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29-214 (2) JCM HOME IMPROVEMENT Estimate P.O. Box 329 Leeds, MA 01053 Date Estimate# 4/8/2008 59 Name/Address MICIMEL HUSH ELIZABETH DENNE 117 ACREBROOK DR. FLORFNCEMA-01062 Project Description Qty Rate Total REPLACE REAR ROOF ON MAIN PIOUSE, DETAIL'S BELOW I.Remove existing roofing. 2:Remove roof sheithing, 3:lnspect insulation for mold and replace as neccessary.(Any insulation to be charged extra,cost plus 201%and labor(&,,$35.per hour) 4 Reinstall new 1/2"plywood. 5:Reflash chimney as needed, 6-Install certainteed 3 tab shingle over ice water bai-Tiet-.Color to match remaining roof area's. 7:Remove ridge vent. S:Make sure that gutters are installed correctly and install gutter guard's. Job cost include.s,all labor,material,permit fee's.plu-,removal ol'all 5.000.00 5.000.00 construction debris. A deposit of MOM due upon acceptan e,1/2 contract price at start with final payment upon completion. JVf signed 4/ 708 Total $5,00000 r s . 04Tt pT0 Lx#y of Nart4alliptall z $� � �laesacl��cseffs DEPARTMENT OF BUILDRG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as i:is/her construction sup,.-: ,.or. 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 any 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 . A The Commonwealth of Massac usetts Department of Industrial Acci tents Office of In vestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/C ntractors/Electricians/Plumbers Applicant Information Please Print LeLFiblv Name(Business/Organization/Individual): Address: City/State/Zip: Phone.#: F Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor an I employees (full and/or part-time).* have hired the sub-contracto s 6. ❑New construction 2.M I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers [No workers' comp.insurance comp.insurance. $ 9. Building addition required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.Q Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.F-1 Other comp.insurance required.] -- 1viy applican a c ec box 41 must also out the section belowshowing iFeir workers'compen tion policy information' -­- t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conta ators must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contrac ors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy nun ber. I am an employer that is providing workers'compensation insurance for my eml loyees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: E piration Date: Job Site Address: Cit. /State/Zip: Attach a copy of the workers' compensation policy declaration page(showing he policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead t 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 WORK ORDER and a fire of up to$250.00 a day against the violator. Be advised that a copy of this statemeni may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains penalties of perjury that the information p rovided above is true and correct Signature- Dat : `�A C�� Phone#: Y/ 3 Official use only. Do not write in this area,to be completed by city or town offs ia1 City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electric Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTIONS-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /►� .�j� Not Applicable ❑ Name of License Holder: �� � • '� "10 M 0777w 1 0 License Number L{0 0k �S+ =�mrCnce /4-,H. 1 or /a2 09 Address Expiration ate �/i3-S�S�8y82 nature Telephone 9 Reaisfeced dome Irsiprovement Contracfur° Not Applicable ❑ Al Lf Company Name Registration Number ed 6(X 3ag © / o Address Expirat' n Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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 . °Hl� Q�,n&',--Ex ei>r>p ,o 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 . g SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows I tion(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [0] Other[O] Brief De ription of Proposed �4C I ,1 �1C~J ew Work: e foof cove'-f-i a � n Alteration of existing bedroom Yes No -Adding new-bedroom Yes " No Attached Narrative Renovating unfinished baseme Yes V-'No Plans Attached Roll -Sheet sa.If IVevu=hciitse an% Orac di ton;fo"existln ousin`' O`i�i"tefe"fhe fa lows 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 Woodstov s Number of each g. Energy Conservation Compliance. Masscheck Energy Coi npliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes o. s cons ruc ion wi i 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 Suppl SECTION Ta-OWNER AUTHORIZATION TO BE COMPLETED-WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 l 1''l. Detyle as Owner of the subject property hereby authorize to act oil my behalf, in all matters relative to worklauthorized by this building permit applic tion. Signatur of wner D to I, C$SC /• ,* as Owner/Authorized Agent hereby declare that the statemerifs 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. Print Name !q v ure of O Date ' * Section 4. ZONING All 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 Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved of Parking Spaces (volume&Location) A. Has a Special Perm t/Va nce/Fi nd i ng e er been issued for/on the site? AIA n DON7 KNeW �W - --- --`--��� � IF YES, date issue& IF Y[8: Was the permit recorded at the Registry ofDeeds? �� NO �� DON7KNOVV 0 Y[3 — '------ r-------� IF YES: enter Book / Page and/or Document#___________� �� �� B. Does the site contain a brook, body of water orwetlands? NO �_��� DON7KNOVV v�� v�� v��, IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobeobtained �~� O�to�mmd �~� Date ! � �~/ �~� ' � C. Do any signs exist on the property? Y[3 K ) 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 e IF YES, describe size, type and location: � ! E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part ofo common plan that will disturb over 1acre? YEGK��> NO K���� |F YES,then a Northampton Storm Water Management Permit from the DPW is required. • t f t Department rise only City of Northampton Stara of Perna#: ; s wilding Department Guru tivewayPertt i ! 2`12 Main Street sewe septic,A itAtirtrty _._ Room 100 �e eil Avai#abty Northampton, MA 01060 Two tsoi StructuraCPfarts r � r APR 4498413-47-1240 Fax 413-587-1272 PIa S e Plans _ _ o O SS the pecify At OLICATION TO CC11�$TRUCT,ALTER,REPAIR,RENOVATE OR DEMO ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION' _ _ 1.1 Property Address: T is section to be,completed by`office �y^/-7 f}{PE1 3Q_� l�R. Map � Lot � Unit 't" `c✓en Ce MA• 0 t 0 cO Q Zone Overlay District. .Eliin St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGENT 2.1 Owner of Record: CL 12EaG_r14 OC-NOE /1 cQC--ORS DT?. n,-)Q-tire Name(Prin Current Maill Ad J re s„ 9 '411 ' Telephone Signature 2.2 Authorized Agent: .e o•, ornc QC Z 11-4. 01053 Name(Print) Current Mailing Ad ress: Doi i Telephone EG -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a)Building F ermit Fee S DG1D, vo 2. Electrical (b)Estimated Total Cost of Construe on from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 6co. Ott Check Number This Section For Oft dal Use Only Date Building Permit Number. issued: Signature: Building Commissioner/Inspector of Buildings Date 117 ACREBROOK DR BP-2008-0909 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-214 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category:roofing BUILDING PERMIT Permit# BP-2008-0909 Project# JS-2008-001259 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGC:i'JfER`.' 077410 Lot Size(sg. ft.): 17031.96 Owner: DENNIL";LIZABETH Zoning URA Applicant: Jess: MOIit c!,M ry ,t:'• 1.17 ar^R�t�R�"�nu ri►-� A Iicant Address: Prone: Insurance: P O BOX 329 413) 585-8482 O LEEDSMA01053 ISSUED ON:4111;12008 O 00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & 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 REVOKZBY WCITY RTHAMPTON UPON VIOLATIO OF ANY OF ITS RULES AND REGUCertificate of Occu anc �I FeeType: Date Paid: Amount: Building 4/17/2008 0:00:00 $25.001678 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner Anthony Patillo