16A-020 (23) BP-2021-2277
416FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
I6A-020-061 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2277 PERMISSIONIS HEREBY GRANTED TO:
Project# BATH RENO Contractor: License:
Est. Cost: 30000 LEARY BUILDING COMPANY 104806
Const.Class: Exp.Date:02/17/2022
Use Group: Owner: SHAFRAN STEPHANIE
Lot Size (sq.ft.)
Zoning: URA Applicant: LEARY BUILDING COMPANY
Applicant Address Phone: Insurance:
13 GLENDALE WOODS DR (413)336-261 1
SOUTHAMPTON, MA 01073
ISSUED ON:12/14/2021
TO PERFORM THE FOLLOWING WORK:
RENO 2ND FLOOR BATH AND CLOSET
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.
Signature:
I
Fees Paid: $195.00
•
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of;tilassachtrsetts ~--/ 1/ �
*�., Board of Building Regulations and Satandal ds D _" '� f:
Massaclrtrsetts State wilding Code,7gfl rules EC -9
Building Permit Application To Constrict,Repair, Or Desuolish2a� frevLcd Mar 2011
One-or Two-Family Dwelling �T,�F''ult�,5
Tc Jr r- �-J
This Section For Official'Use Only " ,, ,,Pion,;
Buildi Permit Number: go---4-1 - �}- -7? �� Date Applied: -,, „
w,/,-) (Z-, 1//72.17
/2- 1"3 -Zb7(
Building Official(Print Name) Signature Date
SECTION 1;SITE INFORMATION
1.1 Property Address: 1L2 Assessors Map&Parcels Numbers
gib CI-Ng)k-1 Jti,I.AGe
1.1 a is this an accepted street?yes )4 no A Map Number _ Parcet Ntunber
1.3 Zoning Information: ' 1.4 Property Dimensions:
4 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
3 13 wing ck^s(ft)
Front Yard Side Yards Rear Yard
Required Provided ,Required rtnov,ided Required Provided
1 [
1.6 Water:Snppiy:(114..G.L c.44,. 54) i 1.7 Flood Zone Information: 1.S Sewage Disposal System:
Zone: Outside F'laod Zone?
Public Private El if yes Municipal • unsite disposal system ❑
SECTION 2:: PROPERTY OWNtr x
2.1 Owner'of Record:
,S ZRUP►e Svc/Le/A, ' 4, ei"' MA 01oS3
Name(Print) City, State,ZIP
t-lfl. Cki2d Vr0,11/4.(n,4 61 Sel1 •9609 STF.vlak� �F2,E St1w., g Co.htt, m.Cu ,
I :_aft Street JT'eleprone Emil Andress
SECTION 3.:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Buui""7d�g O Owner 0nd ❑I ] R epairs(s) ❑ Alteration(s) D"c1 Addition Elr
Oemoiiti n `0 Accessory Bldg.121 Nutttber ofUnits Other 13-Spelli'y..
Brief Description of Proposed Work': ukTE bvlP�onn mo Ott
a'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Material0
1.Building $ i S' 000 1: Building Permit at Fee: S Indicate how fee is,determined:
I 0 Standard City/Town Application Fee
• 2.Electrical $ St 000 0 Total Project Costs(Item 6)x multiplier x
3.Thumbing ):'$ l 0 , 000 2. Other Fees: $
4.Mechanical (11VAC) ' $ N ,, List:
5.Mechanical (Fire j
Suppression) A. Total All Fees:'$ �
Check No (10/ Chedk Amount I Cash Amount
1 6.Total Project Cost: 1 $ 3 000 ,li„g Bala Due:,l O� i I,]Pain in FiNll n(ltttcta�r„L_b�. .1.,:
SECTION CONSTRUCTION SERVICES
5.t Canter r.ttiiw:Sipe.»Ligeiue.(CSE).
I Q /o�gacD 111 z2
License Number Expiration Date'
Name of CSL Holder `, List CSL Type(see below) U
13 G,,E,uth 1/3cliS Da.
Na_ands Street Type Description
U Unrestricted(Buildings up to 35,000 cu.fl.)
/T N�µP io1� 1 (AA O t O r R , Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
Roofing Covering
-WS ? Window and Siding
I11 S1F Solid"`Fuel Burning Appliances
II �tM I/ 6U. Ott.- (.,w I Insulation
address :3 Demolition
. "Registered'Home'Improvement Contractor(WIC)
lei nt, 3 i • z2
.pc 6vl LAWe- )rJ t. , HIC Registration Number Expiration Date
HIC CompanyiNanie or MC Registrant.Name
15 LA „m.&& WOWS D Q 1T0,G LeAv 0.44 . (pAt.
No.and Street l Etmariliadidvess
Ss T vi P M.v n) J M a Ot DY-k
City/Town,State,ZIP eleple
SECTION(:WORKERS'COMPENSATION INSURANCE AFFIDAVTTM.G.L c.ISZ.§ 2 b
` timers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit witl Tesuit in;the.denial of the' of Me butlaling,pertiit.
Signed Affidavit Attached? Yes P. Nv .I7
SECTION 7a:OWNER IJT IORMZATION TOBE COMPLETED WHEN
'OWNER'S AGENT OR'CONTRACTOR APPLIES FOR BUILDING PERMIT
I,asOwner°Pale snbjeat property;-hereby authorize 17-m Lao
to act on my behalf,in all matters relative to work authorized by this bdilding permit application.
9laa(g)
Print , + 's N 'leti tropic Si: ) bate
SECTION*7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name r , • , I hereby attest under the pains and penalties of perjury that all.of the information
contained in this ap . o s i and) . .,- best of my knowledge and understanding.
/Z• i ZI
Print Owner's or °udiorized r '(a:Wr orti, ignature) Date
NOTES:
I. An Owner who obtains abuilding p:•4 to do his/her own work,or an owner wh&hires an unregistered contractor
.(neat wgisterecl in&e. Improvement Contractor(WC)Program),will ''have access to the'arbitration
program or guaranty Rind under M.G.L.c. 142A.Other important information on The MEC Program can be found at
www.mass.govioca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned;provide.the information below:
Total floor area(sq ft.) (including garage,finished basementlattics,decks,or porch)
Gross living area(sty. it) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of bal f/baths
Type of beating system Number of'dmks/porches
Type of cooling system Enclosed Open
3. `Total Project Square Footage"may be substituted for"Total(Project Cost"
City of Northampton
.FJ�'.
ba' � Massachusetts , f,
124
i 'ay y O =�yrw T�pr�ypr.,e TIO
uf'f §$ "' � i i�J' OF B{i'��L{t!! Jt1�TtiS�l.J�iVNYT
° At ` 212 Main Street s Msnicipal Residing
ems ` Northampton, MA 01060 s``�A G,'.
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION.PROJEC ITS)
In accordance of the provisions of MGL c 40,554, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by ma c 111, S 150A..
The debris will be disposed of in: \iAt-1-67 (7-c-c-11-/-1)Jck
Location of Facility: AS i I/tAMPTDA.) / MIS
The debris will be transported by:
Name of Haulier: Le/Aril 600lA (i ( ,o
Signature of Applicant: Date: I Z• R-1I
.176-1s,
The Commonwealth of Massachusetts
Department of Imlustrial Accidents
I Coe s Street.Suite lea
.....
t — ) Boston.451.4#2114-201 7
wwwmass.govidia
...0. Winters*Compentiation,intialttatitta Affidavit Builders/ContractarstEhtetri ci ii i'i uni1)e n.
TO HE FILED WITH"UHE PERAMTING AUTHORITY.
1 n olican t Information Pk:is Print I i.‘,iiiIN
Raffle 43usarecse‘Or.conizairtsin ludinatioal/: Lak &WW,14,/i , /eV L. -- — —---
AdtkereS: ( toy DIA,C Wo.C.>5 It. _ —
City/State/4x_S.,)7,-44.6w,- IV oto13 , ..Phone#: its 37)u, -
t ,
Are yrs an employer?Check the&pm-update box: I
i Type of project(required):
1.Ci I,am a eamksyer with _ etnaloyees dila Jodie*pannake4 4' '1,1 7. 0 New constnxtion
2Cflatto a ode wowing*ot promessins ad have ma enettnyees waking tot me ita } 1t. itertledeing,
my rapacity.iNo workers'comp.sestmoce tequireski
9. .Demolition
30 t arn a humeessins does all work myself.(No waken'corm.ineutan.s.—tespeinall
4.0 , L i 0 ci Butkfing addition lani a hinhaawner and will Ix Main hanceactem 80 italifittlat ilit*Ork on ray peva:kr. Lwill
ensure that all warn-tots either have waken"emacionanen insurance ot ate sole ; tic)Electrical repairs ot additions
proprict:He with no employem.
12.0 Plumbing repairs or additions
5 Ism at general ecuattonor and I lime hired the ilub-cdottactots hued ua the anasthei sheet.
' LORoof repairs
These siih-coestr rs acte haw employees and have workrs'e cutu ip.insurance.;
A. 'We ate AI otitptarst.i.ft and ars hffihres base eltertiorlial Oen.-601 of exeroptatepee)11CiL 4.K
.1 010* 14.00ithes-
and we have no employees.(No waters'comp,insurame required.)
•Any applicant thin cheeks ben tat mot atso fill out the section below show mg dint riecokne t;ormentatiott policy intormatim.
4 Reiterewatesi veldt ninon din affidavit•datieranat,they are dos:4 adi wend.JtX31:1 Omaha*otirmatIc•Axtereoarv.alma wuhrold A lit**affidavit nalienting suck
;Characters that dank nes box mud amcbed an aelthiamel rhea sentanim Ow nom 4164 i.t.b.44.1:4TZt.:401('S mod Age wia.shse cc riot tht.,*4:entities,have
empleyer% 1 i the suuretraciors have employers they mum 111UVIthr irlelt WOlik CM'V•nnip p...111.:y 1140161.11.
I am an employer them is prorialka.:walkers'compemsadost Imamate for my employees. Below Li the polity mad**site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Sire Address: CitylStateiZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
'Failure to secure coverage as requited under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
andfOtone-yearimprisatiment as tiVeM i ewil penalties in the form ofa STOP WORK ORDER and a:fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage serification.
/id*fieredry icerkti,unt it al • •f,pet.4ttrylafiat,dte.injOrtwupoituttled Abort is true and eiirrea
o
Signature: , Date: j 2.. y 24
Phone#69 Go•ZiAr//
Officio,woe only: Do not write in this erre.at be completed by eity ar rerun official
1. City or Town: fits dattLicense n d
[ issuing Authority(circle one):
1.loa-d of Ikon Z.8-1•Kag nepartment 1 Cit /Town Clerk 4.Electrical!-vector 5.l'hunkIng laspeetor
6.Other
Contact.1ter3bon: Phone#s:
s , .
FORM 153 The Commonwealth of Massachusetts DIA Use Pnly...
Department of Industrial Accidents It
Office of Investigatians- Dept, I
eAi= X Congress Street,Snit*100,,Boston,Massachusetts 021.14 2OJ.T
httpJ/eeww.mass.govldia InvestiSWO lilt k:
y`yI
.CV AFFIDAVITr-" OF EAT FTi Aa FORCERTAIN'INt CORPORATE
OFFICERS OR DIRECTORS
=Chapter 159 'fthe Acts of 2002 amended c. 152, ai(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 accident's with a written
..FLt tights
under
this
chapter.
Said shall _1 1 the
of skisti hts t nd l this Said-c tmui-ssionet: plum-triicu ate -eguiattitnis to,carry out the
purpose of paragraph_Violations of this paragraph shall subject the corporation to the penalties set
forth in section 2.5C."
Puua AMIT -1k52,1144.)ais_astelltrilkait &We the amtl s i `. ' _ ._._....
Leary Building,Inc. 1039 East Mountain Road,4Nestf'reld, MA 01085.
(Nam:urnUr4-IUr4ti UU arid Ada':iaa_\
each hoidingat 4east 2514 ,o'f the issued'and outstanding stock in said corporation,do hereby invoke the
right to be exempt,from the provisions of M. . ,. c. 4 52, §25A and therefore are not required to carry a
workers'compensation policy covering the undersigned corporate officer(s) or director(s). UWe the
enders signed ado 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,liwe the undersigned-dnunderstand that; should the above-named corporation hire or haver in
its employ any employee(s) in addition to the undersigned corporate_o:fficer(s)or director(s),said
corporation is required to obtain workers' compensation coverage for the ree(s)as prescribed by
M.G.L. c. 152, §-25A.
I/We the undersigned have read and understand the statements and obligations as delineated abasPe and
If
_- T _ Y__ L t t_ i t � Y• t t be have checked the appropriate_box below iiiy/uur name(s) indicating my/our desire to be exmpt.or
not to-be exempt from the provisions of M:G.I..-c. 152.
r--
Signed derth pains- penalties of perjuar ,
" Timothy A. Leary, Pr sidemt 07/15/2014
Signature Print Name*Title Date(mm/dd/yyyy)--
I wish toe a my right/o exemption or a I wish NOT to exercise my right of exemption r;,
Signature Print Nave&Title Date(mm/'dd/jryyy)
0 I wish to exercise my right of exemption or Ot twig)NOT to exercise my right of exemption
Signature Print Name o Title Late(it mtdcl/yyyy)
0 ■_.:_i._ __..__!__ ._-_...'_L. _C_-.......:... ... Eli t wish NOT t_ _-__.-7__ _._-.)_t. _C _._ai_._
� wuu w w�wuuc my fight of cxctuNuvu w ,.L_J t wish w c.�c/uac guy l�gul w ccui�uvu
Signature Print Name&Title Date(mat;/dd/yyyy)j
Cwish tm exorcise^my'right ofoxemption or J 1 with NOTio-e iercise.'myTight,,o+f exemption
Note:A`Li.ELIGitai.E CORPORATE OFFICERS MIST SIGN. THERE CAN RE NO MORE THAN 4 SIGN1ATURES. htstructions
on hock. Form 153-7/2010
uorninonaith
um
of Massachusetts Building Division of Prof ryashac — �— .
Board of Professional�icensure
9 Regulations attz9 StatodaMs
CS-104806
`;„ Expires:02i171�022
TIMOTHY A LEARY
13 GL;ENDALE WOODS (WOW
SOUTHAMPTON MA 01073 .+
Cot11n7tSSIQ '.
___ ,,. hc96"r "imelaA &Bssit ss Regulation on
oR ConsupmOe £ r
1ENt O TRAGT
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13 GLENDALE W undetsecre Y
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