29-183 (4) 10.5 BRIERWOOD DR BP-2016-1230
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 183 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate<gory: renovation BUILDING PERMIT
Permit# BP-2016-1230
Project# JS-2016-002115
Est. Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LEARY BUILDING COMPANY 104806
Lot Size(sq. ft.): 10367.28 Owner: JONES PETER A&ELEANOR B
Zoning: Applicant: LEARY 13UILDING COMPANY
AT. 105 BRIERWOOD DR
Applicant Address: Phone: Insurance:
1039 EAST MOUNTAIN RD (413)336-2611
WESTFIELDMA01085 ISSUED ON.4/21/2916 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR DAMAGED SIDING &WINDOW TRIM
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 4/21/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1230
APPLICANT/CONTACT PERSON LEARY BUILDING COMPANY
ADDRESS/PHONE 1039 EAST MOUNTAIN RD WESTFIELD01085 (413)336-2611
PROPERTY LOCATION 105 BRIERWOOD DR
MAP 29 PARCEL 183 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 40 —11'
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR DAMAGED SIDING&WINDOW TRIM
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 104806
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
—D&emolition Delay
Sign re of Building Official 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.
hDepartment use only
- City of Northampton Status of Permit: .
Building Department Curb Cut/Driveway Permit
APR �ol� 212 Main Street Sewer/SepticAVailability
t+ Room 100 Water/Well Availability
------- <=as Northampton, MA 01060 Two Sets cf Structural Plans
one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
"This section to be completed by office
1.1 Proll Address:
Map Lot Unit
1 ;Zone Overlay Dis$rict
Elm St.:District CB District.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) C rrent Mailing Address:
Telephone
Signature
2.2 Autbja6zed oent:
Nam (Pint) - Current Mailing Address:
1
Signare T6epl
SECTION 3-ESTIMATED STRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building L Seo (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+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date ued:
Signature: !� `
Building Commissioner/Inspector of Buildings Date
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 L::....,„<,.' R. .,. L ._,... «: R
Rear
Building Height
Bldg.Square Footage % .........
Open Space Footage _ _...,:,. % --
(Lot area minus bldg&paved
parking)
#of Parking Spaces -
Fill:
(volume&Location) w. <_ .._..:.: :. __ _< <..:' „
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES Q
IF YES, date issued:.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES Q
......... __...
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES NO
._...................................._..._..._.................._._..._.............................._._ .._............_._..._........__..__..._......._..._..__...
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
Kj
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aroplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Rooting ❑
Or Doors C]
Accessory Bldg. ❑ Demolition ❑ New Signs O] Decks Siding [O] Other[0]
Brief Description of Proposed
Work: Vepr"117- DAMP&' b S;J)m'"
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 11 a 11 nd 11 or addition to exisfing housing, complete the#ollowing:
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. Magscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes Na. 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
1, e��'� as Owner of the subject
property
hereby authorize
to act on my If, in all matters relative to 4vork authorized by this building permit application.
G
Signatur of Owne Date
� -� as Owner/Authorized
Agent hereby decFare 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 and penalties of perjury.
Ir-- EAR
Print Name
Signature f Owner/Agenf Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name or License Holder: M L 1 L({�
License Number
/,J AFI . AA Z- a'r_
Address Expiration Date
r
cj -�-�
Signatur Bleph e `
9:Registered Home Improvement Contractor: Not Applicable £
Company Na a Registration Number
!
, I
Address Expiration Date
Telephone S' Z i.
SECTION 10-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 Attache Yes... ... £ No...... £
11. Home Owner Exemptioni
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
i
The Ca mr4onweaallth of Maassaachusefts
u m Department of Lalrust�'iaal Accidents
1Q.
�.
Office of bivestigaatioas
4_ "='(
600 �Vashington Street
y, Boston, MA 02111
=?— www.maass.goy/dia
Workers' Compensation Insurance AfTdavit: Iiaildelrs/Contiraeton/]Eleetric�zus/.?flunmbe>rs
Applicant Information ?lease F Tint LegibRy
Name (Business/Organization/Individual): 6�� a'rciN� a<�,
Address: /��
�� SIA>r f�KyU,y�rk.�
City/State/Zip:lam` ,�CL4) MA Uo g Sf Phone#: 2 36 . 1 Q 0
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. E] Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y p tY• 9. ❑ Building addition
[No workers' comp. insurance compinsurances
required.] 5. We are a corporation and its 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. (No workers' I VOther 5LD/.)4 r1nA,2
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing tlheir workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and tlien hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaratiop page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGA,c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerd u p 'ns a d penalties ofperjury that the information provided above is true and correct.
a -
Sip,nature: Date: !
Phone#: ` !
Official 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/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
City of Northampton
Massachusetts
t IJ
; DEPARTM€NT OF 8 UZ- -VG IP7S.r FCTZCNS
212 Main Street • Municipal Building
Northampton, MA 01060 sryl v��ti
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill) sonotube holes (before pour) a rough building inspection
(before work is concealed) insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancv until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
I
City of Northampton 212 Main Street, Northampton, IMA 01060
Solid waste 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 properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: fl 6 Da.
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant1M fre
G 0./& '4-
Date Signature4f PFermi A icant
FORAI 153 The Commonwealth of Massachusetts DIA Use Only
Department o f Industrial Accidents
Office of Invesitigations - Dept. 153
I Congress Street,Suite 100 Boston,Massachusetts 02114201,7
http://w*w.mass.gov/dia Invest./SWO ID#•
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M.G.L c. 152, §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 Lo M_GJ,. c 152., §i(4) os an,ended, Ii'We clue undersigned ofEteers of_
Leary Building, Inc. 1039 East Mountain Road, Westfield, MA 01085
(Name ofCorporation 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 and
I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be eg npt.or
not to be exempt from the provisions of M.G.L. c. 152.
Signed u3ider the pains an4 penalties of perjury: m
r" Timothy A. Leary, president 07/15/2014
Signure ,//� Print Name&Title Date(mm/dd/yyyy)
❑✓ I wth to exerc5se my righ(o exemption or ❑ 1 wish NOT to exercise my right of exemption
t
� r
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&7itle 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. THEAL CAN BE NO MORE THAN 4 SIGNATURES. Instructions
an back. Form 153-7/2010