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17C-303 (6) 105 CHESTNUT ST BP-2021-0010 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-303 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: BASEMENT RENOVATION BUILDING PERMIT Permit# BP-2021-0010 Project# JS-2021-000016 Est.Cost: $30000.00 Fee: $195.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LEARY BUILDING COMPANY 104806 Lot Size(sg.ft.): 28488.24 Owner: LILLIAN ZALTA Zoning: URB(100) Applicant: LEARY BUILDING COMPANY AT. 105 CHESTNUT ST Applicant Address: Phone: Insurance: 13 GLENDALE WOODS (413) 336-2611 SOUTHAMPTONMA01073 ISSUED ON.7/22/2020 0:00.00 TO PERFORM THE FOLLOWING WORK.-CREATE IN LAW APMT IN BASEMENT 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 Sip-nature: FeeType: Date Paid: Amount: Building 7/22/2020 0:00:00 $195.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _Nc r City of Northampton *fus,olPermit: Building Department, C41 b Cut/Driveway Permit 212 Main Street,^% l SeweOSep is Availability t Room 100 rt�o!` �I/A �,�112f�tr 1 Avarrab�irty�_ Northampton, 11AA 01 tiq�'��, S sof Slf(ictuirat Plans phone 413-587-1240 Fax 413-58 ,SA Plov&te Pens__ APPI Ir-ATION TO CONSTl UC7 ALTER,REPAIR,RENOVATE' E'f*0,X16VI A10"EOP TWO.FAY.!LY DW.E!_L ING .S>ECTXM I -SfTE WIDRMATION 1.1 44noertV Address: This section to be completed by office /D S 0,�e T uucS 1 Map Lot—__- Unit_---.____ Qr6�_� M,& zoo* OverfayEJfstr& Elm St.District CB District SECT".2-PPOQEERTY(,JiJ NERSHIPIA ITHORIZED AGENT 2.1 Owner of Record: &UAit1 ZAL;i—L . !oS r %y✓i � ��wt t'.11Ji r MIS Cfh L2 Name Curren Ma ilag Address: R" X04 ?_22N Tele ne S* ture 2.2 Authorized Agent: m Ld ko L/ /,L 4UJL)bALQ' 1AJ0oG5 1)7 01 3 Nam (Print) Current Mailing Address: _T_ S Tel SECTION 3-ESTIMATED NSTRUCTION COSTS Item Estimated`Cost(Dollars)to be Official'Use Only earn eted by permit a plicant 1. Building IDI 000 (a)Building Permit Fee 2. Electrical SOCIO (b)Estimated TotalCost of 1 Canstr.uction from 6) 3. Plumbing �-Q7C� B-uuding,Permil Fee !. :Mechanical(HVAC) / G 5.Fire Protection 6. Total=(1 +2+3+4+5') ')c wo Chcck Nurnbcr L n This Section For Officio#Use Only Building Permit Number: ply Date Issued: Signature: , p Building CommissionerNnspector of Buildings �T� Date i_ I @, EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 1 - - SEGTION 5-DESCRIPTION OF PROPOSED WORK Icbeck ab aPaficable! New i 4ouse Addition Replacement Windows ' -AtteratiorrNRoorhing or Dean X Accessory0dg. ❑ Demolition ❑ New Signs [C]] Decks [[] Siding[0] Other[CM Brief Description of Proposed Work: Ls6L���4 i ji l w jAPAo�,�►tail i id) tQiltS EM oor of (Cu1V�V Alteration of existing bedroom Yes No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement es NO Pians Attached Roil -Sheet. 6a.[If New.house-and or.addition to existing housing, complete the follbwina: a. use o;ouiiding . One ramify �wo ramify Oilier b. Number of Teomsin each famfly uv*: Number ofBathroo+en�s c. Is there a garage attached? d. Proposed Square footage of new cdon. Dimensions e. Number of stories? f. Method of heating.? places or Woodstoves Number of each g. Energy Conservation Conroliance. k. Energy Cornphance form attached? h. Type of construction: i. Is construction wnthin 1,00;ft.of wattZ Yes No. Is cor,r6tmr esrek within 1 00ya. floodpiaie Yes rtJo ]. Depth of basement or c Ilar or below finished grade k. Will.buivuting conform to tape Bukgng and Zorrirng regulations? Yes No. 1. Septic Tank ty'Sewer Private%VeA Qty°water Supply SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT Oft'CONTR*CTOR:APPLIES'FOR BUILDING,PERMIT i, /J/JA ) Q71 as Owner of fire subje(;i property hereby wAhorize o j lA) 1) to acty behalf,in all rrfatfers re ative to 1kork onzed�bwlding permit WoZation. Aic(natdre of Owner Date r, C o as Owner/Authorized Agerr't fiereby dedare l�khe stat s.ara m(orcea 6n Ase fore gcing aWtication are true and accurale,to the best of my knowledge and belief. Signedunder ,pains and peritaMes sof Perjury. MI) {Print-Nisme 7 a A Z"2� Signature of eriAgent Elate SECTION 8-CONSTRUCTION.SERVICES &1 Licansied C Meftmtien S flerstispr Not Applicable 0 Xwm of License Holder:M t17��/ LJ ��l SCG Ucense Number 1 7� (t(,&k&k A kbits N, S U_ZUN lMaU MA a 11q 3 Addr�ss Expiration,Date J Sig r i 9:RestC�tarradil�nrite'il rlt�rl#'Ci©nllraQtor: NctApplieabie C1 ,&X14 /N c /8100S Company me ' Registration Number J3 46q-_'NiDAt,E hJ0005 bI? . c�u�viau 44A �=7,3 3 - I , 22 Address //� Expiration Date Telephon@ 1/.) n G 1�,!/ -SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(fYLG.L a 152,.§:25C(8)) Workers Compensation tosurarrce affidavit must be completed and subfn4tted-with.tt is application. Failefe to provide this affidavit will•result in the denial of the issueonce of the buiidimg.permit,. Signed Affidavit Attached. Yes....... No...... ❑. Cit vi irvi CALam r 'V DWP 4' Off' BUZIDZNG zMWj CPZOt�� 212 Main Street •Municipal Building a VortbAWton, MA 01060 n'=Ik r4 F1 - �Tf 1 i +" i/\rte/ i V it.i tri i✓V Mrd i.rL i I..r to accordance of fhe proVisions of MGl<c#m,'SS4,,l acknowledge that as a edition.of the building pwmit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a propwly licensed solid waste disposal facility, as defined by MGL c 111, 'S 180A. The debris from.construction work being;performed at (Please prini muse number anu siieei name) Is to be disposed of at: (Presse int name nd location o acitrty) Or dill be disposed)of in a dumpster onsite rented or leased from: (Con4ony Name and Address) SignAcoflPerrmnit nt or G r nate If, for any reason, the deb6s,will nct be disposed of as indicated, the Applicant or Owner shall notify the BWding,'department as to the location where the debris wdt be disposed. Me Cawrmorrweatth of Massaehusetles r Department ofltndustrial Accidents 1 Congress Street,Suite 1 Boston,MA 02114-2017 www.raaas&govldia Workers'Compwraadow Insarance Affidavit:.Bu ld'ersfContractorslEketricianslPtumbers. TO BE"LED WITH THE PERtMrfnNG AUTHORITY. AiwWwaW intarmaliow ,Please Print Legibly '+�Ai�iC'(�F3tasir+ess/t9rgari atiorillntl vii t lj: J �i bJA,1L, IA,4, Address: 1L4WAU� 1,-'006 • Lle- . -4.t,1-'YnrOA.) MA 610:13 Qty/Statelzip:- -- 1j b2 5 �� fPA13 -33(, -ZG 11 Are you au employer?Cheek tlse appropr-satebox: Type of project(required): I.Q I am a employer with em pl'oyccs Qfufl anNor part-tisazc)t* 7. CJNCW C0n3tMCtl0n 211 am a sole proprictor orpminership andhave no employees working former in :40 any capcity.�wo&em'comp:insurance regnixedl}3.[J Iam m how.digal work.z3.t:fNa workers'cotnp�iinswamcereq*ed.i* emolition 10 S`m-ldtrig addition 4.❑I asst a het aeowner and wrll be hrrirrg contractors to,conduct all work on:my lwoperty. I will ensure that alI convacturs either have workers'conation msaraiwe or are sole U._Q) lecuica.repairs or dditions propnctors with no c Wtoyces. 12.Q PItrmbing repairs or additions 5.C]lam a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13 iROOf repairs Thiese sub-Dmtracton have�dgployees and have wurirkers'aattpp:;insurance? -1_-71 p b �tTie att a carporatsan arfrl ctlfiraers havE:e�cercised l4+ee rs2,fit of.rxempti er ]GL c. 14.00ffier 2,41(4),and we have no employees.[No workers'camp.insurance xequiretl.l "Any applicant that t;ir els;box#1 must aiso'filit out fire secgon below 5howar g)thoa workers"compensation policy miormatien. 'Homeowners who submit this a'Bfidavit itadicating racy am4aing all work and then hire amide oontractors Must Submit a new affidavit indicating such. ZContraceors ghat check thz'box must at=hed an Additional sheat showing the name of6e str'b-contractors and state wheeher or:not,those awii i have efnplgyees. 'Ifthe nib-contraotors'have ernplaytes,they must provide their watkers'comp.:poliry number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Insurance Company Warm_ Policy#or Self-ins.Lic.#: Expiration Daze: Job Site Address: CitV/State/zip: Attach x copy of the workers'Compensation policy declaration page(showing the policy Nomber and'expiration date). Failure to secure coverage as requires under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as we`d as Civil penal i es in tWe form of a STOP W-OR ORDER:and a fine•of up to$254.00a day against f11e violator.Acopy,of this statement may be forwarded to�1c Offize,of Investigations of the DIA for insurance coverage vesifsca6am Tdo hereby carts un r ai and nalties ofperjury that the injnrmationproviderl:above is a cona�t 1 sigR attire: _ Date: �i IZCi'- ZO Phone#: 34' c FJffzrirs/use onfy- Do not write in this area,;to be completed by eitr or town official City ar Town: >?ert�itlLiKri►sr Issuing Authority(circle one): 1.Board of HeW& 2.BoAding Department 3.City/Town Cterk 4.Electrical Inspector 5.P'lombiwg Inspector 6.Ether n lR Gantact Person: Phone.#: 1� F�1Z� 153 The Commonwealth of Massachusetts DIA Use Only .C\- Department of Industrial Accidents Office of Investigations - Dept. 153 I Congress Street,Suite 100,Boston,Massachusetts 02114-201 http://www.mass.gov/dis 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 to M.t T.I.. c 152., §1(4) as arnended, 1/We (lie undersigf±ed _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 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 abta�ve and I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exmnpt.or not to be exempt from the provisions of M.G.L. c. 152. c r— Signed wfder_thp pains and penalties of perjury: �, ' Timothy A. Leary, ?resident' — 07/15/2014 -� i. SignO ure - Print Name&Title Date(mm/dd/yyyy). _ ❑✓ I w h to exercise my right'o exemption or ❑ I wish NOT to exercise my right of exemption i I, 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&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or ❑ 1 wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ 1 wish to exercise my right of exemption or ❑ I 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 153-712010 :�. ,. - - --- � - - 1 I = ! 7 � I� i _. _. _. _.._ _�—._�.�_.r._ ___ ._._._�i—_._._t��a.T.. .__.. ___ _�_—__.—�_�_.___� -_...._..��..._.. i 1 � ;. - � � � � i � --_. __.. 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