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38B-247 / r" Proposa l Page No. of Pages \ CSC// U NEWMAN'S CONSTRUCTION 1 a n 4nn t 697 Bridge Rd. sk Northampton, MA 01060 1104 413- 586 -1093 PROPOSAL SUBMITTED TO a PHONE DATE //:/// t ll \h i-__.- F c fo._ .51P — i 6 :35 F" F i.,, STRE T / 0,vzeG \ S JO VC: CITY, T z� Q 4 (-CI k ©`r, JOB 1 CATION 1 ` v/ � s +. A) � m () (yk) E ARCHITECT �� Y\ DATE OF PLANS V 1 JOB PHONE We hereby submit specifications and estimates for: ' C7i-r- ,. t(Z( �, 4 3 L �Y Q � CY3.. �Vr • _ �` �V�GL ' \i2!. 124tH C , J j , L ✓151 1�_ fALv�'fn p ►!L. � ? ca_`n ALL _ `� " n 5'l /l __ .I Cf. 4 14-.) f} Z_.4 14.. ‹.,02 p....t t. fi i R V s ., c i _ 5 ,' OI, CA-Y.-tq 5. � ca y2.0 A: •1(:4? C.L. •' vv. t1l y %i 7)17 4" 5 tG y_. ' G f 4� `a (.:'+ Y1 `t ✓LG y ont y L 1 1 . H 5 . /G� / / l � _ G 1/ '1';' r4.5 hi( AL t)r.vt i v.,.-wi 0 r i.? " 14 .194-!.. (14 51i; ? 3 cr r?2 ct 4) i t2* cQ. / f t-V- - II _II r j ++ j I W rifle // X30 x 13.►2CGr, T2 c. f t..k'' _ S h r e z __ 1 t S o h_ f of • a22___ jzcc6 c t2 c) to;&. 0 9C (_toi..,rr0J c! 5/c) . _ i- 4;c1 s iP) / 4,4 g,�f c. _) 6 eK.. 111 s L 1/ :A / Jp ./.6„) n b.f e. , c,- 4i-fi 57S6/44 ei1-7 444, p i . k• L !./ `: e.. k.661- i 1 p: )Ly r24 ✓e. 6t 1O OS ice4)1/4)tv cu; I! -aCC.1,.'5G61rz S 1 al lol; r propose hereby to furnish material and labor — complete in accordance with above spec) ications, for the sum of: 1 t- � tJ %��L P CL C & V C 7 i W Y1 �c � ucve �v C dollars ($ t ). Payment to be made . follows: la cc • ‹c h • ' ZJ • _ + \ :( j All material is guaranteed to be as specified. All work to be completed in a workmanlike C ) manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This propo ..jf ay be /�_ \ Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not acre � within V days / Arreptanrr of Proposal — The above prices, specifications �� � and conditions are satisfactory and are hereby accepted. You are authorized Signature 1. _ ..wli '4- .. a . V�� to do the work as specified. P mtgent wil`l made as outlined above. Date of Acceptance: l ` ' ( 1 ` Signature $. 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 permits 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 me. Date Address of work location . 2 The Commonwealth of Massachusetts Department of Industrial .4ccidents - ,._ Office of Investigations - I -:- - 600 Washington Street Boston, M4 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers Applicant Information Please Print Legibly Name Business % Organization'Individual): N 5 m,4.HfS C , r .r✓c J b c/cd _ Address: 677 ?yam 4 t , Ci ty /State /Zip: j 1 fi d,o',, Phone #: <-//." 5F6 Are you an employer? Check th appropriate box: Type of project (required): 1;2' I am a employer with 9., 4. ❑ I am a general contractor and I ❑ employees (full and/or part - time).* have hired the sub - contractors 6. New construction 2. ED am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodel ng ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition o workers' com insurance comp. insurance.* required.] p 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL .44,1Q 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. r 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. / Insurance Company Name: . 'C di &, ,c__., Policy # or Self-ins. Lic. #: G/JC _ /O 0 / 07'GO Expiration Date: 5/V / __S Job Site Address: Myt 5, • 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 81,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 8250.00 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 and penalties of perjuty that the information provided above is true and correct. Sinnature: - -- Date: 01/2.. Phone #: 'lc ;) 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. PIumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: n Not Applica /d ble / ❑ Name of License Holder : / L l S / I: w ° mA V (S / Q 1 y License Number 6 7 7 /3 #2 A- P d p £z - / i y/i e Address - Expiration D . - 10? gn- u - Te ephone 9. Registered Home Improvement Contractor Not Applicable ❑ //m41 l/ S. ( 7 Air. Aa if/. 1 Yo-7d 7 Company Name © , Registration Number /,7 ,2,a( 7 t �� � tit/ ���/ / �/ Address Expirati D Telephone 5'76 O9� — 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 Exemption 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 -vear 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) n Roofing X Or Doors GI Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [C]] Brief Description of Proposed / Work: /i/`4 A-t 77>i .' .: LR t ' 'Am t r... , SLi" '�L�E Alteration of existing bedroom Yes Addi ±new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New hous and or additio to existing - housing complete the following: 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 1, , 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 I C al /1'i „- 4,1 , as Owner /Authorized Agent hereby de 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 and penaitiespf perjury. ' � . y am- „"" "---- Print Name 7 s Signature of Owner /A.�-nt Date I_ I !Section 4. ZONING Ali information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning , This column to be filled in by Building Department Slat 1 Lot Size __.......,..._ _....-�..„.......__- f : Frontage Setbacks Front _` __ __.,_ Side L:...._.__m R. ,.. __... L ..,__ R.., ,,,,. ...._..__.m _.: Rear _____.. _______ _ Building Height _....._ .,__..:.,.:. Bldg. Square Footage % ...._..,_... .._ Open Space Footage _... (Lot 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 DONT KNOW 0 YES 0 IF YES, date issued:: IF YES: Was the ermit recorded at the Registry of Deeds? NO DONT KNOW 0 YES 0 IF YES: enter Book Page. l and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 5 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued. C. Do any signs exist on the property? YES ' NO 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 f2f 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 t,uimton plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water ManagemehtPemiitfrom the DPW is required. J. only E 'v �� ity of Northampton Status of Perm REC uilding Department Curb Cut/Driveway Permit l 212 Main Street Sewer /Septic Avaiiability °C-[ — Room 100 FNaterfWell Availabilit y ort ampton, MA 01060 Two Sets of Structural Plans . is = 3 -5 7 -1240 Fax 413 7 587 -1272 PlotfSite Plans N O OF {pMpTON MA 01060 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 /i O // iii i 5 71- Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: K/ L Ep , %W 27 // 0 /v° S7 Name (Pent) Current Mailing Address: Telephone ./ 3 — 79 7_ 34,7 V Signature 2.2 Authorized Agent: Ele s4i d 7 .-2, Name (Prin Current Mailing Address: ' / Signa - Telephone SECTI 1 • 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be / / � p��� aO 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 6. Total= (1 +2 +3 +4 +5) Check Number 7s ( 0 36 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building, Commissioner /Inspector of Buildings Date 11 OLIVE ST BP- 2013 -0377 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 247 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 -0377 Project # JS- 2013- 000611 Est. Cost: $11200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CYRUS NEWMAN 064690 Lot Size(sq. ft.): 16335.00 Owner: LEPINE KEITH Zoning: URB(100)/ Applicant: CYRUS NEWMAN AT: 11 OLIVE ST Applicant Address: Phone: Insurance: 697 Bridge Road (413) 586 -1093 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:10/2/2012 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 10/2/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner