29-371 (7) 15 AUSTIN CIR BP-2019-0054
GIs#- COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-371 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeorv'ROOF BUILDING PERMIT
Permit# BP-2019-0054
Proiect# JS-2019-000083
Est.Cost:
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WALTER MAREK III 055201
Lot size(sq. ft.): 11020.68 Owner: HOOVER GAIL E TRUSTEE
Zoning: Annlicant. WALTER MAREK III
AT. 15 AUSTIN CIR
AnnlicantAddress: Phone: Insurance:
73 SOUTHAMPTON RD (413) 527-7667 O Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:7/1112018 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & REROOF HOUSE WITH ASPHALT
SHINGLES, 12 SQUARES
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:
FeeTvoe: Date Paid: Amount:
Building 7/11/20180:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax: (413)5874272
Louis Hasbrouck—Building Commissioner
(� C VE Nn Lkq
Departmentrue only
City Of mpton of Permit:
Building m4UL I1 2M ugpmemy pcogb
212 M In S reet Sew Avagability
!( RO r PJ u!ng x srs a spool ale lWell Availebll
Northampt n, ffdd �"on VA`""60 of Structural Plans
phone 413-587-124 Fax 413-587-1272 Plot/Site Plana
Odrer Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 PropertyAddress: I secdon to be completed by office
Map Lot ��l Unit
i
Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �'q
6 ' l t ��o J U2(l I S �-tJS i/N C L6tC C -FL
Name PrintCurrent Mailing Adtlress: f q
Telephone Trr
Signature
2.2 Autho Ized AgePT�
W IN,.t J1 W`OCUTP(Ai
Name(Pon Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leled b DEnnit a licanl
1. Building �/ O (a)Building Permit Fee
2. Electrical O (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Farrah Fee V
4. Mechanical(HVAC) ` D (
O
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signatur .
Building Commisn /lnsprwtord6uikirgs pato
wryia/-etc 3 @ alp\Cay"(L,/ b
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 fiIIM in by
Building Depmhncnt
Lot Size
Frontage
Setbacks Front
Side LN R L R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lav mea minus bldg&paved
miin
ofParking Spaces
Fill:
volume&I.ocanan
A. Has a Special Permit/Variance/Finding ever issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded a[the Regi try of D ds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of w ter or wetlands? 00 DONT KNOW O YES O
IF YES, has a permit been or need t obtained from the nservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and cation:
D. Are there any proposed Chang to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and tocation:
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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [DI Deck�sy[p Siding[p] Other[m
Brief Work:Description of Proposed SIR�fb ,✓(, V (�
Alteration of existing bedroom V Yes-No Adding neww`bbeedroom Yes ✓� N
Attached Narrative Renovating unfinished basement Yes _ No
Plans Attached Roll -Sheet
So.If New house and or addition to exisfina housing, complete the following:
a. Use of building :One Family _ Two Famiy 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 fl.of"lands? Yes _No. Is construc0on 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 CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property 1 om — /�/j
hereby authorize 'W n `A_ `/ /rVL_�7_
to acAct 9y"�my behalf/in'h7-all matters relative to work authorized by this building permitpapplic ion.
/r1a7 x-rc
Signawre of Owner Data
" `l 1/ Alfde as Owner/Authorized
Agent hereby declare that the statemen and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed undo the pains penalties of perjury.
Print Na�
Sig Nre of Owner/Agent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construqtlon /
Sue Issor: Not
n NoApplicable El
Name of License Holtler: `t Vy� c`, --0s les"l
S Licens¢N um
W1 ^ � 6/ s
AddressExpiration ate
u q�Z 1�
sigriature Telephone
R fists a m ve n Not Applicable ❑
( A) MOQA-1 �
Comoa� ame I Regis ratio Number
7ss p� u
Address ExpiratiorliDate
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 permit.
Signed Affidavit Attached Yes.... No...... ❑
City of Northampton
-+ Massachusetts
\ �I IB:PARmO4NT OF BUILDING INSPriCTIONS �
212 Main St .t • Municipal S"1,Un9
N..tb mptnn, Mx 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modemixation, conversion,
improvement, removal, demolition,or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by reeistered contractors.
Note:/f the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: \\W`�1Q, { / Est.Cost9 �O v
Address of Work: 11Mq �7\� �f
Date of Permit Application / 16 I b
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereb apply for a building permit as""t the agent of the owner:
7�0�� (�✓� lylk4�,r�1X�- �S��I�
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Q
MassachusettsoBPARTIffiiT of Duzw Xo ZNSRXC r Ns212 Main stra t •Noaicip l auiltl q
Horth, ton, NA 01060 r✓h:":yi1P
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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 propedy licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
IS Cir .
(Please print house number and street name)
Is to be disposed of at:
UwlIel l�Y
(Please Orint name and locatio f facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address) T
V
Signature of Permit Applicant or Ownar ate
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
A�DI CERTIFICATE OF LIABILITY INSURANCE Dan aD1e ""'
THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER TME COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREX(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: lithe arU11p1e habitats an ADDITIONAL INSURED,the pot mutt be wx%roW. IfOugROGATIONEWAMMmbiWto
taterves red coadRlonsofthspolicy,crtain policies may reglnrean wlDorsenwlD.Asb wmdmUftowdRDabdotanotconferdghtstothe
alllflatoholdrb 0mcemlm •.
PRODUCER MIOT
K.S.K.INSURANCE AGENCY,INC. 413 5274859 P 413 527-8314
203 Northampton St. L UsYlasiasOksk-Insurance.am
P.O.Bax 597
Easthampton MA 01027 causes A PHENIX MUTUAL INS CO
wanusta ASSOCIATED EMPLOYERS INSURANCE CO
W.Marek Incorporated
73 Southampton Rd
Westhampton MA 01027
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFYTHATTHE POLICIESOF INSURANCE USTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NIMEDABOVE FORTHE POLICY PERIOD
INDICATED. NOTWRHSTANDINGANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACTOROTHER DOCUMENTWRH RESPECTTOWHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS.
INN WPEWIAURaNCFWININNW W IAWB
X COYMmCW.aEIEALLLWBBAY 61000,000
cwLnunoE ®oLUIR 50,000
CPP0719447 11/012017 11/012018 eeawomoai sSAOD
S1.000.000
rcLPaauUruPER' 2,000,000
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1.000.000
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AmMU UMBILTY COMBW® LMR f
ANY AUID BODILYNMtY1PWP�4 f
ALLOYrrEO 9CHEDUIID aOpGY MMRY(PWWtlfNq f
AUTOS AUTOS
HIREOAUT06 NO".c"NED NiaPER1Y DNIMBE f
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WORREIBCa1iMBA11pR x PER p1R.
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B cEDPRiur.� RexcMLlNiweroiEC�Ne Y NIA WCC•50"014280-2015A 0&102018 02/102019 100000
ry.nmwym RlD - 100.000
500.000
DEBCRI"ON OF DPEI4nONBrLOCIRIDRBr YENC1ES(IMOND 1011AWftlmel lbOb WIWR.�rM WwAmrmnegNONry,fiMJ
GENERAL CONTRACTOR
f
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY DF THE ABOVE DEBaN POMCIes BE CARCHLFD BEFONE
TINEExPalAlgN aTE 11931EOF, NOTICE Wal BE DFLVERED IN
ACCORDANCEWIIHT1a:PIX1CYPROV900 6.
AurIB]R®RrRemfrlRne ".) <uA,
07988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014MI) The ACORD mane and"D are M91Sire6 marKS of ACORD
The Commonwealth ofMrssachuseds
Depariment oflndusuraiAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www%ntass gov/dia
Winters'Compessalloa Learuce Affidavit:Bmlders/CoetnctorW kctiielaos/Plambem
TO BE FILED WITH THE PERaHTTTNO AUTHORITY.
Applicant Information Please Print Leoribly
Narne uwsibradOrgmioasov/lndividoal):
Address: 3 tZlnr'},�tia�,t 'J \
City/3tate/Zip: 'r' /•4T O�, Phone#: _I I� �'1/ �
MYoa m empk)xYCheet the aPN^Pfi+k box: Type ofprojeet(requlredx
ldz)amaw,l,wv --EL_wpioyew(Mieedlorpvtama).• 7. Now eona(mcfion
3.❑imawk prapieararpvtomhip aodhawmempioyaeawd®a fbracm 8. Remodeling
se,, cty.IN.
3.❑rwabomeowas daiogal watmyuK[K.want®'wrap.be.ropmW.l t 10
❑Demolition
4.❑IsmahomwwavdwaibebuiogmWecbntocaob tdlw mmy PmPwty. iwia O❑Bulld]ng addition
cosmetlmt ail caobacewadtler hayewwkas'wvpanamm masaaa wwasok 11.❑Electrical repairs or additions
pmpfiaoa win vo e�kyear.
12.C]Phunbing repairs or additions
50 l we a geaaai caabeckrmd t bevy hied the mbuavbacka lite w the w deet 13.❑Roof
Thee mbcmtrertorshswemployas edhav<wadma'w�.asmavvt mperra
a.❑We are a co oration and in offima have amcad Mdr fight acxa tan WM6 c. 14.❑Other
15;§i(4),a adore bnem empkq [No wmtaa'c memese,rtpirut]
•Aoy.ppgemtam eheclabmflrased aboflaamasmp MJ 4owkgW whm'eampms impotkymfoamban
t Hoamwoeawho submit Win effNavit'odimkg theyem domgali wort mi Wen hire ouaWe woheam miw wmmt a new atHdsvit indicedng such.
j(;OYbw;tga the Chet arta 60I m61 ®addlhnaal shCt her daa®Cnfdle orb-COaa9ebfa and now whAbC m ad th0%®bb.baVe
employees Rhe sobamhacrm hrveempbyg tl1ey0W pmvde War wodma'coup.tvlry a®bw.
lose me eseployer ddirprowding workers'campeneoaon msarwarformy esepmyses. Below 6 fhepohey andjob site
mfonadmn. I Co
InsuranceCompany Name: l�
Policy#or Self-ins Lia Expirdtins Date:
p
Job Site Addrxss: 11;
Attach 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 fine rap to$1,500.00
and/or one-year imprisonment,as well as civil pere tties in the form ofa STOP WORK:ORDER and a fou:of up to$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Office ofhrvestigatiom of the DIA for insurance
coverage verification.
Ido htxty certify unda'rAa ofp Bury door due infosaredon pyaaldt��/a6(ps�e to now and corn
Siaaatlae: !/1 7 Dater/%//X
Pho
o,Jjleidare only. moor write In foie afv%mteroapdet'edty coy or naw offavai
Ctty or Town: PermieLicesee#
Issuing Authority(circle one):
L Board of Heehh 2.Building Department 3.CRyfTewn Clerk C Electrical Impactor 5.Plumbing Inspector
for Other
Conduct Person: Phone#:
7/412018 Office of Consumer AOairs 8 Buslrress Regulation-Mass.Gov
za
HIC Registration Complaints
Registration 159488
# Commonwealth of Massachusetts
Registrant W.MAREK INC. ';®, Division of Professional Licensure
Name WALTER MAREK 111 Board of Building Regulations and Standards
Constrychbri` 0pervisor
Address 73 SOUTHAMPTON RD.
City,State WESTHAMPTON,MA 01027 CS-055201 U fatpires:06/23/20:
Zip - A
Expiration 041292020 WALTERLMMON,IIf',^}
Date 73 WALTER
L MAREK,
RQAFK,'
WESTRAMPT6MMA 0101Y
Or" I1��y
Complaints Details
No complaints found for this registrant. a-,
Commissioner ci,
You can also v ew arbitration and Guaranty Funtl history.
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