38B-064 CITY OF NORTHAMPTON
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A. . CC ����� �
Address of Work: pzcz `.J G
The debris will be transported by: t ' �•�re)hr"- ,2 - / Uwi
The debris will be received at: Vv = / t % J 6
Signature of Permit Applicant
Date 3 "3 - de /
Building Permit Number: N
, ;.,; ° a' i•-`'• x M e l : , Y s , x ' "1 /, ' ;:'
Bo orBuilc ing .egulat ons and lanaarus
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 133234
Type: DBA
Expiration: 5/25/2011 Tr# 283603
WESTERN MASS. MASON
DAVID OSIECKI •
383 COLLEGE HWY
SOUTHAMPTON, MA 01073
Update Address and return card. Mark reason for change.
Address Renewal Employment Lost Card
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration: 133234 One Ashburton Place Rm 1301
Expiration: 5/25/2011 Tr# 283603 Boston, Ma. 02108
Type: DBA
WESTERN MASS. MASON j
DAVID OSIECKI
383 COLLEGE HWY W f
4
SOUTHAMPTON, MA 01073 Administrator Not valid without stgna re
11assaW - Deh tilmcnt u ts
l `. Uttar d E)I Bniltlinu IZW u1,1[nm and tit .1 tip
Construction Supervisor License
License: CS 89376
Restru to. 00
l ire
DAVID OSIECKI
383 COLLEGE HWY
SOUTHAMPTON, MA 01073
cx irdtto- 115/2012
rr 12808
nun.�iu +rt
LICENSED REGISTERED INSURED
at 2 MASON S ...v.-
WESTERN MASS Ila
. - , :
383 College Highway, SOUTHAMPTON, MA 01073 - (413) 527 -1800
i . °VES TE N MASS A; ONS.COM
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QUOTE
To: GINETTA CANDELARIO Date: 1 -13 -2011
257 SOUTH ST. Quote # 674378
NORTHAMPTON MA Project: DEMO GARAGE/ FOUND.
Phone: 695 - 6322 Other
Phone
Description of Work To Be Done:
L
\
1. PATCH AND STUCCO REAR SECTION OF FOUNDATION ON THE EXTERIOR AS NEEDED.
BECAUSE OF THE WEATHER CONDITIONS, THIS JOB MUST BE DONE IN THE SPRING
TIME.
TOTAL $ 750.00 y;
r
—2 ��DISMANTLE AND DISPOSE OF EXISTING GARAGE. .:'A i k _ I) i k )' -''` ' r L (3 /- ,t ' „ ° ` I
) c j-
i
' TOTAL$ 1500.00
3. SPRING TIME. INSTALL SMALL RETAINING WALL AND WINDOW WELL, LEVEL OFF GRADE
FOR ADDITIONAL PARKING, APROX COST.
I TOTAL$ 2000.00
WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR - t
IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS, FOR THE SUM OF:
This quote may be withdrawn from us if not accepted within 30 days. LI BBB ONIINf
Quote Prepared By: Da vid Osiecki R z ° '` $ ` t ' ` 1
p Y� ����ti >����t
TERMS: Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an I
extra charge over and above the estimate. By signing this quote you agree and understand all the above terms and conditions that apply to this job. MIMI
Any changes that are to be made, must be discussed prior to construction and agreed upon by contractor and may also effect to the final price. V1SA
PAYMENT TO BE MADE AS FOLLOWS: One half of quoted amount is due when job construction has begun. Remaining balance of bill will be paid
ill, full when job is complete. A Finance Charge of 1 -1/2 (18% annual rate) per month will be added to any unpaid balance over 30 days.
OP . ' ACCEPTANCE OF PROPOSAL: The Above Prices, Specifications And Conditions Are Satisfactory And Hereby Accepted. You Are Authorized To Do
I The Work As Specified. Payment Will Be Made As Outlined Above.
Signature: Date. Signature: I Date-
. ! ,
"ha i i uu For Chooz,. ''iestt'r°n lease Masons!
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
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The Commonwealth of Massachusetts
Department of Industrial Accidents
il■
Office of Investigations •
600 Washington Street
Boston, MA 02111
- ,
www.mass.gov/dia
'114r
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusineseorganizatiorilindivirbiaD: LA's xfirb
Address: •
City/State/Zip: Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): /
1. aam a employer with A 4. 0 I am a general contractor and I
6. ci New construction
employees (fall and/or part-time).* have hired the sub-contractors
t
listed on the, attached sheet 7. 0 Remodeling
2.0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8• D Demolition
envloyees andhave workers'
working for me in any capacity. 9. 13 Building alidition
comp.insurance.f:
[No workers comp. insurance _
10.0 Electrical repairs or additions
5. Ei We are a corporation and its
3. Di am a homeowner doing all work officers have4xercised their 11.0 Plumbing repairs or additions
right of exemption per MGL
myself [No workers' comp. 12.0 Roof repair s .
insurance required.] t C. 152, § 1(4), and we have no
enployees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Honaeowners who subrnit this affidavit incficating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
employees If the sub-contractors have employees, they must provide their workers' camp policy number.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
> %
Insurance Company Name: (-) )
Policy # or Self-ins. Lic. #: c:C 2 `1 Expiration Date: -
_5
Job Site Address: 3 vZ City/State/Zip:*
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 WORIC ORDER and a fine
of up to $25000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Erv of the DIA for insurance coverage Verification .
rdo heieb; certify untler the penaltiev of perjtay that the information provided _above:trirue and_corma.___
S UN • tire: o /
Phone it: 4 `16
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: Person: Phone #:
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ` f/ Not Applicable ❑
Name of License Holder : ( 4_c � t Ci , CL l `� i v / 3 2 (
License Number
3 IA
Address v Expiration Date
/ CO
Signat Telephone
S: =Registerecri�erI+roiremii airi #rate~ rt - 1" ;, ._ Not Applicable ❑
Lie j e '-•- /1 /WI y i 1 /33 3 4 1
Company Name Registration Number
Address Expiration Date
Telephone
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 ❑ No ❑
11. - Home Owner Exemptioi
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. El Demolition New Signs [0] Decks [p Siding [D] Other [D]
Brief of Proposed K C 64,-/C ` /
Y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building : One Family 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 construction. 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 finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a;- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
17A./ I ai�e ` i , 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 u er the pains and penalties of perjury.
f ad(
Print Name
/if
Signature of Owner / . t Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information j .' »,, - '"' "
Existing Proposed Required by Zoning
This column to be filled in by
Building Department g f i f t,< "," °
Lot Size `- ¢ w
Frontage '. . i 1 1
''
Setbacks Front 3 i I
Side L: ' R. __' L:1 ? R:! ..
Rear I I -- . t_
Building Height j
Bldg. Square Footage ) 1 I I% 4 I I
< � '
. Open Space Footage ; o %
(Lot area minus bldg &paved L ; , I L __.. = +®
parking)
# of Parking Spaces
Fill: n __�..._ , ,....�__�� �.� .,_e , �... .wwM. — __...
(volume & Location) —. 4' 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES Q
i
IF YES, date issued:
•
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book 1 1 Pag j and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES i 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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
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City of Northampton
IVED Building Department xelli'b 7 w
a _ 212 Main Street s s � °.
Room 100 = r E
f 2 2 2 011 Northampton, MA 01060
• I • ne - 13- 587 -1240 Fax 413- 587 -1272
fl e
of BUILDING INSPECTIONS ® ,
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
,Map ` Unit
- Lot �
SG /o ' �
done , Overlay District
Elm St District " CB Dist
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Reco ` G �� � �
rs� ti C r Q
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: ,�^,� /1414-) rJ
� est(r- Mtf /) ' SJ
Name (Print) Current Mailing Address:
Signature / r Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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 s 7 —
6. Total = (1 + 2 + 3 + 4 + 5) /S VG' u Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
CNELE
hh��
File # BP-2011-0692 , LEFT' YS Q
APPLICANT /CONTACT PERSON WESTERN MASS MASONS NEED T) € / o b(621 S
ADDRESS /PHONE 383 COLLEGE HIGHWAY SOUTHAMPTON (413) 540 -1959 CER FKAt(a4-)
PROPERTY LOCATION 257 SOUTH ST / P6R0
MAP 38B PARCEL 064 001 ZONE URB(100)/
(
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �/
Fee Paid 7 (2;Z- >
Typeof Construction: DEMOLISH DET GARAGE Nl A T RE Len SAFE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 089376
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
Approved 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
Demolition Delay
3/2//J
Signature of Building Official 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.
c �
257 SOUTH ST BP- 2011 -0692
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 064 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit# BP- 2011 -0692
Project # JS- 2011- 001136
Est. Cost: $1500.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WESTERN MASS MASONS 089376
Lot Size(sq. ft.): 9408.96 Owner: CANDELARIO GINETTA
Zoning: URB(100)/ Applicant: WESTERN MASS MASONS
AT: 257 SOUTH ST
Applicant Address: Phone: Insurance:
383 COLLEGE HIGHWAY (413) 540 - 1959 WC
SOUTHAMPTONMA01073 ISSUED ON:3/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMOLISH DET GARAGE
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 3/2/2011 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner