29-071 (2) 1
William Sheldon, Jr.
General Contractor
License No. 072460
60 Crooked Ledge Road, Southampton, MA 01073
(413) 527 -4227
Customer name and address: All home improvement contractors and subcontractors,
engaged in home improvement contracting, unless
specifically exempt from registration by Provisions of
a ° `� Y Chapter 142A of the general laws, must be registered
4 ' • Th with the Commonwealth of Massachusetts. Inquires
about registration and status should be made to the
VA, E,, ,, , , , z Director, Home Improvements, Contract Registration,
One Ashburton Place, Room 1301, Boston, MA 02108
Phone# (ii °' CI (617) 727 -8598
� " 'C L �
We submit specifications and estimates of work to be performed and materials to be used.
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'� `t.. :'j d e � ' - ,s t A ` cus ti. C Ct !
A +1
Proposed Start and Completion Schedule (weather permitting) ,, • ..` �,,,
(. d start date °ti , %-t^ r-- . : - ( %,- -.7 , -¢ ii.
;.`.f! — '�' -° completion date ,./"."
i
Contract Price and Payment Schedule
$ upon signing contract (one third of contract price)
$ due upon 50% completion of contracted work
$6.0 due upon completion of contract
WARRANTY:
The contractor warrants that the work finished hereunder shall be free from defects in the materials and workmanship for a period of twenty -five years following completion
and shall comply with the requirements of this Agreement. In the event any defect of workmanship or materials, or damage caused by 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 inspections in connection
with the agreed upon work.
ACCEPTANCE OF PROPOSAL
I have read this document 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 y, s ified Payment will be made as outline above. F • ji 1 7
Signature ate d date Signature ' , / �' --' date it„
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
t 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
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4 The Commonwealth? of 1l Massachusetts
—x - - -- Department of Industrial Accidents
_
Office of lnvesti, anions
a - _ ,
_ 600 Washington Street
Boston, MA 02111
www. mass .g ov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print LegibIv
Name ( Business /Organization'1ndividuaI): S/ /d e,'... ( ( ^ ..4‘-'-''' "f•t. L
.
AddreSS:
City !State, /Zip: cv 0 73 `3c' : �• - '1,'. �, p lc Phone #: ( r / 1 3 ST ( Z
Are you an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 6. ❑ New construction
employees (full and/or part-time).* tn have hired the sub - contractors
2. ❑ I am a sole proprietor or parer 4. I am a general contractor and I
listed on the attached sheet. 7. ❑ Remodeling -
ship and have no employees �
working for me in any capacity. These sub - contractors have
employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance. S. Demolition
required.] �- ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ED am a homeowner doing all work
officers have exercised their 11.E] Plumbing. repairs or additions
myself. o workers' comp. rght of exemption per MGL ,, r
�' 1: ❑ Roof repairs
insurance required.] ' c. 152, §I(4), and we have no
employees. o workers' 13 • ❑ Other ,c, c< -
' /1,,
i comp. insurance required.]
Any applicant that checks box #1 must aiso 51I out the section below showing their workers' compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing. ail 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 errmloyees, 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: , 1'S .'
( D //.r1::a r -,t _
Policy 4 or Self-iris. Lic. 4: w C .2 3 1 5 3' 1 /7 3-GC' -" t 7 Expiration Date: t 2 ( o z/ J;'
Job Site Address: ,2A 4 t, -t. - i l';_, L 1"c - • j I c' .' , C c . ' City /State /Zip:.,' C._ 55
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 , position of crrrinal penalties ofa
fine up to 51,500.00 and/or one -year imprisonment, as weIl as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DL& for insurance coverage verification.
I do hereby certify under the pains . andpenalt es of perjury that the information provided above is true and correct.
-Z "6 _.r ° , -,... , / /
Sienatur ter`' , Date: - -/ l ' C1 \"
Phone 4:
O use only. Do not write in this area, to be completed by city or town of zciaL
City or Town: Permit, - Licenser
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Lather
Contact Person: Phone
SECTION "o - CONSTRUCTION SERVICES I
8.1 Licensed Construction Supervisor: I Not Applicable ❑
Name of License Holder :
License Number
;dcress - Expiration Date
signature Telephone
r.. Reeistered Home - Imnroveretent Cantractor Not Applicable ❑
:omoanv Name Registration Number
.ddress Expiration Date
Telephone
ECTION 10- WORKERS' COMPENSATION 1N51: RANCE AFFIDAVIT 41V1:G:L c. 152, § 25C(6)) I
'crkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit. •
ened Affidavit Attached Yes....... ❑ No ❑
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. CINIR 780. Sixth Edition Section 1083.5.1.
