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10B-024 MGL c. 142A. PHONE DATE /� REGISTRATION NO. i ll i (7)31111/ � � _ X 1� JOB NAME / NO. JOB LOCATION > ii /0 (ii -4- Lt7A We hereby submit specifications and estimates for work to be performed and materials to be used: 1 Ciflp '...." bc(r /lam i I . -e S Ge .ii�� s. � i r - j-criA.tis)-(7f7 O , i) c c -,s . ) l ., 3o t/ � )) )r- i r � i r w sty. s f f _ ) �-( s `1'S fi d)irr t'l f L i . CL 1n C ..- .... - � {� IA ' ` IIv —{ ' 1 o ! f r' Cec c / 1 P , O: I2(Mc,-.5 1,,,-/J 5 �y/5 ._ / t d A I / c) n 1(�,.Ac o' t(L (,lei 1 1 tb . i r(r- )✓ - COP - Sr - FCi f -,0 j k 4 ClA1diold( I s � ) A/ th > Construction related permits: � - U6 4 / 0 4 (6 V T IAA ti i,eir)aiD 1,20 WORK SCH DULE Contractor I t begin the work or order the materials before the third day following the signing of this Agreement, unless specified her 'n ,ri ng. Contractor will begin the work on or about /Y (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be onsidered as violations of this Agreement. WARRANTY ���� f The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed -upon work. Wepropese ereby to fur ish mate I and labor - complete in accordance with above specifications, for the sum of : -6 dollars ($' PJ� ,---- ). Payment to be made follows: -- % ($ ) upon signing Contract; �� �e.� Name of /, Contractor / Designated Regi 1 nt ($ ) upon completion of ; ).�. P ...t'01 14r. Street Address % ($ ) upon completion of �� ,n, r City / State ($ 1 c7 v� shall be made forthwith upon 1 - 11 - .) - ' ! completion of work under this contract. Phone Federal ID No. Notice: No agreement for home improvement contracting work shall require a > down payment (advance deposit) of more than one-third of the total contract price Name of Salesman r or the total amount of all deposits or payments which the contractor must make, in � ' � advance, to order and /or otherwise obtain delivery of special order materials and Authorized Signature equipment, whichever amount is greater. - Note: This proposal may be withdrawn by us if not accepted within days. Acceptance of Proposal -1 have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. NOT SIG THIS CONTRACT IF THERE ARE ANY BLANK SPACES. /-,-)- � l ./. 1- -- /( -y /y � , � j) Signature 4- �{ / Date / /' 'v" k-'—. Signature Date PRODUCT 5554 fivETWe inc.. Groton, Mass. 01471. To Order PHONE TOLL FREE 1- 800 - 225.6380 IMPORTANT INFORMATION ON'BACK Policy Number ��8���C318094 GUARD NorGUARD Insurance Company - A Stock Company ` - ~ Renewal of ������C214172 tGR� OUP NCCI No.(25844] Policy Intormatson Page [1] Named Insured and Mailing Address Agency W Marek, Inc FINCK & PERRAS ]NS AGENCY 73 Southampton Road 6 CAMPUS LANE Westhampton, MA 01027 Easthampton, MA 01027 Agency Code: MAFINCIO { Federal Employer's ID 90 Insured is Corporation Risk I0^Number 000117402 | From February 1O,ZO1ItoFelr `ry1O,ZOl3,14:O1 AM, standard time al, the insunad's mailing address. i --- - ------- ----- ----------- ----------'------' [3] Coverage A. Workers' Compensation Insurance ' Part One of this policy applies to the Workers' Compensation Law of the ho||ow|ng states: tes Massachusetts 8. Employer's Liability Insurance Part Two of this policy applies to wort in each of the states listed in item [J]A. The limits of our liability under Part Two are: Bodily Injury by Acctdent each accident $100 Body Injury by Disease each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and YVy/m|ng. D. This policy includes these endorsements and schedules: See Extension af Information Page ' Schedule of Forms '-----------------'--------- -- ---------------------------'-------------'-- - ' '� --------'----------------------------'-------------------------- ----'------- -- '' —' [ Premium The Premium Basis and, therefore, the premium will be determined by ow Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) ________________ i .L.4.4.07e x:2 40.00.00 Total Estimated Policy Premium 5,718 Total Surcharges/Assessments 316 [Total ~~ Estimated Cost 6,034 ~~~~~ uN7EuNALusp xX Page 1 Information Page MGA wnwc3180+4 WC 000001A Date .uz/n3/zoo mAmorc 16 South River Street ° PO. Box A'1 - i^ YV}\kes-8arne, PA 18703'0021°wwwguard,cnm SIEGFRIED PORTH A R C H I T E C T A.I.A. 116 PLEASANT ST. SUITE 331 EASTHAMPTON , MA 01027 PHONE: 413- 529 -9434 11/27/12 TO: LOUIS HASBROUCK BUILDING COMMISSIONER 212 MAIN ST. NORTHAMPTON, MA 01060 I SIEGFRIED PORTH ARCHITECT REQUEST THAT YOU GRANT A MODIFICATION TO WAIVE THE REQUIREMENT FOR CONTROLLED CONSTRUCTION FOR THE PROJECT LOCATED AT 11 MULBERRY ST. LEEDS, MA. BECAUSE THE WORK IS OF A MINOR NATURE, AND WILL NOT AFFECT HEALTH, ACCESSIBILITY, LIFE SAFETY, OR ANY STRUCTURAL ELEMENTS. >, b d0.. N r 4 THAW 'O SIE 1 5 r * RIK W Marek Construction Inc 73 Southampton Rd Westhampton, Ma 01027 (413) 527 7667 (413) 977 9539 Louis Hasbrouck Building Commissioner City of Northampton 212 Main St Northampton ,MA 01060 Re: 11 Mulberry St. Leeds Ma I am requesting a waiver for the project located at 11 Mulberry St. The work is of a minor nature and the cost associated with controlled construction are considerable compared to the cost of the proposed project. I have consulted with Porth Architect and have enclosed a letter from them in support of this request. Respectfully Walter Marek III W.Marek Construction The Commonwealth of Massachusetts =" Department of Industrial Accidents Office of Investigations _- .. 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): ,,,A- ) . I'I Address: - City /State /Zip: LA � y,, Phone #: L_ -2 s- ° ) /c1) Are you an employer? Check the apropriate box: Type of project (required): 14E3 I am a employer with 4 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub - contractors 2. CI I am a sole proprietor or partner- t listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have ship and have no employees 8. E] Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions f oficers have exercised their 11. 3. ❑ I am a homeowner doing all work h id hi ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.[] Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. r r Insurance Company Name: �j Policy # or Self -ins. Lic. #: 1 �' I ) "R1 + Expiration Date: 1) /} Job Site Address: 1 1 �l - /l 1 City /State /Zip: Ler_ s /10 dk.'= Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a co py of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the gins a pe ties of perjury that the information provided ahoy is true and correct. Signature: -/ Date: !/ t -I Phone #: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Versionl.7 Commercial Building Permit May 15, 2000 4 , SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required • Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED. WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date _ _ , 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. Signed under the pains andsenaltiesotperiury. Pint Name _ Signature of Owner/Agent Date SECTION 12 -CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : fitri_ License um er Address Expiration ate 401P I fr7 41 adi fir AV • Signature Telephone SECTION 13 -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 66 No 0 Version1.7 Commercial Building Permit May 15, 2000 ., SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR :116 (CONTAINING MORE THAN 35,000 C.F. OF ENSLOSE© SPACE) 9.1 Registered Architect: � Not Applicable ❑ _ _ _ „,........ ,._ ____ _ _ Name (Registra Registration Number Address L_ 1 --- -ly Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor � . + W - . � ,.._... . .____. _..._.. ._._._._ _.....__.... .._..�_w.___m Not Applicable ❑ Company Name Responsible In Charge of Construction , _.fi. .__.. ! _ ...... Address. .., S gnature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING Existing Proposed Required by honing This column the filled in by Building Department Lot Size Frontage , . _.., .... .__......_.._.. _.,...r. -_.. Setbacks Front Side L.___:.__ R: .. L.: ? R ::' Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) .,_._.�..� ...._.._. <..� ...a...�..., ._._m # of Parking Spaces I _ _ Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ? Page. and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 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? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • } Version1.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs ❑ Additions ❑ Accessory BuildVd ] S Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑ Brief Description Enter a brief description here. Of Proposed Work : J I I e5 SECTION 5 USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A I ❑ A-4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ _ 2B - r ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ i, 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B 1 ❑ U Utility ❑ Specify: � M Mixed Use ❑ Specify: - _....._....._..,m_-„�..... .,...._., __ S Special Use ❑ Specify: � _�...®.�,„„ _�- � ___ COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: ___ __ __.. ._ _ ___ ._ _____ _ Proposed Use Group: _ _ __________ ._ ___.__ ._ Existing Hazard Index 780 CMR 34): , ___ ._,,,_,_ ,_,__,_ Proposed Hazard Index 780 CMR 34): '_ ,.... __________ m_ SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor (sf) e ; 1 st 1 _,- _,.,„.._...,_ 2nd _, 2 nd 3rd .._.._, ..____._ _,__.._._ W..._... .,... 3 rd 4th .._._ ________ ._. 4 th "_ __ Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) _._. Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone _ __,_._„ , Outside Flood Zone❑ Municipal ❑ On site disposal system f Version1.7 Commercial Building Permit May 15, 2000 s D ue'only RECE I 0 ty of Northampton Status of�e�r t � , .-- . B ilding Department Ccrb CC�t/Dn # 1 erm £4 f NOV f 212 Main Street SewerlSepfiAvailabrlt#y 8 Room 00 atert efl Sr3lCablllt} i hampton, MA 01060 wg%I ctura >?iaz gii ; '� DEPT. OF BUILDING I@p�� J No i 3- 87 -1240 Fax 413- 587 -1272 PI t/Stte Plan NORTHAMPTON, MA 01060 ' O t h e r s peci f y APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office i ir° kALI ^ p{.i4 5 Map Lot Unit L i Zone Overlay District - 7() i.- , - AA, ,. - � a�.�------ � - -- � ��---- w - --- ��-- .Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner f Recd ' C 4411„1...ttPX 1,77-511,,,,,,,,,,,_____ __ , , 7-0&-7-1----1 4. r ),6 iL Name (Print) Current Mailing Address Signature ,T 'A . / 'r vi — Telephone 2.2 Authorized Agent: _ .':---- -- --inA-.7-4c- - Name (Print) Current Mailing Address / _ —1 _ a "' --1 ' . _._ Signature �� / Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only c pleted by permit applicant 1. Building a .) (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) Check Number ;/ 605 / AS — This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date 11 MULBERRY ST BP- 2013 -0604 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10B - 024 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0604 Project # JS- 2013- 000966 Est. Cost: $25000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WALTER MAREK III 055201 Lot Size(sq. ft.): 17772.48 Owner: HAMEL EDWARD P & MARY M Zoning: NB(100)/WP(100)/ Applicant: WALTER MAREK III AT: 11 MULBERRY ST Applicant Address: Phone: Insurance: 73 SOUTHAMPTON RD (413) 527 -7667 () Workers Compensation W ESTHAMPTONMA01027 ISSUED ON:11/28/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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: 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 Signature: FeeType: Date Paid: Amount: Building 11/28/2012 0:00:00 $150.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner