35-169 (15) 1345 HURTS PIT RD BP-2017-1052
GIS4: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35 - 169 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REMODEL BUILDING PERMIT
Permit BP-2017-1052
Project 4 JS-2017-001808
Est.Cost: $19000.00
Fee: $114.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WALTER MAREK III 055201
Lot size(sq.Lt.): 19994.04 Owner: PELIS LAUREL,
Zoning: Applicant: WALTER MAREK III
AT: 1345 BURTS PIT RD
Applicant Address: Phone: Insurance:
73 SOUTHAMPTON RD (413) 527-7667 0 Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:REPLACE 6 WINDOWS AND 1 EXIT DOOR,
REMODEL BATHROOM AND BEDROOM
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 $114.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 7 BP-2017-1052
APPLICANT/CONTACT PERSON WALTER MAREK III
ADDRESS/PHONE 73 SOUTHAMPTON RD WESTHAMPTON (413)527-7667 Q
PROPERTY LOCATION 1345 BURTS PIT RD
MAP 35 PARCEL 169 OW ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
E _ : .0 REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ���
Building Permit Filled out
Fee Paid
Tvpeof Construction: REPLACE 6 WINDOWS AND I XIT DG•',REMODEL BATHROOM AND
BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055201
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
roved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:¢
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received& Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
_ Permit from Elm Street Commission Permit DPW Storm Water Management
lition Delay
S ture of I uilding a fficial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning& Development for more information.
LULL/'`_ 'i__- 1 i Department use only
-I 1 City of Northampton Status of Permit
.r 1 al Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site 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
3ti S BA PI L * Map Lot Unit
Zone Overlay District
Fl Jrer I1144 . 3 ia4a.
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I rxurt\ flits I3NS � pt (R; 1-tiery=t
Name Bring"( Current Mailing Address:
�� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address
, cll� l7) 1.C31
Sig ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I co6D (a)Building Permit Fee
2. Electrical f (533 (b)Estimated Total Cost of
/ Construction from(6)
3. Plumbing 3 3 c Building Permit Fee ,xA ((��
4. Mechanical(HVAC) ) `�//7'
5. Fire Protection _ c
6. Total=(1 +2+3+4+5) /6/ 0OD Check Number aR/
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks
y[p Siding[p] Other[o]
Brief Work: scriyfion o(fraposad /^ k A�1 Y�/ -� 2o�j vwn. f^ ( fy♦.�
z{7ptign fj i gi spd j XI: ,,a�/ G1 I �,/
Alteration of existing bedroom Yes "\ No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes U No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing,complete the following:
a. Use of building :One Family II Two Family Other
b. Number of rooms in each family unit. Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new cons ction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands. Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below fi fished grade
k. Will building conform to the Building and r oning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORO' I1APPLIES FOR BUILDING PERMIT
I• A...11�b✓4 �`^1 ) as Owner of the subject
property /��/�l
hereby authorize 1/k,CL 11 v / r rA(OC
to act n my t ha in II matters relative to work authorized by this building permit application.
3lalli)
Sig ature of O/wne/r},/ Date
(/V&IIV /' /G✓eI . ,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 a penalties of perjury.
Wouim k✓eiyZ
Print Name
al
Si'nature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column robe filled in by
Building Department
Lot Size ct J`( -
W (`„
Frontage C7 v'.
J`-
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Loi area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document It
B. Does the site contain a brook, body of water or wetlands? NO t„) 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? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: kt-I S BII 11S 9
The debris will be transported by: a
The debris will be received by: ( A1 Rec1JI �
Building permit number: J� y��
Name of Permit Applicant r . I
/441 104
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
t•– = I
rgDepartment of Industrial Accidents
t ,
ll Office of Investigations
r —'"el— Con
caWha j= n 1 gress Street, Suite 100
• ° Boston, MA 02114-2017
1 www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information gyp,^ / Please Print Legibly
Name (Business/Organization/Individual): ( ,f✓IQIrd` (,
Address: �3 Sothi irr1�&
Cit /State/Zi rat 3 a) Phone#: (-41" TI) C� }`-
Y PYaPr��i�
Are you an employer? CheckUthe appropriate box: Type of project(required):
I.la 1 am a employer with I 4- ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. irif Remodeling
ship and have no employees These sub-contractors have 8. "❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.: 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
Y12.0 Roof repai
insurance required.] r c. 152, §1(4),and we have no �-1
employees. [No workers' 13.aK Other l'/��' WyS ti./.-)4'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors 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.
Insurance Company Name: 4e7 (-
Policy#or Self-ins. Lic. #: CLL-`s� u 0 1 S Expiration Date: �`j b I fl
Job Site Address: RH1 c 13tH b1 ,vl L. ��t City/State/Zip: �'jj7v^C V/fl' J)JC)
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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains an realties of perjury that the information provided above is true and correct
Signature: /I./ '-`/ Date:
Phone#: cfR t --ti 1 J
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 if:
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor�,r( �/✓� Not Applicableppli ❑
Name of License Holder: J& 41 ' ' t( 4f _4 =� it CJ occ
�j Live I rp Licenu'Nu r
�� C '1 �l1-Y4 l•{rte' Expiration Aeems to q)-7 fj^�1
Signature /Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
LJ . I'✓l trA( - IS`1
Company Na I , Registration Number
73 ^ ,9 �) �/4 yffuJN7
Address A l / / r, \a E r ti n Date
11 Telephone 43 y� / `c?
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 ,14 No ❑
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
,1CnRn CERTIFICATE OF LIABILITY INSURANCE DATF'"N°°"""
0911312016
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: N the certificate holder Is an ADDITIONAL INSURED.the policyUssl must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and;:onditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in leu of such endorsement(s).
PRODUCER CONTACT
AWL_
N.S.K.INSURANCE AGENCY,INC. P�AIHQF NAEr„v.„.(413j.5274859 Fax
.y �hL413)527-83ti.
ase
203 Northamptot St, Amens. dicksleeaks tinsurance coat.. .
P.0.Sox 597 _
AFFORaaO coYeySyla _ xAKr
Easthpmsm MA 01024 mauve A LT
PEC
ENDURANCE AMERICAN SPECIALTY INSCO
INSURED _ ._ . _.. . ..
w1yRAr{L,ASSOCIATEDEMPLOYERS INSURANCE COMP,I
W.Marek incorporated ,attietik -. ___—_ _ _. i. _ __-
73Southampton Rd _ •
-
Wa:Hhampton MA 01024
INSURER P' I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 TO CERTIFY THAT THE POLICIES Of INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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.
—. _- "-__• AAAA
INER.. A.160 Mr/O. __-.. pppp ��T EFF PeqpLK10EtP
TYPE OF INSURANCE A11RnWVD PpyCV NUMBER
�Lra4DWYYYY1,lYBNWYYYv1f OATS
X j COMMERCIAL GENERALJASNITY . GAct§OCC RENct '11000000_
A • i CIAIMSMN)f X '. ,y.CUP DAMAGE TORETED ��
_ j ♦RIIFIYSEAIPa.v-un 1 _
1
100
_ 1 CBPS2000012400 '114)1120151 11/01/2016 jjec Expire,.jos ovvr,H. +;5,990,._ __
IS � ENEau ALcre�ATg 1L20001060
e
� ylA 4xE ,le TIMI'n-PFS peg OO
•
Pc c `i- ;. .:0c PROOLc s etwPs>o (.;G At,WOL000
P _. l 1
AUTOMOYE LI ABILOY 'G'tM18'NEDSW(.LEi bIT !F
IEAYcmtll -. SP-
.
ANY AV"O IBJMLY INJURY LPorpv §_
. All OANCI: SCNFDUI ED BODILY INJURY Metk I $
4UIV5 L.__,AG TOS _ _...
niRE iRetbS AuRD N1Y DAMAGE.HAGDAMAGE. r
—_.', i ALTOSras f.venthar
LMeaELLALWP _ Ixcok i :nxLuaaFm,F 41
a 1. y MS:MAOE. _A.LQRcuATL-
___..
ANO EMPLOYERS'NSAUONN F.
WNMEAFSCCYFEUAI LITi I STATL'.[Ei CTi- .
esOPRtlTOUPAATNERE%EC RI\'L II E EACH ACCNEN+ t_1O0,000
B pr.l(£0.MEMP 3Ei:L UDEC !Y '.NJ WCC'SOASO1A2904015A IO2/1O12015-0211012017` j-
wndM«y m
NH ( E.0,SEASE_EA ENEL,D Ei{1001000
It 0,v„ e
es.J IPi4, . OPERATIONS Debt DISE' .-POLI' LIMIT ' 500 000
•
•
•
•
DESCRIPTION OF OfERAPONS.Lockman I VENKLES UCORD let,A VINIo1Y Rdnar$Sth.d'N,may be.NCMd if ma.Mom Is rpulnd!
GENERAL CONTRACTOR
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF NE ABOVE DESCRIBED POMCMES eE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AV1Hp1nED RFP'ESFNTATIVE ,L A rt / _, CTS}
C 19418-20144 AAACC0 SORBIOM'CORPORATION.E 'jy/TI � AilrightsriigghthtsAJsrrreeserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Massachusetts Department of Public Safety
j Board of Building Regulations and Standards
License: CS-055201
Construction Supervisor
WALTER L MAREK,Ill
73 SOUTHAMPTON RORI 1
WESTHAMPTON MA'.1PM fi
r---I.arct Expiration:
Commissioner 06123/2018
Commonwealth of Massachusetts
j Department of Public Safety
License: 1-1E-156706
Hoisting Engineer
WALTER L MAREK,Ill
73 SOUTHAMPTON R 1
WESTHAMPTON MA 2 - -
:..4 .,
r*
'f�_1_- , l.✓� Expiration:
Commissioner 06/23/2017
TF tc m,77or7/7/0/7-777.74„.71/1,
Office of Consumer Affairs&Business Regulation
iiiii,='griogM t IMPROVEMENTMP0T CONTRACTOR
e
d ' p Ex iration: 4/30/2018 Private Corporation
moi'
W. MAREK INC.
WALTER MAREK Ill
73 SOUTHAMPTON RD.
WESTHAMPTON, MA 01027 Undersecretary
Gtr,-)[0 .]
r1 ---- 1,,, rn'CC
V Ffo JYV
—vAI vm7r, I urtrAlt _4(0 sing
1
L
L-1-04-1-1--
1-4�i-----