to exercise my right of exemption
Note:ALL ELACIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4'SIGNARIRES. heallegiartS
on bark Fenn 153-1/1010
City of Northampton
td" -,IF r", ...a; Massachusetts '`�`"_� ..;.
4 f f D RTY IQT OF BUILDING` INSPECTIONS `.
t 3 * 212: Main Street 0,Municipal Building "ti0
'.,. Northampton, MA Q1Q60
uk -
CONSTRUCTION DEBRIS AFFIDAVIT
)(POR AbLDENIOLITTON AND RENOVATION PROJECTS)
In accordance of the,prow is ions of-MG c 40,554,a condition of NAi'din Permit
Number is.that all debris resulting from this work shall be disposed,of in:a
nrnncrhrtironcarl NAInCtO Meru-sent fnri i r nc rinfintat4 flAr Ntra r`11.1 C -i-cnti
r �r ar.sJ.ala. 7, r ,.
The debris will be disposed-of in:
Location of.facility: \jLt7' R ,
The debris will be transported by:
Name of Hauler: tole/ .6,,,a,0 R6, (c)
Signature of Applicant: Date: 9•Z�r"2/
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