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35-169 (20) Department use only City of Northampton Status of Permit: Iry Building Department Curb Cut/Driveway Permit 212 Main Street APR 2 21, Sewer/Septic Availability t(, Room 100 Water/Well Availability Northampton, MA 0,1r0§g7---T- ­ Two'Sets of Structural Plans phone 413-587-1240 Fax 41 3-5 1 r, : Plotl�ite Plans _ _ _-- Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office / I �� �, �- �� Map Lot L Unit „--I ,, A ^ Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of eco d: c4krel ��;�� 5 '� 1� ► 1' (ecce WName(p ) Current Mailing Address: Telephone 2.2 Authorized Agent: { =x/ �r�rc.L Name(P' t) Current Mailing Address: Ll Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building O (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) J Check Number Q 7 t This Section For Official Use Only Building Permit Number: V�' cam`- ' Issued: ed: Signature: Building Commissioner/inspector of Buildings Date f,4j M/t r�l� @ Co►'�CGS ". �Ue 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 filled in by Building Department Lot Size ►� ad1 �s Frontage 0 01 100 Setbacks Front * SV L� Side Lai" R: 10 L:k R:; Rear Building Height 10 Bldg.Square Footage ,�0 1041% D 3� Q°A Open Space Footage r % (Lot area minus bldg&paved 30 I�� parking) UU #of Parking Spaces Fill: volume&Location A. Has a Special 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 O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ®' 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? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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? YESO NO kv 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 ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [Q Siding[0] Other[0] Brief Den�ofXropo d Work:XJ�t--t-2aO!', rel Alteration of existing bedroom YesO<_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 followinst: a. Use of building :One Family CK Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? V`i f d. Proposed Square footage of new construction. b Dimensions I k e. Number of stories? ' f. Method of heating? U I I Fireplaces or Woodstoves ' Number of each g. Energy Conservation Comp�ance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes 0�—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? Cl� Yes No. I. Septic Tank a City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I L LkAA as Owner of the subject property hereby authorize to act on my beha4- Imtters relative to work authorized by this building permit application. Signature of Owner Date l u 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. Signel unper the pains an penalties of perjury. Martiw Print Name ' Signature ner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Cons oSu � rvi or. ,gyp Not Applicable ❑ Dame of License Holder: t r v� �� G t Licens Num ger i 3 ,� 0 t E a3 ao - AILS /G - /3 �> ! � ExpiC ratite e Signature Telephone 9.Registered Home improvement Contractor. Not Applicable ❑ (A j-Mo,a c, I Sq Lin Company NameR i tra' n Number - �O Address � Expirati Date 0))� TelephoneL113 0111 Ci 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 Attached Yes....... No...... 0 ---- II ----------------- t � I � LVL Engineered Beam to carry Exsisting Roof ACORION Exslsting .';, m &ceiling Load � � House New Addition -——- �I �F �� I �� I ; (KITCHEN) Exat sting I OGB%R BB%GIME rtes Dlshuhshm �p uay O V BACK ELEVATION Scale 11b" 1st Floor 5cale 1/4" ADDITION-1345 Burts Pit Road W.Marek Inc. l3 5outhampton Rd. Westhampton, Ma. ROOF SYSTEM 2x8-12'Rafters 2x8-12"Gelling Joists 5/8"Zip Sheathing EXTERIOR T IRUnderlatment/Ice Barrier Match House Trim Drip Edge Eaves-12"Vented 50 Year Shingle Rakes-4"Solid Ridge Vent !! INSULATION R-19 FRAME YVALLS YqALL SYSTEM R-49 CEILING 2x6 Exterior YUIIs 16"oc R-19 BASEMENT WALL5 1/2"Zip Sheathing Siding as House FLOOR SYSTEM Exsisting 2X10-Floor Joists Gut Access to Basement` New GrawlSpace Basement 3/4"Advantech Sheathing 4"Concrete Slab Xslstina Baaement, 2xb PT Plates I -- -------, I I ---- Gross Section I I New Addition Scale 1/4" I I b"x16"Footing& I I I I b"x5'0"concrete YValls I I I I ------------ 12 5' ADDITION-1345 Burts Pit Road Foundation W.Marek Inc. Scale 1/4" 13 Southampton Rd. Westhampton, Ma. 5VI�-I 41 -A l05 - os ,goof 1 I i i i I s nc n CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �-- ro.,06,202. THIS CERTIFICATE IS 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 THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT K.S.K.INSURANCE AGENCY,INC. PHONE 413 527-7859 FAX 413 527-8314 203 Northampton St. E-MAIL travissias ksk-insurance.com P.O.Box 597 INSURE S AFFORDING COVERAGE NAIC# Easthampton AAA 01027 INSURER A: PHENIX MUTUAL INS CO INSURED INSURER B: ASSOCIATED EMPLOYERS INSURANCE CO W.Marek Incorporated INSURER C: 73 Southampton Rd INSURER D: Westhampton MA 01027 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER DDIYYYYI LIMITS ' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 FMSF CLAIMS-MADE F-1OCCUR DAMAGE TO RENTED $50,000 CPP0719447 M101/2019 11/01/202() MED EXP(Any oneperson) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $1,000,000 JECT OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S D I I R TENTI N S WORKERS COMPENSATION PERTIITI OTH- AND EMPLOYERS'LIABILITY _ ITA I FIR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT S100,000 OFFICER/MEMBER EXCLUDED? N/A WCC-500-5014290-2020A 02/10/2020 02/10/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE'%��'1/'f/�y�� /`✓ ,Z <DA> ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstrilCtion'Sup2n;isor CS-055201 Expires: 06/23/2020 J: r WALTER L MAREK.Ill 73 SOUTHAMPTON ROAD WESTHAMPTON MA 010273 Commissioner r���r•`�nrruirnirtnr'uI!/r n Regulation office of Consumer Affairs&Business Reg HOME IMPROVEMENT CONTRACTOR TYPE:Coroorabon Rem 159488 on 04/29/2020 W.MAREK INC. W ALTER MAREK III 73 SOUTHAMPTON RD. Undersecretary WESTHAMPTON,MA 01027 _ The Cotntllotlivealtlt of}Yfassr?clrusetts Department of lndtish ial Accidents 1 Congress Street, Suite 100 Boston,llM 02.114-2017 Zee'`c ivivminass.go6lrlra Workers'Compensation Insurance Affidavit:Builders!Contractors/Etectricinns/Pl umbers. TO BE.OILED WITH THE PERNMING AUTHORITY. Applicant Information Please Print Le ibl r Name(Business/Organization/individual): (�/ ,� C:• _ Address: City/State/Zip: t' '�►�' tiro >JI � Phone#: Are you an employer?Check the appropriate box: Type of project(required): IS 1 am a employer with_-n— employees(full and/or pan 'l. ❑New construction 2. 1 am a sole proprietor or partnership and have no employees working for me is S. n Remodeling any capacity.[No workers'comp.insurance required.] i 9, El Demolition II 3T]1 am a homeowner doing all work myselL[;,`.o workers'comp.instumce required.]t 10❑Building addihoa j 4.0 I am a homeowner and will be hiring contractor to conduct all work on my property.I will i ensure that all contiactorseitherhave wotkers'compensation insurance or are sole 1 l.n Electrical repairs or additions !i proprietors with no employees. 12.0 Plumbing repairs or additions ! 5.Q f am a general couttactorand l have hired the sub•contcactors listed on the attached sheet. 13,n Roof repair- Mese sub-contractots have employees and have workers'comp.insurance.t 6.Q we are a corporation and its officers have exercised their tightofexemption perMCL c. 14.n Outlet 152,91(4),and we have no employees.[iso workers'comp.insurance required.] `Any applicant that checks box flu must also tilt out the section below showing lhcirworkers'compensation policy information. t Homeowners who submit this afdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- tContmctors that check this box must attached an additional sheet showing the name,of the sub-contractors and state whether or not those eatilics have cmploj ces. If the sub-contractors have employees,they most provide their workers'comp.policy number. I alit all employer that is providing workers'compensation insurance for niy employees Below is thepolicy and job site inforntatiott. I Insurance Company Name_t,_,_ Policy It or Self-ins.Lic.#:W0 0� G�~ Expiration Date: Job Site Address: 7 1'S ...> �, I City/State/Zip: 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 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify int sr the pants Id penal` f perjlrry that the in�oruiatiolr provirlerl above is trite and correct nature: �'_ Date: Phone##: �I C-,1n T 7�9 Official rise only, Do not write in this area,to be completed by city or town official. City or Town: Permit/License#E Issuing Authority(circle one): i.Board of Stealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: l