Definition of Ho meowner: 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
ccmpietion 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aoolicable)
New House Replacement Windows Alteration(s) 7 I Roofing
E LI
E Or Doors
Accessory Bldg. L Demolition LJ New Signs [p] Decks [� Sidi [ Other [p]
Brief Description of Proposed ,--
Work: �1 5�=.�� V�,r,s S' c. a�—
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Nc
Plans Attached Roil - Sheet
6a: if New honso and-di-addition to existiriafiiousina: comorate the fo :Willa:
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 stones?
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. flocdpiain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulators? Yes No .
I. Septic Tank City Sewer Private well City water Supply .
SECTION 7a - OWNER AUTHORIZATION T'O BE GOMPL =:i tv WHEN
OWNERS-AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 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 Cwner Date
I 60); I `.•."' - A SJ'�c. c A..ti.. '--- , a.,
= CAIIger /Authcrizsd
Agent hereby declare that the statements and information on the forking application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of penury.
Print Name
ji t _ . 1 . „..,... —,.,- 6/1 G. /
.cnature of Owner /Acent =ate 1
of
ii
Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning.
This column to be filled in by
Building Department
LotSize _ ..._ _ .....__._ ..._ _ _. _ ......... ____...,._,_ _.,_._ _ __ _ . ..........._..:
Frontage _ ____ _________. _
Setbacks Front f
Side
Rear _ _ .. _.�
Building Height
Bldg. Square Footage — .._ 1 %
Open Space Footage _ % I _.__
(Lot area minus bldg & paved --
narldne)
# of Parking Spaces - - ----- __
Fill:
(volume & Location) - -°-------- --- - -- :_, — - ------ -----
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q __
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued
C. Do any signs exist on the property? YES Q 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 Q NO Q
IF YES, describe size, type and location:
E. VV II the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a coil urron plan
that will disturb over 1 acre? YES Q NO Q
IF YES, the a Northampton Storm VVater Management Permit from the DPW is required.
• Department use only
City of Northampton Status of Permit:
Building Department 'curb Cuf/DrrvewayPermit
212 Main Street SewerfSepfic.Ava
Room 100 Water/WeiI.AvailabiUi
Northampton, MA 01060 Two Sets of Structural "Plans _
phone 413 -587 -1240 Fax 413 -587 -1272 Ptot/SEr- � .. `�
Other ip - I, .
T
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISI-hA ONE OR TWO FAMILY DWELLING
J UN C 2008
SECTION 1 SITE INFORMATION
Thisrsectiffi be cairjpleted by. ciffice
1.1 Property Address: i ____._ I
pr(?..- t3, ^vc4.. 0 (- Mai, '.- -- -L ot Unit
A 0 ; .v+( .2'le Zone Overlay District
EIm St. District C8 District
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SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ! I
r
Name (Print) Current Mailing Address:
•
Telephone
Signature
2.2 Authorized Agent: I:
Name (Print) Current Mailing Address:
S h /C�c� ( ,r ,, $/ e... � A— ,�o:> ) t oh'-t 1 x/ 3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS C �/ fv
Item I 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
6. Total= (1 +2 +3 +4 +5) I Check Number 461 #.76----
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building, Commissioner4nspector7it buildings Date
22 ; :.#,, BP- 2008 -1125
GIS #: COMMONWEALTH OF MASSACHUSETTS
io= 071 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2008 -1125
Project # JS- 2008 - 001655
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SHELDON CONSTRUCTION INC 152162
Lot Size(sq. ft.): 12632.40 Owner: KELLY BRYAN M & BRIDGET K
Zoning: URA Applicant: SHELDON CONSTRUCTION INC
AT: 22 ACREBROOK DR
Applicant Address: Phone: Insurance:
60 CROOKED LEDGE RD (413) 527 - 4227 WC
SOUTHAMPTONMAO1073 ISSUED ON: 6/17/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 6/17/2008 0:00:00 $25.00201
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo