30d-017 BP-2022-0001
43 LADD BUILDING COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30D-017-001 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-2022-0001 PERMISSION IS HEREBY GRANTED TO:
Project# RENOVATION Contractor: License:
Est. Cost: 2500 LEARY BUILDING COMPANY 104806
Const.Class: Exp.Date:02/17/2022
Use Group: Owner: GLASS LAKE PARTNERS LLC
Lot Size (sq.ft.)
Zoning: Applicant: LEARY BUILDING COMPANY
Applicant Address Phone: Insurance:
13 GLENDALE WOODS DR (413)336-2611
SOUTHAMPTON, MA 01073
ISSUED ON:01/03/2022
TO PERFORM THE FOLLOWING WORK:
BUILD WALL FOR STORAGE AREA
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.
ill\
Signature: i i
. It a >9 . Cigil • ,
Fees Paid: $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
-. RECEIVE1.)
The Commonwealth of Massacnus ttAN - 3 2022
: , pti , ,
% Office of Public Safety and inspections
Massachusetts State Budding Code(7 80 CMR) _;T OF F t 1 oir:r,trlSPFC-7iONS
Bui g Permit Application for any Building other than a-One-Fir T—
° `.--
�.. (This Section For Official Use Only) _
Building Permit Number .1'" I _I Date Applied: Building Official:
SECTION 1: LOCATION ?tome,L d t i Noa,-[uP.t"rr nI0 CA 1- vMi� £)4.¢Ac.,T1
No.and7
Street Ci / owg� U/ Zap Code Name ofBu ing)(if applicable)
Assessors Map# Block.#aril/or Lot ,#
SECTION 2 PROPOSED WORK
Edition of MA State Code used q lK If New Construction check here er check,all thatapply in the two rows below
Existing Building U i Repair U 1 Alteration k ,I Addition 0 i Demolition 0 (Please fill out and submit Appendix 2)
Change of Use D Change of Occupancy 0 'Other D Specify:
Are building plans and/or constnuetiond.ocuirtents being supplied as part of this permit application? Yes ❑. No.pl-
Is an Independent Structural Engineering Peer Review required? Yes. 0 No.Q('
Brief Description of Proposed Work: 13,u1,D S9 r lb414. (TALL_ At_ r,00&, tia Club 4
T Sf'TioN OFF Ago% ni= SPALF P S-17. 2 AG.E
'SECTION 3:.COMPLETE THIS SECTION IF,EXISTING BUILDING UNDERGOING REItIOVATION,ADDtTtON,OR
CHANGE IN USE OR OCCUPANCY
Check here if Buildingaritidgfiztg lnvestigation and'Evaluation is enclosed(See 730 CIVIR 34) '❑
Exist2ingUseGraoup(s): h.,s1wjicc ProposedUseGroup(s):
.SECTION 4:BUILDING HEIGHT:AND:AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Yes Floor(sq.II) + / h
' I°,
' Total Area(sq`ft.))and Total Height(ft.) iiv ow jI o i boo .----
SE ON 5t LISE GROUR(Cheek as applicable),
A: Assembly A-1 Cl A-2 D .Nightclub 0 A-3 0 A-4 D A-5❑ B: Business , E: Educational ❑.
F: Factory F-li❑. F20:. ' H; Hip Hazard H-10: H-2 0 H-3, C )ri-4❑; H_5❑
I: Institutional T.T.O' I-2.ci r-3 Q I-4 0 M: Mercantile Q it Residential R-IQ R-2 0` R-3 D R-4 p`
S: Storage 5-1 0 5-2 U_Utility 0 (Special Use 0 and please describe below: 1
1 Special Use'Descriptiem:
SECTION G:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB 0 IIA 0 JIB 0 IIIA IIIB 0 IV ❑ VA 0 VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 3053 for details on each item)
Water Supply: Bend'Zone.Informal on: SewageDisposal:
ire i}Permit: Debris Removal:
?..'- L% C' e k (v"s sc ss 00A Zone TrdVA t m"' v 6id i� A trench will not be Licensed Disposal Site
1 �"r a` ( required'or trench f or specify:
Private 0 or indentify Zone: or on site system 0 permit is enclosed 0.
Railroad tight-of-way: 1 Hazards to Air Navigatfon. MA Historic CorrunissidReciew t oeessi ,
Not Applicable] Is Structure within airport appsoacdi area? Is their review completed?
or Consent to Build enclosed CI 0or Nok Yes D Nog N�i4,
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: '1 T1 Use Group(s):. Type of Construction: V
I Does the building contain an Sprinkler System?: _k__Special Stipulations:
1`Desigrealetrytant toad per'le r and Assembly space:gyp► I
SECTION 9: PROPERTY OWNER AUTHORIZATION i
Name and Address of Propel Owner
(\A►,a 1 o Sb ) t(1L Sl47r00-, P 4iuecr6/cO2_ '
Name(Print) No.and Street City/Town, Zip
Property Owner.Contact Information:
(.,Ntetz 2 cS -S47- 2513 - - M ttakE1.6 P-Q. �w ). c
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
M telt r /3 GL tMAL (.)cobs be. SDuTuyreiPX.A) M141 Oio'?
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 building permit application.
SECT4ON/0:CONSTRUCTION 100N7PROLfPleaseifill out Appendix 1)
Ifa building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here.
Otherwise provide construction control forms(see section-I07 in the code)as required.
10.1 Registered I'rotessional Re ponsible for Construction Control (the professional coordinating document submittals)
Name('-U-.,. t) Telephone No. e-mail address Registration NUMBer
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
LEA/ Ol Ahdl(, 6nIPAAlf:Campany/(t�iarn
xIZ S 4 rrUte C V,
Name of Person Resp nsible forConstruction License No. .and Type if Applicable
13 &WO ALE. wcS NZ ,S'pt l"Todtd /AA Pio/?
Street Address City/Town 'State Zip
`/iS-33(r ice" - �Tn�► 6 L6ui�Or.UA- 6.
Telephone No.(bu�s)� Telephone No. (cell) a address
SECTION IL.NORKFR °CON ENSA.TI N INSURANCE Ar"F1DM 1T(M.C,.L.c.152.g 2SC(fi)) Il
A Workers'Compensation Insurance Affidavit frmm 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 • seance of the building permit
Is a signed Affidiwi t submitted with this application?' Yes No D
SECTION Mt CONSTRUCTION COSSI SAND PERMIT F.
Itemi Estimated.Costs.(Labor l'
and Materials) I otai Construction Cost(from item 6)=$
-1.Building 1 S ` COO Building PermiPt Fee=Teta +--.:... - ;an Cost x (insert here
2.Electrical ' $ appropriate m ipal facto =$ .
3.Plunging $
4.Mechanical (HVAC) $ Nettie:Minimum I 6• =$__0 9 (CO .ct municipality)
5_Mechanical (Other) $ Eneiose check payable m
6.Total Cost $ 'ZS0Q (rnn+ar m t lirririnali++r)a mmw Sind write Cheek or hcre A a<0
SECTION 13:SIGNA'l`URE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains:and penalties,of perjury that ail of the information contained in this
application is true and accurate knowledge and understanding.
.
—pvi, Lelia'-j F((4i1fl elkrr '/3 -33ce- ZIdt' /ill•11
Please print and si84i name Title Teiephone•No. Date
• 13 GlAollme, Wooer be S_OlT7'i,WMrjav ffPs cull %i,►1&taaeyButhtA4..(,,,.t_
Street Address City/Town State 7ip Email hddress
Municipall,es t its ii a aut,thire•aectian u en a licatian oval. j/Z )•3•ZO 2 Z
P� P F'P' �P�'
Name Date
City of Northampton
Massachusetts,
DEPARTMEXT OF E@TILDING INSPECTIONS , E1
212 brain Street « Niarieipal Building
Northampton, IA 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
rilrrwlmrkr 4ironceri Aerncte rlicrrcnI fnriIitvr nc rImfinori by I\Ari r 111 C 1 C( A
The debris will be disposed of in: Va 7U_I)J+(^
Location of Facility: c i o hM P-ro,- / MA
The debris will be transported by: (fie 6utL0I1U (o
Name of Hauler: Lia
Signature of Applicant: Date: /Z • Zi .ti I
- ,
The Commonwealth of Massachusetts
,, ...,...,_
Department of Mdustrial Accidents
I Congress Street,Smite MO
Boston,MA.O2114-2017
reww.anass.gavidia
Workers!Compensation Insurance Affidas it:Builders(ontractorsfEleetrans/Phinibers.
TO BE FILED WITH THE PERNIITTINI;.11 THORITY.
ilitnaitIIMUWIIIikIiIifi Please Print Lenibh
Name(BusinessAOrpinizatoalludivialoal): tally 12 tA1451A)id, IAA,
Address: i 3 4(.6-)biki.6 lA),":'4C, 1)ft , —
City/State/Zip;SegopAr-iee t jvlik_otc,23:1._ ,,,,,, phone#: /i}, 356 •7,4(/ _ _ , ,
v I t I
Are yen as entritticerr i'Seek the appropriate hint
ICI I lam a craptroyer with_ ___ertaptloyees(fig niatko pert-unit 1,.• i Type of project(required):
7: 0 New construction
2,0 tont a sole moronity or parimaithaa sot Piave on atraployorm.working for on irs 1 K. 0 Ponnotieltiks
any 4:44114*[No worker*"coop.taornance narportit! ,
9. 0 Demolition
10 lama hoilstooTICr doing ati work myself['No woritos'cry*toranance..t.i..,d,r
I 00 Building additioni
4.0 I on 1 triernotnoter tunkt will he honor corarrasum.at conduct all worts intro property I volt
ensure that all contra:tom eithet ito ittarkers'compensation insurance or are wile '[ 110 Electrical repairs or additions
rn,r,respos u Kit nu eittrit.yee4
i I i 2 ; j Numbing repairs or additions
Sri I am a geramat contractor and I haw lured the subsrastracturs itgcti MI,rite atetskihNi vitect
Thew vuteftmeanoczats haw entstioyem lad barl.e okrorkort'sloop.susattatne., i 3.3Rcof repairs
MC&e
,, 14:p2Ilker 'Ort/wC koki.t.,
,s.I! k'ce are a..sagssansoa use ita offs:ass inveetoiscisod user TkOrg talc-atavism mr , .
fr a 54 t 3,04,.and-we mime tw tooloyets.!No itertierts'comp.insurainverniatamq i
i
*Any nmittotortbars Aocks ton WI roam atne fill otattier sercoto below nhowart their wartas'corns padre,treformormt
*flornitowners who taboret tho atinittitt aukteartaag they*SC doing silt wort and Ares hire outside oormactors mail sullasit a,new affidatr it norinwing mil.
:Cortionitars duo deal das ticotamot.attached ari attetittorial shoot showinitthenann ads:itthsarattactres.and Akar whether or viol those entitira haw
,-,-,0.,...,, PO*•,*1 , •••-•,-tra•rw ive.v• ti,,,. 01.-ia NAVA Pt•z•:AM.
, •,,,_,.„,.• ;',.....,,, . ,,,,, ' .- ; ,
I nett an employer Mot is providing workers.'crowfoot cation insurance for my entpkres. IfelOw is'the policy issuijob Silt'
infortimmitec,
lumuance Company Name: _
Policy a cc Self-ms.Lie.i;-.. Expiation Date:
Job Site Address. City;StateZip,_ ________ _
Attach a copy of the workers"compensation policy declaration page(.howing the polies number and expiration date).
Ertikire to secure came-rage as-acquired under IiiiGE c. J52,§25A is a erizainal violation portishalik by a Case tip to S1,500.00
areor cane-year taipaisonment.as well as chit penalties in The icon of a STOP'WORK iORDE.1 and a fine of up to S250.00 a
nay, against the vaailmor.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance
overage iettektannt.
I do hereby certify an er ep I and' perjury drotthe information provided alurre iv true and correct
Siermture: Come- /2,.•247. 2-1
Official use only. Do not write in this area.to he completed hy city or town officiat 1
City at Town: Permit/License h
Issuing Authority(circle one)
I.Board of Health 2.Building 1)epari!tient 3.I'ityrlown Clerk 4.Electrical Inspector 5,Plumbing,Inspector
6.Other
1 11
N Contort refti011:
11 Plank-t:
_ , A
I t
F rYRIV1 153 The Commonwealth of Massachusetts DIA Use Only
Department of Industrial Accidents
ti Office of Investigations.- Dept. 153
t Congress Street,Ste PUS,Boston,Massachusetts*2114-2047
a= littp://www.inass.govidia Invest/SW°FD#:
s
, d FIn A V1T 1W 1 YFMPTTfN F'fR CFPT A TN r'r P P(1A A Tv
OFFICERS OR DIRECTORS
xC i apter 169 oaf:the Acts c "2092:amended .iG. . .c, 152, §1(4) oy,addifrqgihefollowing parqgra
"This chapter shall be elective for an officer x r 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 accidentswith a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C."
Pursuant to M. L. c. 15.2. §ti4) a' amended, ia' e the artde,rsigied officers of:
Leary Building,,lac. 1039 East Mountain Road, Westfield, MA O.1085
Name of Corporation and Address)
each holding at least 25% ofthe issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of c. 152,.)25A and-therefore are not r ired to carry a
workers' compensation policy covering the undersigned corporate ofliicer(s) or director(s). 1/We 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.
Furtiner,i/we.the undersigned do understand that, should the above-named corporation hire 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
1'u1.G. c. 152, §25A.
I/We the undersigned have read and tirlderstan-i'the statements and obligations as delineated abave and
I/we have checked the appropriate box below tnytour name(s)indicating rityfour desire to be,ea pt.or
riot to be exempt from the provisions of M.G.L. c. 152. f--:
Signed der'the pains-and penalties of perjury:
_
/ .% Timothy A.beery,President e07115920 4
�Sign: / T Print Name&Tide Date((snun/dd/yyyy)
ly.l 1 w .h 10 exerN,:,''e my right/of exemption or C 1 wish NOT to exercise toy rig1ttit f exemptkon ;,
Suture _ Print Name&Title Dstte( Pd r✓21�tFN!/FfWlr
I wish to exercise my right of exemption or _ I with NOT to exercise my right of exemption
Signature Print Name&Title Dote(miri/dd/yyyy)
E` I wish to exercise my right of exemption or EiL wish NOT for exercise my right of axempon.
Signature Prim Name&Title Darte+(inm/ d/yyyy)
E] 1 wish to exercise my right of exemption or E 1 wish NOT to exercise my right of exemption
Nina:.:ALL')L'IGt3LE CORPORATE OFICERS MIST SIGN. TIIERE CAN.$E NO MOItE TITAN 4 SSE NA'FU1ES.
.on back form 153—7/2 40
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-}SOME t 1,4PPOVEMEN '
„- °° :=.77
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From:
� P
1M �EA2 J 1 CL�Cihf�n�7
toot
,--/
To:
Johnathan Flagg
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The IVIaJJal..l lure i.Building r..vuc,section iv?.i a'ifVV tor an exclusion from requirCM'erItS Fvi
construction control in certain situations;In accordance with code section 104.10,I request that you
grant a modification to waive the requirement for construction ccrntrotof the project at
Lis LADb. Ave IUUr'ibts�Ms'zan�
because the work is of a minor nature,will not affect structural elements, health,accessibility, life or fire
safety,and will be done in accordance with the prescriptive requrwemerrts of the code.
Thank ynrr for ynrrr rnnsiri'rat*ion.
Respectfully,