31B-181 (5) 40 TRUMBULL RD BP-2019-1360
cls#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31B- I81 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: BASEMENT RENOVATION BUILDING PERMIT
Permit# BP-2019-1360
Project# JS-2019-002190
Est.Cost: $35000.00
Fee:$227.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: LEARY BUILDING COMPANY 104806
Lot siu(sa.R.): 11891.88 Owner: PRUETT KYLE D&MARSHA
Zoning: URC(100 Applicant: LEARY BUILDING COMPANY
AT. 40 TRUMBULL RD
Applicant Address: Phone: Insurance:
13 GLENDALE WOODS (413) 336-2611
SOUTHAMPTONMA01073 ISSUED ON.61312019 0:00:00
TO PERFORM THE FOLLOWING WORK.CONVERT BASEMENT TO IN LAW APARTMENT
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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 6/3/20190:(0:00 $227.00
212 Main Street,Phone(413)587-1240.Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
File k BP-2019-1360 IL
APPLICANT/CONTACT PERSON LEARY BUILDING COMPANY
ADDRESS/PHONE 13 GLENDALE WOODS SOUTHAMPTON (413)336-2611
PROPERTY LOCATION 40 TRUMBULL RD
MAP31BPARCELl8I 001 ZONE URC(100V �11
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLO D REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TypgofConstruction: CONVERT BASEMENT T04WEAW APARTMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 104806
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
5-31•Zp�9
SignRufre 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.
r 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 CuBDnvaway Permit
212 Main Street Sewer/Septic Availability__
ti
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
";0phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
APPLICATION TO CONSTRUCT,ALTER,R1 PAI SM A ONE OR TWO FAMILY DWELLING
SECTION 1—SITE INFORMATION MAY 29 2019
1.1 Property Address: ns
Set lion to be completed by office
1-�pT¢Den.guLL 1'�� trFPT OP ell*yjyf�j'INSPECTIONS Lot VTh
NOPTH0.IM'reN�/.ABiLG
NoQ4NA p.PToN Zone Overlay District
EWA tit Dbbkt Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDRGENT
ZI-OW nar of Racord:
V-JtE +I MARSafN �¢ N a Li- 4b
N tP tri) _ CuMm"wil g Address:
Telephone
Sig re
2.2 Authorized Aoerrt:
/ LCALV Co lS (MI5 bt ,ScUTNAsrPrel.l MA 0(b34
Name Pro Current Mailing Address:
Mlil SSL 2611
Sign re rel on
SECTION 3-ESTIMA E C TI N COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit aplificant
1. Building no 00c) (a)Building Permit Fee
2. Electrical Cw (b) Construction
from(Total 6)
3,
3, Plumbing 10 000 Building Permit Fee
4. Mechanical(HVAC) ��7• ��
S.Fire Protection
6. Total=(1 +213+4+5) 35 FOCI Check Number
This Sectim For Official Use Only
Building Permit Nu r: Date
Issued:42
5C
Signature: -3 J-20)q
Building Commissioner/inspector.M Buildings Date
+-% @teary bu;ldtns .Car1ti
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Secticii ZONING hSl lnfrnrmtien Musa ea CmmpbMtl.Permit Can Be Denied Due TO incomplete lnformat"
Existing Proposed Required by Zoning
This.]...In be filled in in
Building Depmtmmt
LotSize
Frontage
Setbacks Front
Sig L: k: _._ I.: __. R
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(W urge minus kldg:&paved
#of Parking Spaces
Fill:
.dome&Fncaiw
A. Hasa clal Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 4 YES Q
1F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter -Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO X� DONT KNOW O 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? YES0 NO
IF YES, describe sire, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO ,�Jf
IF YES, describe size, type and location: NC
E. Will the construction activity disturb(clearing,grading, xcavation,or filling)over 1 acre or is it pan of a common plan
that will disturb ower 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSEDWORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterabon(s) Roofing ID
Dr Doors 1:3Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Iq Sidingl[3] Other IEZ
Brief Deschof Proposed
Work: �cy,watt-r � 1, m Fiai]fdBWT -0 /N /aw APA07Men T
Alteration of a�togi bedroom_Yes No Adding new bedroom Yes Na
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
lis.If New house and or addition to existina housing, complete the followina:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit[ Numbercf Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensi
e. ekanber of stories?
L Method of heating? Fireplaces or Woodsloves Number of each
g. Energy Conservation Compliance: Mawcheck Energy Compliance form attached?
In Type of construction
I. Is construction within 100 fl.of wetlands?_Yes _No.. Is construction within 100 yr. floodplain_Yes_No
I. Depth of basement or cellar Floor below finished grade
k. Will building conform tolhe-Building and Zoning regulabons? Yes No.
I. SepticTank CitySewer_ Private well City water Supply
SECTION Ira-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,roPar � wn
�HC Purv`fr as Omer of the subject
D
hereby authorize /�wTQY
to act onmy behalf, in all'matteI'S reto Pork authorized by this building permit application.
Sign> 141
.ffOwner Date
I, ! .F2d ,as Owner/Authorized
Agent hereby declare that lh 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.
Print Name
Signat of 0"mAgenDara
SECAOMA-CONSTRYCT7ODIN66 WCEB
8.1 Licensed Construction Supervisor- Not Applicable 11
Name of License Holder'. //y 6S - 10-1 0(0
IS
/ ��,f�� II `� rr�� License Number
IS .24GY.MLF woos t)p_ LJo TL4hDTUY Mk afo�1 7
-Add. y sxWAWaah
yr3 536 zrou
Sig alure u
9. Registered Holme Improvement Contractor: Not Applicable ❑
LER¢tiI 1 Yl1L0111In I1VC ��IO(i�
Comoanv Registration Number
13 lIF_UGIFi Limas tt\L Aa--,wA .� AA own 3 ' 1 ' ZV
Address I Expiration Date
Telephone 14' Lm
'SL'C'flOri-10�tlODRKER3"COMPENSYRtt)N'INSt1RANCE'APPID79YRf'(SIU:L.c.'YSt,'g'Z9C(B)1
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
SignedARdevit Attached Yes....... N.-- ❑
City of Northampton
•s r: . : ��s. .ne(
IMsaachuaette r
y DEPARTT OF BUILDING LNrSPECSSCNS 4 \
212 Main Street • Hunlcipal Building
V..t3uo ton, rat D1oso
AFVi@Ayff
Herne Improvement Contractor Law
Supplement to Permit .Application
TheOffice of Consumer Affairsand Business Regulation ("OCABR")regulates the registration of contractorsand
subcontractors performing improvements or renovationson detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
MX�L Chapter:142A requiresthat.the"mconstmcdon,alteration, renovation, repair, modernization, conversion,
improvement,removal,demoation,orconsmmtion of an add horn to any pmTsang owner-occupied buitaing containing
at least one but not more than/our dwelling units....or to structures which are adjacent to such residence or bu#ding"be
done by registered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity mast be registered
Type of Work: A LT6RATiwS Est,Cost: Oo
Address of Work: N0 '[&AFvLL RD
Date of Permit Application: .S ']� /Q
I hereby certify that:
Registration is am required for the fiallmving teasoms):
_Work excluded by law(explain):
_.ADb ernkr$P.W..00
_Owner abtaiairrg awn permit(explain):
_Building not owner-occupied
_0th-0th
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,C.L.Chapter 142A.SUCH tyNiTIERS ALSO A3517ME'757E RESTOTtS111lLT7ESFbR AL1.470RK
PERFORMED UNDER THE BUILDING PERMrr.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties ofperjury:
I hereby apply for a.building permit as the agent of the owner:
.Sr-ZF-14 %m Lm% /s/dGS—
Date Contractor N e HIC Registration No.
OR:
Notwithstanding theabove notice,I he ply fora uildi a as the owner of the above property:
S- 14
Date rName
City of Northampton
Massachusetts
Cy�P f y DEBABTMSIIT OF BULLLam LBSBEOmrO
212 Mein Straat *Municipal Building ���, �A
Northampton, M 01060 ��• Pa
Debris 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 shelf be disposed
of in a properly licensed solid waste disposal facility,as defined by MGL c 111, S 15DA.
The debris from construction work beingperformedat.
qD -TP.t1MUI.I. . QO -
(Please print house number and street name)
Is to pbe(disposed of at: /�
/'AU� U.U1(n GR�f
(Ple nt - a� Iocat n of facility)
Or will be disposed of in a dumpsteronsite rented or leased from:
(Company#tame and PdcMess}
Signature of Permit pplic nt or O r Date
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.
TheCommonweahh of Mosytirkinsefft
Department of Industria/Accidents
I Congress Street,Suite 100
Boston, MA 02114-2017
www.massgovMia
T\\urkcrs' Compensation Insurance.4Rdavit:Builders/Contractors/Electricians/Plumhers.
TO Rti.t1Lk:U WITH TME PERM1T11'ING AUTHORITY.
Applicant Information n �• Pleaset'rint Leuibly
Name(Business/orswimioNlMividual): ILA 61 0tAls
.Address: /•I I'LicytA6E /,JoakC N
City/State/Zip:���—u.xo,ou F MR dO}? Phone#: 63 33110 Ua
Are...a....lo !ck.h tk aw a w ate it Type of project(required):
1.[:11amaempl.yrrwith_ __ -_ empbywa(fWlwdionPN-lima).! 7. Qhfelw coastructlon'
2 0[am a sole ronsmosser partnership and have metal working fisrennein $ P[{Re mleiing
aayeamea y.INaworkera
s- mp.insuresellresellnresell /Lf
9. Demolition
J.O I am a homeowner doing all work myself[No warken'camp.msurmce rttll'
1Q0 Building addition
4.17ensu a himdenlmwmT and win to hiring contractors ed conduct all work ce onw a sole . 1 will
ensure that all wmracmrseitber have workers'compena.rmn insurance or are sole ILQElectrical repairs or additions
pmpncmrs.irh nu em,noves.
12.Q1hrmbing repairs or additions
3.�1 am a general conmcmr m4I have hired the pibcont.emrs hsma on are aanahatl 9i an, 13,IRon century
,�-,/These sul.contrecmrs hoe nnmbyeas andhave workers'comp.ircumsr-x.:
6/3pfW.are. mistrumn and its officers have exercised their right ofcxenwtiogput MGL a 14'E]Gther
2,$I(4),end xe have noemployees:[No workers'come.insuretwe rtquired]
'Any applicant that checks now 01 must also till out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire omsidc Contractors must submit a new etiidevin indicating such.
Tc.nowt rs that check this ho.x most attached an additional sheet showing the name of the sub-cumraz1ms suit state whether court those entities have
empmyees. If me subco.m.e.,have employees,they as,provide Icer workers'coi pthcy nuni
I am an employer that is providing aorkers.'compensaum,insurance far mr,employees. Below isthe pallet ardjob site
iaformadon.
hummnce Company Namr.
Policy N or Self-ins.Lic.k: Expiration.Date:
.lob Site Address: ..__ .. c1gs'Saicvft:_
AtiacM s eepyef41e worivern' ,policy.ammber and exploration date}
Failure fo secure coverage as required under MGL c. 152,.§25A is a criminal violation punishable by a fine up io$1,500:00
and/or one year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a f ne of up to S250.D0 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 cerify a th psi and pend perjury that the Information provided above is true and correct.
Si Daze: F q
tffrctat use only. bo not write in this area,In beenmpleteaby city or town official
City or Town: Permit/License a
Issuing Authority(circle one):
t. Hoard ofi4aah L Hnr7dfng Department S.City?ewe Clerk 4. ERctricafflaspeetor S.Plhm6ing Inspector
6.other
Contact Person: Phone h:
FORA; 153 The Commonwealth of Massachusetts D+a ureoaly
Department of Industrial Accidents
Office of Investigations-Dept. 153
1 Caagress,Sheet,Suite ter,8omee.Massseheafb621 W2017
btlp-Jtwww.mass.goetaie lnvesUSwo to a:
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169ofthe,4ctsof2002amendedMGL. c. 152, §1(4) by adding thefollowingparagraph:
"This chapter shall be elective for an officer or director of a corporation who owns at feast 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(tights under this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph. Violations ofthis pa a raph shall subject the coopontiortto the penalties set
forth in section 25C."
Pursuant to M.G.I.. c.152.;§1(4)as amended, I/We. the tmdetsigued officers of
Lamy Building,Inc. 1=Fast Mountain Road,YYesdWd.MA Q1QW
ahi..<C«@ara6ra 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 polity covering the undersigned corporate offrcer(s)or director(s). VWc 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,Uwe the undersigned do understand that,should the above-named corporation hire or have in
its employ any employs)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.
VNe the undersigned have read and understand the statements and obligations as delineated arcane and
-
I/we have checked the appropriate box below my/1w manc(s)indicating mylour desire to be eiWapt.or
not to be exempt from the provisions of M.G.L.c. M.
Signed uatder.*f pains an[ZFenalties of perjury: "a'----
/ ' t Tmr +"A Leary.PreWdent - 1Nf15r1014 -,o
---- Prim Ntox&rTdc D,de(sfdNyyry)�.
Q tw so,
exerrsmy right exernpom, d ❑ 1 wish NOT in exercise my rind ofexemptim r
sigomure PrintNamc&Title Date.(mm/dd/yyyy)
❑ [wish to exercise my right of exemption or ❑ 1 wish NOT to exercise my right of exemption
signature Priat Name&Titk Dft(mm'kYYM)
❑ 1 wish to exercix my right of exemption, or ❑ t wish NOT to exercise any right of a ernpnim
signature Priat Name&Tithe Date.(mm/ddtyyyy)
❑ I wish to exercise my right ofexemption or ❑ I wish NOTtoexecise my right ofesemptim
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