32C-303 (2) 11 VALLEY ST BP-2017-0779
GIS ft: COMMONWEALTH OF MASSACHUSETTS
auk:32C-303 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-2017-0779
Project# JS-2017-001291
Est.Cost:$8000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: LEARY BUILDING COMPANY 181065
Lot Size(su. ft.): 6098.40 Owner: BRENNAN EUGENE E GLORIA J
Zoning: URC(I00)/ Applicant: LEARY BUILDING COMPANY
AT: 11 VALLEY ST
Applicant Address: Phone: Insurance:
1039 EAST MOUNTAIN RD (413)336-2611
WESTFIELDMA01085 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: CONVERT TO 2 FAMILY
PROPERTY....PROVISIONAL APPROVAL....Needs electrical, plumbing reports and pre-building
inspection
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:
FeeTvpe: Date Paid: Amount:
Building 12/15/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0779
APPLICANT/CONTACT PERSON LEARY BUILDING COMPANY
ADDRESS/PHONE 1039 EAST MOUNTAIN RD WESTFIELD (413)336-2611
PROPERTY LOCATION 11 VALLEY ST
MAP 32C PARCEL 303 001 ZONE URC(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee •:id
Build 1 Permit Fill, out Mar
Fee Paid NaraIMP—
TyppofConstruction: CONVERT TO 2 FAMILY PROPERTY Fe4— F RAAAl ipJS re`-'110
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owned Statement or License 181065
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON 0 -
INFORMATION PRESENTED: C , (' I
Approved Additional permits required(see below) (FR' CO N0131°' t(G'� fy {""
PLANNING BOARD PERMIT REQUIRED UNDER:§ F{,6 6 V d T"
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan rt:
K-'
ZONING BOARD PERMIT REQUIRED UNDER: § J
Finding Special Permit - Variance* K---
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
Demolition Delay JJ
ZIIJI(‘-
Signature of Building Official Date l
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.
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Pen-nit
-- 212 Main Street Sewer/Septic Availability
L._r_ Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
E 12 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
DEPT c=r JWIICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
cnz to
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
�^�+_'QUAt CST Map Lot Unit
`^
I ` a`O" Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_CC-C to £NNAN /5- UA(,-el CrA-)o lt;r+AM°'To.J
Name(Print) Curren al ng Address.
1( ZyN NS24
Tee
Signature
2.2 Authorized Agent:
/OP E. Mor,-uz40. Qe AtSiErEal MA o1031 _
Name P / Cum`Mailing Address:
Atif: v.V Ni 336 'ZOO
Sig .tura
SECTION 3-ESTIMATED II.NSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. BuildingCOO�a (a)Building Permit Fee
2. Electrical e6 (b)Estimated Total Cost of
�/4/cc) Construction from(6)
3. Plumbing -0 s/ 2. Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection ,,,,¢¢ �� ///
6. Total=(1 +2+ 3+4+ 5) .y,�g--- is law Check Number /3 y %for
r This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Budding Commissioner/Inspector of Buildings
Date
ANTE 3 ND Pc,UnngrNE Cie £LEcrR-Icgc, PERAA.a5 saucC 1999
ct-teor Patmktt-g Fat 2- PAvN.I
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in In
auiidine Department
Lot Size
Frontage
Setbacks Front
Side L: R_ L R:
Rear
Building Height
Bldg Square Footage o
Open Space Footage
dot arca minus bldg&paved
parking]
#of Parking Spaces
Fill:
{volume&Incanonl
A. Has a pedal Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO AO DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained o , Date Issued:
C. Do any signs exist on the property? YES O ND
IF YES, describe size, type and location: y-
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO Q/S
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 O NO/(y)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors 0
Accessory Bldg. 0 Demolition ❑ New Signs [p] Decks [0 Siding[I7] Other (
Brief Description of Proposed V�
Work: C '✓ee.-V To 2- cAn-tw e20F69-1-1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _ Yes No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing, complete the following:
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
a 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 ]a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 4The-o1(R 6.26-.A/c), _as Owner of the subject
property
hereby authorize / LtAta
y
to act on ,�af, in all mat,_s relative to�4ork authorized by this building permit application.
/ . (74. 14 /2 • g. 1,
Signal Owner .-n Date
I, ///YIO fry,17/ �'/ z , as Owner/Authorized
Agent hereby declare thyt the s .tement- and information on the foregoing application are true and accurate.to the best of my knowledge
and belief. 1
Signed under the pains and penalties of perjury.
--------
/JOixit .
Print Name _11 S -
Siena a .... /Z- SS .Ila _
Signa of owner/Aget W V Date
ri
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable C
Name of License Holder .<w LOCI t > ' 111 t recce
License Number
icy q C. M- ,.T..,., 0 Part A o« -C 2 ii • /1
Addre Expiration pale
gnature T Tel hone
9.Registered Home Improvement Contractor Not Applicable0
onobso /
Company Na e Registration Number
/O3? em," ('Vla,.x;.«., Qe eieStp n (Art gloss 2- 20
Address Expiration Dale
Telephone /
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MA.L.c. 152,§25C(8))
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� diipermit.
Signed Affidavit Attached Yes tFY No . ❑
11. - Home Owner Exemption
The current exemption for"homeowners was extended to include Owner-occupied Dwellings of one(I I or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license.protit;ted that the owner acts
as supervisor.CMR 780, Sixth Edition Section l081S-1_
Definition of Homeowner:Person is 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 stmcmres a.ccesson to such use and or f'ann
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 Oficial that heishe shall be
responsible for all such work performed under the buitdiee permit
As acting Construction Supervisor your presence on the job site will he required from time to time.during and upon
completion of the work for which this permit is issued.
.Also he 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 persons)
you hire to perfi'um work for you under this permit_
The undersigned"homeowner"certifies and assumes responsbili v for compliance with the State Building Code City of
Northampton Ordinances.State and Local honing Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _ _
City of Northampton 212 Main Street, Northampton. MA 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 150k
Address of the work: 1/ VA al S7
The debris will be transported by: fritey &aa4
The debris will be received by: Ott gety -z&
Building permit number: /
Name of Permit Applicant 46,4 al
Date Signature o Permit Ap.o nt
The Commonwealth of Massachusetts
=-- Department of Industrial Accidents
,=ar�
Office of Investigations
1 Congress Street, Suite 100
• '' Boston, MA 02 114-2 01 7
i.
�.. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business.Organization Individual): Ly e 6uwb mit C.
Address: /6'35 6 g< NJoo, y, /
City/State/Zip: 73, Ec.p • MA eye,gd--- Phone #: 33(o'1-69t/
Are you an employer? Check the appropriate box: --C",..., Type of project (required):
I.❑ I am a employer with 4_ ❑ [am a general contractor and I .
employees (full andtor part-time)_'
have hired the subcontractor 6. [I]New construction
listed on the attached sheet. 7. ❑ Remodeling
2.n I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity employees and have worker' 9. ❑ Building addition
[No worker' comp. insurance comp. insurance.-
required.] 5.. We are a corporation and its I 0.0 Electrical repair or additions
officers have exercised their I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself [No worker' cora right of exemption per MGL
1 p. 12.❑ Roof repairs
Insurance required.]r c. 152. *1(4),and we have no
employees. [No workers' 13.Ne, Other ✓ECstaN
comp. insurance required]
`Any applicant hat checks box=I must also fill out the section below showing their workers compensation policy Information_
'I loincowners who submit this affidavit ndicating they are doing all cork and then hire outside contractors mum submit a new a flldavit indicating such.
teontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities has
employees. If the sub-contractors hat e employees.they must pros We their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below iv the polity and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. Expiration Date:
Job Site Address: City'State./ip:
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 of MGT c. 152 can lead to the imposition of criminal penalties ofa
fine up to 51,500.00 andior one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 cerefr un ai s and perjury that the information provided above is true and correct.
Signature: Date: rZ• ?IQ
Phone r,: / 7 • Z&/(
Official • '• only. Do not write in this area,to be completed by city nr town official
City or Town: Permit/License#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
a a.. V.,aa *Ail/AR V haat.}} .,aJ.,_ee.,o....a.xa1,3
Department of Industrial Accidents
d _ Office of Investigations - Dept. 153 •
I Congress Street,Suite 100,Boston,Massachusetts 02174-2017
_1_
-
http://www.mnas.govJdia lovesf./SwOID#:
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 toTvlx i3,.c. 152, §1(4) as amended;i/We the undersigned officers 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 theabove-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
1/we have checked the appropriate box below my/our name(s) indicating my/our desire to be eXettipt.or
not to be exempt from the provisions of M.G.L. c. 152.
Signed der the painsandpenalties of perjury: — -
iz< e
Timothy A. Leary, President .07/15/2014
Signature j' Pnnt Marne Sande Date(mmiddryyyy)—
Q 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 0 I wish NOT to exercise my right of exemption
Signature Print Nan,&Title Date(mmlddiyyyy)
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)
Q 1 wish to exercise my right of exemption or CD 1 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 153-72010