24C-195 (4) BP-2024-1333
78 NORTH ELM ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24C-195-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2024-1333 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
Est.Cost: 30000 LEARY BUILDING COMPANY CSL104806
Const.Class: Exp.Date:02/17/2026
Use Group: Owner: MURPHY DAVID A
Lot Size(sq.ft.)
Zoning: URB Applicant: LEARY BUILDING COMPANY
Applicant :Address Phone: insurance:
13 GLENDALE WOODS DR (413)336-261 1
SOUTHAMPTON, MA 01073
ISSUED ON: 10/10/2024
TO PERFORM THE FOLLOWING WORK:
ROOF REPLACEMENT
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 Drive«ay Final: 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: /62_
Fees Paid: $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
r/139---___.Q_C V&D
tZ., The Commonwealth of Massachusetts OCT 1 Q 4
Board of Building Regulations and Stanaiards 2 24 FOR
M ICIP LITY
Massachusetts State Building Code, 78 CMS
US
Building Permit Application To Construct, Repair, Renovate r e' sli'lso c ged r 2011
06o
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: et JO- c'-1'/ 433 Date Applied:
---SY-e7/6". -7--//‘iat) 81-c`-‘ /1711 -0--y
Building Official(Print Name) S. ture Date
SECTION 1:SITE INFORMATION
l.��perty Addre� Cr1.2 Assessors� Map& Parcel Numb
/LS etva / C
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
UV-Q, eos,bcNcC SG 1300 401
Zoning District Proposed Use Lot Area(sq It) Frontage(I1)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
bpx MurZrn i -T Akc r7zziv / it4! O(o v o
Name(Print) C•ty, tate,ZIP
k /J o>z,-M O t S - S
No.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s)% Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify:
Brief Description of Proposed Work': Poor Pe ac.Ep .i2WT
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ .p,DOD 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All F. $ }� l
Check No. I tt:1 Amounf' 1
6.Total Project Cost: $ 30/000 CI Paid in ' 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i C.S • logtO( 2•l/ •2�
License Number Expiration Date
Name of CS Holder
� List CSL Type(see below) (J
l3 G,, - p bS b2
No.and Street Type Description
c OtjT*4A/1 -f Tot- NIA. Dlo71
U Unrestricted(Buildings up to 35.000 cu.ft.)
It Restricted I&2 Family Dwelling
City Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
nn SF Solid Fuel Burning Appliances
y/6)33(�•Z(p// ' (' I ulLOING• Costa, I Insulation
Te one ttrail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t6 e'e' Zon...AING PG HICRergistration Number Expiration Date
HIC Compafhy Name or I-IIC Registrant Name
/3 1, n* 44J0o4:6 .OM .. Go,N,
No. d Street Etktail address
oo-r m PzoN , Mt4 010 3 f i33?3( •u,/
City/Town,State,ZIP Telephone
SECTION 6:WORKERS' 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
SECTION 7a:OWNER A HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 6U/l p/,VGt Co
to act on my behalf,in all matters relative to work authorized by di' building permit application.
1 1 t► V ' '. /0• • Z`/
Print Or er's Name(Electronic.ignature) I)ate
SECT ON 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my n. e below, I hereby attest under the pains and penalties of perjury that all of the information
contained in thi app at".n is • s. • urate to the best of my knowledge and understanding.
a
O. q.-1-1
Print Owner's r Autho es :ent's . e(Electronic Signature) / Date
If NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
` :x\
The Contntattivealdl of Massachusetts
- • - -( Department of Industrial Accidents
1_ i I Congress Street,Suite 100
— i�ls ill
Boston, MA 02114-2017
-g„,��f rt"ww ntass.gov/dia
11 ur kcr%' Coutpensation Insurance Affida%it: Buildersl('ontractors/Ekctricians l'lunrlrers.
-1'O BE HEED WITH THE:l'Itat]IITI-IM;AUTHORITY.
Applicant Information /� Please Print I.e."ibl%
Name(Busincssior nt,ttionflndividualY---- Dat•OlA Gt__
Address: !3 Ci)t.E.4(J041.‘ WooeS ®2
City/State/Zip:y�� AI,, pi , i 14 4tp13 Phone #: Et( 33L•• V..,I/ _
Are you an employer?('heck the appropriate boa:
Type of project(required):
La I am a employes with _employees(full anut or pan-lime'.* 7. 0 New construction
2.01 am a sole Iwuptielor or icrrtnc-rship and have no employees wurkang for ne in 8. cj Remodeling
any capacity.[Nu workers'comp.insurance requined.J
9. ❑ Demolition
10 I am a home rerun doing all work myself.(No workers'comp.insurance nquircd.["
4.0 I am a humuwr and will he hiring corfracurs to conduct all wink on my property. I will
10 CI Building addition
m n-
ensure that all corium-tom either'rave workers'cY top..rsation nrsuranee or are sole 11.O Electrical repairs or additions
pruprieturs w ith no employees
12.11 Plumbing repairs or additions
sO 1 am a general cunt:aeku and I have hired the subcontractors listed on the attached.heel- goof
These subcuntraeto,s have employees and have winters'comp.insurance.
13�� "cot'repairs
I
. Other
6. we are a corporation and its offkcrs have eat:wised their ngbt of esenrpli nt par al(.l.e.
52,$1(41,and we have no ernpluye.•es.[No wuri.,er.'comp.insurance reyuued.l
'Any applicant that darks how 1=1 must also till out the seellim below show ing then-winters'curnpensatiun policy arfornratiotr.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors mini suhurit a new affidavit indicating such.
1Contracturs that check this hoe muss attached an additional sheet shoring the name of the sups-covunacturs and state whether to not those enities have
employees- lithe sub-comraetars have emplos•ee..they must pruvidetheir winker'comp,pangs number
I am an employer that is providing workers'compensation insurance fur nt)•employees. Belun•is the police"and job site
information.
Insurance Company Name: —
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State./Zip:
Attack 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 tine up to S1.500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 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 turd lilt' -n am! ' of perjury that the inlirrmutiott provided above is true and correct.
Signature: ( Hate /0 - ci • 2`1
Phone:.: 6,.. 3ts, . 24,
Official use only. Du not write in tIris area,to 1w completed by city or lawn official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.('it 1 Town Clerk 4. Electrical Inspector S. Plumbing Instwetor
6.Other
Contact Person: Phone#:
City of Northampton
`S • •• Sj
Massachusetts tips :.. c'<<G
`;( t ' DEPARTMENT OF BUILDING INSPECTIONS•
212 Main Street • 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.
The debris will be disposed of in:
Location of Facility: al u,,,JId,
The debris will be transported by:
Name of Hauler: t n(Mout► !moo
Signature of Applicant: Date: /0 -Q• ��
FORM 153 The Commonwealth of Massachusetts DIA U se_Only__
Department of Industrial Accidents h
1--e, Office of Investigations- Dept. 153
= 1 Congress Street.Suite 100,Boston.Massachusetts 02114-2017
-4 http://www.mass.gov/dia Imest.,S\A 0 II)4:
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE '
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M.G.L. c. 152, 5§1(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 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 ivi.G i, c 152; §i(4)its amrntitai, i/Wr the undersigned nffiicers 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 outstanding 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). I/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.
Further, 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
M.G.L. c. 152, §25A.
I/We the undersigned have read and understand the statements and obligations as delineated above ana
I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be existnpt or
not to be exempt from the provisions of M.G.L. c. 152.
t--
Signed der th pains and penalties of perjury:
Z- ` (' Timothy A. Leary, President 07/15/2014 -,_,
•
Sign ure // Print Name&Title Date(mm/dd/yyyy)_
❑✓ I w h to exer Ie my righ o exemption or ❑ I wish NOT to exercise my right of exemption t,
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or 0 I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mm/dd/yyyy)
❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption
Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. Instructions
on back. Form 153-7/2010