38D-059 Yassac.-1..,se.7:s -
C' ,R2g:-HatiCrS Zfld "S:anar-'s
Construction Supervisor
_.ce-3 e CS-055201
WALTER L MAREK ,
73 SOUTHAMPTON RD 1
WESTHAMPTON MA 01027
06/23/2014
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RACTOR
:
Type:
1;.,M2:.J=""k egistration: 159488 O&NBusiTness Regulation
• ftiemceEolfmcoRn Consumer AEfNfaTircs
- • 4/30/2014 Private Corporatic
W. MAREK INC
WALTER MAREK III
73 SOUTHAMPTON RD.
WESTHAMPTON, MA 01027 Undersecretary
GUARD Workers' C+�ptflsation and_lmatgyer's Liability Policy
4( NorGUARD Insurance Company A Stock Company
INSURANCE Policy Number WMWC:422910
GROUP Renewal of WMWC:318094
NCCI No.1:25844]
Policy Information Page
[1] Named Insured and Mailing Address Agency
W Marek, Inc FINCK & PERRAS INS AGENCY
73 Southampton Road 6 CAMPUS LANE
Westhampton, MA 01027 Easthampton, MA 01027
Agency Code: MAFINCIO
Federal Employer's ID 90-0129473 Insured is Corporation
Risk ID Number 000117462
[2] Policy Period
From February 10, 2013 to February 10, 2014, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100;,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
L___D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium � �____
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page) __________ _______ __J
(-2.1-4"4-"eV Cam` a
Total Estimated Policy Premium $ 5,718
Total Surcharges,/Assessments $ 225
Total Estimated Cost $ 5,943
INTERNAL USE xx Page - 1 - Information Page
MGA :WMWC42291O WC 000001A
Date :01/29/2013
M ANOTE
16 South River Street•P.O. Box A-H•Wilkes-Barre, PA 18703-0020• www.guard.com
, Department of Industrial Accidents
;I:......,—
%. L Office of Investigations
?,Ifl� 600 Washington Street
Boston, MA 02111
w www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizationilndividual): 17 eWJI 1( c,
Address:.73 t •uY> R R . �w S
City/State/Zip: i/�( Phone.#: 141/ 6172 _973s_____________
Are you an employer? Check the appropriate box: Type of project(required): l
1.01 I am a employer with_ 4. [] I am a general contractor and I o
4 * have hired the sub-contractors 6 ��New construction
employees(full and or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
slap and have no employees These sub-contractors have
8. % Demolition
working or me in any capacity. employees and have workers'
g Y 9. I�Building addition
[No workers' comp.insurance comp.insurance.t
required.] 5. ❑ We are a corporation and its 10.��Electrical repairs or additions
k officers have exercised their
3.❑ I am a homeowner doing all work 11.��Plumbing repairs or additions
myself. [No workers' coxrip. right Of exemption per MGL I2 ��Roof repairs
insurance required.]' C. 152, §I(4),and we have no
employees. [No workers' 13,❑ Other
comp. insurance required.]
'Any applic,ent that checks box#1 most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating tFey are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
emp;cyees. ..f the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing war.ers'compensation insurance for my employees. Below is the policy and job site
irtformatutn. 'j'
Insurance company Name: -!
( t(' NS 61710 ____ _
M , J 1,
Policy#or Self-ins. Lie.#: ��"11� J!�`d.�, Expiration Date: a 0
Job Site Address: Lfl _ G� � � City/State/Zip, y (1414,._ 1�,
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the isnpo:,ition of criminal penalties of a
fine up to 9.1,500.00 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. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification. _
1 do hereby certify under the pains and penrrft` ofperjury that the information providers)oho e is true and correct.
Signature� i7
� ... Date:a/ 0-
r--0—fficial use only. Do not write in this area, to be completed by city or town official.
ity or Town: Permit/License#ssuing Authority(circle one):
.Boarc'. of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
.Other
ontact Person: Phone#:
R .y
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:WrrJL Not Applicable ❑
Name of License Holder: (J� & ,.. 72. CS . 0 CS,'\
Lice se N ber
Address ��� 5b Expiratio Date
Signature Telephone
9 Aiiiit to ed Home lnfacWiment: ontraE or„tea t -' liZ :ZZ:i Not Applicable .❑
Company Name a ,+ Regist atio Number
cj- ?.3 (X1}N{#1?,ft).\ a ,,,.),,,,,,,,„7-t„Address Expi atio a e
Telephone (13 C)) qs 7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) I
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 ❑
"■, oill Own r xe n a W i 11
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be ,
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
f.. N
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House j Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [p Siding[D] Other[61j
Brief Description of Proposed ,c.—' } }�" L
Work: f,Vk1V� e 65-1 ' (j-- t ^ V`� I tr- / F1 r -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba`I New ousean°d orra.cad:rtior> #oZiislin iiousmq comple ewe of WInq:
a. Use of building:One Family Two Family Other
b. 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 Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.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. Septic Tank City Sewer Private well City water Supply
SECTION 7a=OWNER AUTHORIZATION,-TO BE.COMPLETED WHEN
OWNERS AGENT OR`CONTRACTORAPPLIES FOR BUILDING PERMIT
I, CctiZA k�- LU C0 ,as Owner of the subject
property :o•- pp
� .1,,: 1 W , M e,IL
hereby authorize �V(Tv
to act on my behal,in all matters re a' e to work authorized by this building permit application.
Signature of ner Date q3C))/I 3
I, �l Y w ✓�c 1 `'
l. ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains an penalti of perjury.
Print Name ��1§,ft-i
Signature of Owner/Agen Date
I,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size : == __.
Frontage
Setbacks Front
Side LM R: L:' R:
Rear '
Building Height
Bldg. Square Footage
Open Space Footage , % 9
(Lot area minus bldg&paved ? i i I ' i
parking)
#of Parking Spaces ,
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW e YES 0
IF YES, date issued:?
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW ,`t4p,4, YES l
IF YES: enter Book Page! and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 40 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO tai$
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
E
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO E
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
y� 4
e a P e�seo `
'al yF:"� `x 'S ' % .4"-+`T{„a„*
City of Northampton to ® Fe p ,
1 _ ,, -- - '
Building Department �s g r r, - ° o� y :� � _ :
t 212 Main Street
® s a "^
w J a
�� �6Zd�3 ��.i Room 100
orthampton, MA 01060
r - 3-587-1240 Fax 413-587-1272 g a � f � � - �s'`
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Tftis sectton-tube=completed byoffice
`� hel�i1l fi 4"e Rap t Unit
�/y� �. Zane Overlay first,,, - -,..,,,..,.'=-,1:3-- --,,;,: ::!” .:,,,MI+ �� l �E�m >c District , cn.stct
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: pp
CC '._ -�c�u�r(S�Of� Lk)CaS 21
W��Sovt �/� �W /� •
Name(Print) C urrent Mailing Address: 4-cctl\...0
Telephone ay uD I q 7O • ,as
Signature ) 1
2.2 Authorized Agent: X 'L, � f^ ���V'
Lock._ /YveA( Cur rent Mailin Address: 1`) �{0
Name(Print) 1
L l X53 '
Signature Telephone
SECTION 3-ESTIMATED.CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building C 0� (a)Building Permit Fee
2. Electrical ��jp (b)Estimated.Total Cost of
Construction from(6)
3. Plumbing s• -°
Building Permit Fee
1
4. Mechanical(HVAC)
5.Fire Protection a 915‘6----
6. Total=(1 +2+3+4+5) S"0G� Check Number �J 1 _
This For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0228
APPLICANT/CONTACT PERSON WALTER MAREK III
ADDRESS/PHONE 73 SOUTHAMPTON RD WESTHAMPTON (413)527-7667 Q
PROPERTY LOCATION 47 REVELL AVE
MAP 38D PARCEL 059 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out P9,1
-`
Fee Paid
Typeof Construction: RENOVATE 1ST FLR 1/2 BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055201
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION PRESENTED:
!/Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission - Permit DPW Storm Water Management
�- oli �el y
Signature of Building Of icial Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
47 REVELL AVE BP-2014-0228
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D-059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0228
Project# JS-2014-000376
Est.Cost: $5000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WALTER MAREK III 055201
Lot Size(sq. ft.): 7318.08 Owner: LUCAS CHRIS
Zoning:URB(100)/ Applicant: WALTER MAREK Ill
AT: 47 REVELL AVE
Applicant Address: Phone: Insurance:
73 SOUTHAMPTON RD (413) 527-7667 () Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:8/29/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE 1ST FLR 1/2 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.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/29/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner