15B-049 (14) BP-2023-0586
259 CHESTERFIELD RD COMMONWEALTH OF M SSACHUSETTS
Map:Block:Lot:
15B-049-001 CITY OF NORTHA PTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0586 PERMISSION IS HEREBY GRANTED TO:
Project# RENO DUE TO FIRE 2023 Contractor: License:
Est. Cost: 150000 LEARY BUILDING OMPANY CSL104806
Const.Class: Exp.Date: 02/17/202
MEL CK DANIEL W&MARY HELENA
Use Group: Owner: SIMM S-MELNIC TRUSTEES
Lot Size (sq.ft.)
Zoning: RR Applicant: LEARY BUILDING COMPANY
Applicant Address Phone: Insurance:
13 GLENDALE WOODS DR (413)336-2611
SOUTHAMPTON, MA 01073
ISSUED ON: 05/25/2023
TO PERFORM THE FOLLOWING WORK:
REPAIRS AND RENOVATIONS DUE TO FIRE
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 NORfTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: $ 0 ,
Fees Paid: $975.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi.ner
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The Commonwealth of Massa uses M�r - 5 20� I FOR
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Board of Building Regulations an Stan ards Massachusetts State Building Cod , 780 R MUN CIPALITY
=aT p� u ---- ;USE
Building Permit Application To Construct, Repai ,.Reno ateT L TioFdevis d Mar 2011
1
One-or Two-Family Dwelling --00 1
This Section For Official Use Only
Building Perm it Number: g0'.�3^51p Date Applied:
e,,,,,_./255 i/, 6-25-2oz3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoni • ict Proposed Use Lot Are Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Required i ed Requirert5ided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private 0 Zone: Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system k
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �n/�
(Nuys�nN 4 MQD 1 f 1:L
E /J I IL /ea c Milli
Name(Print) Ci ,State,ZIP'
Zs9 Cii‘61-6Wial,D Va S it • MLSMELis ivc e & m, u_. C
No.and Street lephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)X Alteration(s)A Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': 7.entktl. Fag DAMAC,gt, (pro,,,a) / 0440,e
miTt2tog. LoAti, CAVDoT I qad WiAocc,;S 1 gaUttF fv S&i tt or
vuNic sibui(ti U Filic -2tii
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ /eft) D o o I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression) q1Cash
'`\ Check No. Check Amount: Amount:
6.Total Project Cost: $ is Ul VW 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
, '"--- /�,^ S• 0 2.11- V./I/r1. l-l�A'-' License Numb r Expiration Date
Name of CSL Holder
0 � Mat- ! b� List CSL Typ (see below) 0ooDS
No.and Street Type Description
/fin U Unrestricted(Buildings up to 35,000 cu.ft.)
Soo-a,t4u?T�ti 1 (VIA-lA- 01017 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
//' SF Solid Fuel Burning Appliances
�I� 33(0'1 lol I / pj �It� il1�'r(i0W/it• (o,i. I Insulation
I one E ail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t,EAR s t)11.D 1/VC.mict I N L HIC Registration Number Expiration Date
HIC Compaq Name or HIC Registrant Name
15 GcE.JAALE C%)co S e i (, Late Burro 44j.6,,
No. d Street < E nail address
tJOUTktAM?Tay t Mf} t (loll t.IIJ33(p.Vonn
City/Town,State,ZIP Telephone
SECTION 6: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 No 0
SECTION 7a: OWNER AU HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize " L
to act on my behalf,in all matters relative to work authorized by this building p it application.
W.) i MMt G (Y piuttc C-3-23
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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 best of my knowledge and understanding.
M hike`` ' S -?- 13
Print Owner's or Authorize Agent's Name(Electronic Signature) Date
rr NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca 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 basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
I. ` Massachusetts At/ "'c�
s DEPARTMENT OF BUILDING INSPECTIONS %\
212 Main Street • Municipal Building
Northampton, 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: \fAkl,vti/ L7 CIA k
Location of Facility: GAS T 1kAMP fcAi ) NIA Oio1
The debris will be transported by:
Name of Hauler: Leg 6LL- t)XX
1
Signature of Applicant: Date: S- •°,3
FORM 153 The Commonwealth of Massachusetts DIA U-
se Oily_
Department of Industrial Accidents 1 '
Y Office of Investigations- Dept. 153
1 Congress Street,Suite 100,Boston,Massachusetts 02114-201(/ — -
_6- , http://www.mass.gov/dia Invent./SWO ID#:
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE "
OFFICERS OR DIRECTORS ! • ?1 al:,11rOnt a.Out"i
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 ivi.t i i, c. 152, §1(4) as amended, 1/'vVe the ttndrrsigred nfftcers 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 above and
1/we have checked the appropriate box below my/our name(s) indicating my/our desire to be ehBmpt.or
not to be exempt from the provisions of M.G.L. c. 152.
Signed I,.Itder th pains andpenalties of perjury:
Timothy A. Leary, President 07/15/2014
Sign ure Print Name&Title Date(mm/ddlyyyy)„_
✓❑ I w{Lh to exer e my righi o 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 ❑ 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 ❑ 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 ❑ 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 buck. Form 153—712010
The Commonwealth of Massachusetts
,._�—
-y ;r Department of l/tdafstrial Accidents
i ...„
:'iv l Congress Street,Suite 100
:Tin 8rtstvn,MA 02114-2017
c www�tass.gov/dia
1%urkrrs' (:omprnsatiun Insurance.1flidavit:Beiiders/Contratt asben.
10 BI.. FILED s1 1111 I HE PERMITTING AUTHORITY.
Amnesia 4nferw ado. Plash Prbit Legibly
Name 1: / 12y &v«-0,N4 (wc
Address: I- Gc NoAL- i—)00as tt
City/State/Zip: tccx.)71-(AMPTON i M,3 0lo11 Phone#: i(/3) 33(, Z(o ll
Are yew an swayer?Cheek the appr eprinte ban:
Type of prefect(required):
la I am a employer wid employees(ful endeot pan-lime).• 7. D New construction
20 I am a tole proprietor or prrmenhip and have no employees working for me to 8.gReniodeling
say capscity.(No winters'Damp.Meinienae regrrtwl.l
30 la a homeowner doing all wort myself.(No workers'comp.in required.)a 9. 0 Demolitionm
4.0 I ama homeowner and will be be castration to ni ceeb all work on my property. 1 will 10 CI Building addition
gamma that all contractors eider hew weaken'compensation imwmooe or are sole 11 JJ Electrical reCpairs or additions
proprietors with°°employees. 12.0 Plumbing repairs or additions
13 I m a gaaeeal cantracmor and I haw hind the sebcaetracton bated cm the auacbed sheet 130 Roof
Than seb.ontacmn IMAM.leave eoployees and Imre IMAM.comp.i nsuamce.. repairsrepairs.a
Wean a coeperasioe and its Mims have ourcised their risk of exemiption per MGL c. 14.D Other
t(d) d a - w eae have ao 'b ��
yesa[No 'comp.in.ara.ce l
*Any appliont du,hacks boa SI mmr also till an the airtime below showing their workers'compensation policy iefmmetioa-
t Ilnmeownas who,ubmit the aRidavet i dieaoeg they are deeag all wade and tree hire onside ce>macters mum submit a new Ablest ndimting such.
:Conerx t..rs ih.e:t><',l.eht,box airs atnrhed as additional sheet shown%she name nettle sebomtractors and mac wheeler or not those amities hove
c-mploycc II the>ub :k neractors hem employees.they nu,1 pr.•.idt their sambas'oonp ry,3sl}ntmnccr.
1 am an employer that is providing rumen'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy r• or Self--its.Lie.St: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the surkcrs' cuulpt n.atttru 1e011c di ilaration page(showing the policy number and espiradea date).
Failure to secure coverage as required under MGL c. 152.125A is a criminal violation punishable by a fine up to S1,500.00
and'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the t tolator.A y of this statement may be forwarded to the Office of Investigations of the DIA for insurance
co%eragc vcritikAwn
I du hereby ecru'.aund r the' d o erjary that the ins provided above is true and correct.
Signature: ' Date: ,S • 3 2 3
Phone#: (ti ) 33(o• <<. 1 l
Official use only. Do nut write in this area.to be~spieled by c*Of Town official
('it) or Town: Permit/License II
Issuiri Authorirs tcirclr one):
I. Board of Health 2. Building Department 3.( it),Town Clerk 4.Electrical Inspector 5. Plumbing inspector
6.Other
( untact Pen ..: Phone#:
MASSACHUSETTS DRIVER'S
LICENSE
NOT FOR FEDERAL ID
,'' 102021 S40956942 r
2i»/202 02/17/1984
'° LASS ,
13 NONE
. '41 TIMOTHY LEARY
Or A
4,r 13 GLENDAI E WOODS DR
'��,y^'' � SOUTHAMPTON,MA 01073.9476
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ttM 1.616'01"
Dt)IOMb70/1 Re.07ry2Y2014 02/17/84
�I Commonwealth of Massachusetts
� Division of Occupational Licensure
Board of Building RI�ggulations and Standards
j'T
Constgdit�tf Svisor
CS-104806 _.." _ .E3pires:02/17/2024 I
TIMOTHY A I5EAR j
13 GLENDALE •
SOUTHAMPT9N
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C M.-r nissionsr daero4t;. 70 4,/(44.2..
TIE COMMONWEALTH OF MASSACHU§ETT6
p{fi,:e of Consumer Aftaits&Business Regulation
HOME IMPROVENAEJ CONTRACTOR
TYPE Ceroration
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181045 4.,iCS/14/2924
I-EARY B1.11LDINO,INC ..:
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TIMOTHY LEARY ke ,ajr
13;1LENC'ALE WOODS RJR �. -,,7 ,: 14g,�,ulf a %.e.0,4'
BOUTNAItPTON,MA 01tT�'1 undersecretary
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