29-339 (3) jv-
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a��-4931
W. M. BROWN
ROOFING CONTRACTOR
SLATE—ASPHALT SHINGLES— FLASHINGS—VALLEYS & GUTTER WORK
Lic.#038426 P.O.
1 1 West cuJC
vJ Hst-N'la'MA o or`
Date. A i1......1..,..,al .o.l.......................
CONTRACTCustomers name:... ....sg.aa.........7.a C.la......
t.Address: City.. AA- .x aZ................................State...Xal�a�
..................................................zip...Q1.ojaA
The undersigned Contractor, agrees to furnish all materials and labor necessary for the work(specified below)
on premises located at No.__9_1_A: iC. e,"' P,-�,�_,�( A=
(Street) (City) (State)
(I)(We),the OWNER agree to pay you the sum of: ��.� �++..+, ,,,,, ,.,d Dollars($
as follows:$_LA od, o,�) upon signing of this agreemented P. ACV G,b l
Upon completion of said work(I)(We)further agree to pay the sum of$ �a.o n,a b
SPECIFICATIONS FOR LABOR AND MATERIAL
To be applied(or furnished)(or constructed)to following areas:
Al-
0
ff��
Q 4 1J1w w Ten»/
d
•QQ
Owner further agrees that the equity in this property is security for this contract. This Contract shall become
binding only upon written acceptance hereof by the Contractor or by an authorized Agent of the Contractor; or upon
commencement of the work.
The Contractor shall not be liable for any damage to the interior of the building and it is understood that the
Contractor is not an agent nor a sub-contractor of any other corporation, and that no other corporation is a party to
this Contract.
This Contract constitutes the entire understanding of the parties, and no other understanding, collateral or
otherwise,shall be binding unless in writing signed by both parties.
IN WITNESS WHEREOF the undersigned have hereunto subscribed their names the day and year first above
written.
Contractor
( usband or Purchaser)
By 1, `�-
i
(Authorized A ) Nov . (Wife or pint Purchaser)
_ren� . &i 3) -uq 3 ,
= , 2e�0—t
g�1tAMPT0
Boo Gxf-� Of wart 11aillp#111
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DEPARTMENT OF BUILDrNG INSPECTIONS
• . i 212 Main Street R Municipal Building 'o
Northampton, Mass. 01060 �~ '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Ii censee/permi tt ee)
with a principal place of business/residence at:
l?7 We sq cqt, (phone#)A17
statehip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worlang on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole props rieto general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expimbon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExTimtion Date)
(&Mach additional sheet if naxszuy to include mfvcrostioa pertxLm i to av oocttra )
(L�l am a sole proprietor and have no one wonting for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homcovn3=who employ pczio=to do onj*+�mostrt=oa or repair work on a dwelling of
not mote than thr-units in which the homeowner raids or oa the grounds appurtenant Ihacto arc not generally oomidend to be
employers antics rho work&`&cmpcau4on Act(GL152_,s 1(5)),application by a homcoRVCr for a Gccnx or permd may evidcs oc the
legal status of an amployer under the Workoet C.ompamation AcL
I understand that a copy of this etatemml may ba fbrvrnrdad to tho Dcpwtm of Industrial Attidca&Offioc of Imurinw for tba
coverage Wrificatson and that failtmo to waste eovemp Undcr scction 25A of MOL 152 can lead to tbo imposition of aimi penalises
oomisiiug of a fine of up to S 1,500.00 and/or imptisoamccd of up to one year and eivt7 pcn&W es in the focm of a stop Work Ord-and a
firm
ors 100.00 a day agaimd tnc.
For dal use only
permit Number
Lot#
Signah of License&perulittee e
c
f
SECT ONCONSTtRUCTION,SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
r License Number
1!77 6 SF%2 to
Address Expiration Date
Signature Telephone
LIS.r-113 -.z r
WARM
grWrZei Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 107 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 affid
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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 buildinE 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(
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
A. ., " a �
{ , y
�"k�' xwx` isr ' + � .
SECTION$5 DESCRIPTIO Or,MROPOSED,WGRK3>tchWNI applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a t" Newhouse" nd or ad it`ion to:e�crs"ting Housing, comp1`e d-tK&fol.l:owin' :
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. Mascheck 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
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 OW NERIAUTHORIZATION-TO BE,COMPLETED WHEN
g11YNERS AGENT ORxCONTRACTOR APPLIES:=POR BUII bING,PERMft
3 r -,n.. 4
as Owner of the subject proper
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
_ � V( crcui-tom' 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 and penalties of perjury.
A car,
VA
Print Name
(--"S:F, ft i3/ 1
Signature of Owner/Agent Date
j
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES ,. NO
IF YES, describe size, type and location: rip file-
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location: �kp b,�!t 1,.zi;g3
i ty of Northampton
tS U� 11 l5 ilding Department u e
12 Main Street er- • . .�„ {�
.! L r
NOV 1 3 2C01 Room 100
Nort ampton, MA 01060 ets
4113-587-1240 Fax 413.587-1272 Platlie s.
DEP10F?UILGI'dG I NS �`���`��
N-TWMP10N.MA 01060 Ot e Sp�o�.,: ..
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONJ - SITE INFORMATION
This section to be com Meted by off�cery '
1.1 Property Address: 3
Elm St"District CB D.istr�ct
SECTION.2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:�r
�--i
Telephone
Signature
2.2 Authorized Agent:
XAIf_ r�ci tr.� /n we--/� ����tR�-lu
Name(Print) /t ` Current Mailing Address.
Signature Telephone
SECTION'3 - ESTIMATED:CON STRUGTION"COSTS"'
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical `f (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 ,
This ection.For Official'Use,Only
B�ildmg°Perrriif'"Number: Date Issued:
Si,�nature : " -
Ouilding Cor,missioner✓Ins"pet#oX of Built►raB
yr—�
A} K DR s BP 2002 0523
GIs#: COMMONWEALTH OF MASSACHUSETTS
lap �`- CITY OF NORTHAMPTON
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002-0523
Project# JS-2002-0800
Est. Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: W M Brown 038426
Lot Size(sq. ft.): 10410.84 Owner: FAGADA FOLA
Zoning: URA Applicant: W M Brown
AT. 212 ACREBROOK DR
Applicant Address: Phone: Insurance:
177 West St (413) 247-9937
WEST HATFIELDMA01088 ISSUED ON.111161010:00:00
TOPERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/16/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo