The URL can be used to link to this page

29-152 (13) BP-2023-0360 519 RYAN RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-152-001 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-2023-0360 PERMISSION IS HEREBY GRANTED TO: Project# roof 2023 Contractor: License: Est. Cost: 27000 JAYME MALINOWSKI 114822 Const.Class: Exp.Date: 06/23/2024 Use Group: Owner: NORTHAMPTON REVOLVER CLUB Lot Size (sq.ft.) Zoning: WSP Applicant: J MALS MASONRY AND ROOFING CONTRACTOR Applicant Address Phone: Insurance: 30 CAROLYN ST (413)883-6152 WC2-315-626686-013 FLORENCE, MA 01062 ISSUED ON: 03/23/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-ROOF 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $189.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner II LIAR 2 3 2023 The Commonwealth of Massachusetts Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) r.of ni_m Building Permit Application for any Building other than a One-or Two-Family Dwelling NIORTWA4"' (This Section For Official Use Only) Building Permit Number:.23 ' 500 Date Applied: Building Official: SECTION 1:LOCATION No.and Street T— City/Town Zip Code Name of Building(if applicable) WO Assessors Map# Block#and/or Lot # SECTION 2 PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building Repair* Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: RI 1 mi Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Is an Independent Structural Engineering Peg Revie��r�fired? T-`Yes � No th Brief Description of Proposed Work: �a � /"t-G �1� \ (Chi nei 1I41w, SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2 0 Nightclub 0 A-3 ❑ A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 1-2❑ I-3 0 I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IBCI HA CI IIBO MA IIIB ❑ IV CI VA 0 VBD SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private CIor indentify Zone: or on site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION e and Address of Property Owner t✓ 61 Rycv, )24 , tc�!URQ C� Name(Print) No.and Street 'City/Town Zip Property Owner Contact Information: n_ 1 Title Telephone No.(business) Telephone No. (cell) e-mail address pplic le,the pro erty ow er hereby authorizes: R� a. A 1 g k-1 t. ., EA,, UN- L w y ckui NA- Name Street Address City/Town State Zip o a to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.t SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor // 7 NA Mo.�oil ei a,\�4� R66-5a// Qc q lreA nor Company Name *mob to MC' (t'nowri( CS- I ( ({ ')a CS Name of Person Responsible for Construction License No. and Type if Applicable 3O (eo it Sfi pore,c.e nk 0(0 (oa— Street Address City/Town State Zip y3-g34). u-13-(13 ( ($ beaker. ( 1,`1,06,J5ki C irbu4 a c •.. Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE tt Estimated Costs:(Labor '` Item and Materials) Total Construction Cost(from Item 6)=$ C-T 10 a ' 1.Building $ Building Permit Fee=Total Construction CoW_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to G 6.Total Cost $ 77 2 N (contact municipality)and write check number here /O' I SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the be t of my knowledge and understanding. 10- Is ite 5 - 3/9)/d 3 Please print and sign name Title Telephone No. Date irti;,. : 70 (..Ain name, . P(n` C 9-- UV\c 6(6 b c- h 4Q Mq I i`noti SK'Cc,1-6(o.)d,C6-1-N eet Address City/Town State Zip Email Address ' T `�13 �3 � Municipal Inspector to fill out this section upon application approval: , ' ' w Name Date '` The Commonwealth of alassachusetts Department of Industrial Accidents congress Street.Suite 100 _,.A1}-_- Boston. MA 02114-2017 ` , R www mttss.got"/dia 11 MP kers'( ungtensation Insurance.lfftdas it: Huildersi'("ontractorsfElecirieians;Plumbers. If)ID FILED V.1111 111F_Pt R\II I"I11(:Al 1111014111. .ltinlicant Information Please Trine l.e't ihh Name t}twine ,ire .:11AtJltic.11 ln.tl1t.tu.r€a: \ PA% Q'\f_2 r/1 and ttbdtft .�7 .�Ji�t� tof Adore s e: 3 0 C�; r / City/State I_I PQ��1LQ2. 0(O - Phone#: �- .3 &) e5 err�uu an erupts.) "t heck the appropriate hot: 'E}pe of project(required): r.Ql ant r employer.:iah smpl0poes(full waist part-tom l.• 7_ �Itie%% coti.IEttettun 22 1:eat a+oh:proprietor.or purincv,bip and hose ay..ctet},lt.l et'.a.nkntr test me in 8. 0 Remodeling aat�,capvcaty. [No worker.'e4nnp.ur.utancc rt'qun.al n q. t.__J Demolition ..- 1 Jill a hornevnrtrr dinar aft 1HMk rl» :1r..P ot.uewi,..1 can¢•. nn,sarancr required.1 10 0 Building addition t i alit a 1rMAwt.wace anti wiN ter:hiatrrg coiiit:eclor,t„conduct all rttik on ins prnepa-al±;. t mill l ai).[ell+ 1 if] 1 k c Electrical repairs or additions Ure thin e1ltll'f yeas�NlMke[.�c'tN1q.1'n.Jl/t'ql insurance' r ilk:sett: `}� pt opt re10M.le dip two ciraittol,ecs 12.0 Mouthing repairs or addttions I alit a cncea)cenhiaLtot and I tun e hoed the sub-titan g elm,hied em the anildilta l� I 3.R1Roof Rootrepairs • 16e.c wh ce tetl rc[+n+lass .rear)toast+(hike(.':+ar>i. rrt I taii4X" 14.0Ot ei h. v.c arc a en:prralrt.n and it,,rttteers h:l.c ever osed then n}hl.d eYcnyatu.t pea MIX C. — ----...-.—._-' ) !.:la 1)r_and*At;)ta,e tnr.Cillployec.I'tiO Ofkt.'r. e4r11p.tmnsi tree tcywtial.l •.:�tn..a{ry+llc4111 that cheek.hot.1:runt alum fit)out thc xcttaat ta:lou,how ang their alaalpaemaiou policy letpArlosiaru- *I1.onte'.r riper.r.hc',tll'CIIi thus apt nt:a.it akin:army.the h arc.hang.all work and dm bëttiNtIbTM erase mint a rw ar:Wuhan it nettic:s.big cue-ta. . . »C.onatact4•r.dui check the.,tw.r(ruse attsclreJ ao adtla[toru).IAcct,)aov,mar tfc native rattllso esio+09Wta.dr,oats(,rah wtatltier err rx•t Ilium:outdo:,1wr rrnpio ce-c it t e.uh-contractor.lase en iiece cc,.rice's nlu.A pre.rtde shear worker.'camp.policy nuatikr. 1 am an employer that is providing workers'compensation insurance for my employees.. Below is the policy and job site information. l Insurance('ompans Name: Ksrl 4jrat CQ Policy#or Self-ins. Lie. -. �C..' 1 S" (9).()G2 g�p '��[ Expiration late: 2 /d S /ao -i Job Site Address: lq 4` ifk01 VtQrPtnCQ Cits State Zip: 1co 1\ee M 6(OE72 Attach a copy of the viorkers't at pnsation policy declaration page Ishouinl;the policy number sad expiration date). Failure to scare cos crave.0 requited under 'lit et. c. 152.*25A is a criminal s solution pwirshabk by a tine up to 31.500.00 antFor one-sear imprisonment.as ss ell a.cos ii ptataltics in the form of a STt II'WORK ORDER and a tine of up to S25(1.()[1 a day agauast the s tolalor. A cops of this.t:atcancrit trus be forss aided to the Office of Investigations of the DIA for insurance ctrstra}=c serilieation. I du hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /02 3 / .�u j 3 ��j�--� 2 C� plttrnc : ( 3 3 Official use only. Do not write in this area.to be completed by city or town official ( its or Tuwn: Permit'l.icense to Issuing.luthorits (circle one): I. Board of health 2. Building Department 3.('ily 1 nesn Clerk 4. Electrical Inspector 5. Plumbing Inspector I..Other ( untact Person: Phone#: City of Northampton 'v( 1 v• Massachusetts rr j :, k DEPARTMENT OF BUILDING INSPECTIONS si �-P • 212 Main Street • Municipal BuildingCi.- ANorthampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, 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 MGL c 111, S 150A. The debris will be disposed of in: lV..A52 3 ii Sub,,,,,,, i, Location of Facility: 0.-, Li- �• 1JQ.. The debris will be transported by: Name of Hauler: �G tMe_.., kb 1� kkAr.} .1)= Signature of Applicant: -_______ Date: -3/ 0 3 /)0 e) 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY Liberty Mutual. INSURANCE POLICY Liberty INSURANCE .AR INFORMATION PAGE 175 Berkeley Street Boston, MA 02116 Issued by LIBERTY MUTUAL FIRE INSURANCE 16586 Policy Number WC2-31S-626686-013 Issuing Office 016C RENEWAL OF: WC2-31S-626686-012 Issue Date 01-19-23 Account Number 1-626686 Sub Account 0000 1. Insured and Mailing Address JAYME MALINOWSKI RISK ID 001202200 30 CAROLYN ST FLORENCE,MA 01062 Status 01 — INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 03-25-2023 to 03-25-2024 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Pa.;e Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 550 Premium will be billed ANNUAL Producer 0004-072061 KSK INSURANCE AGENCY INC 203 NORTHAMPTON STREET P 0 BOX 597 EASTHAMPTON MA 01027 WC 00 00 01 A © 1987 National Council on Compensation Insurance,Inc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1