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11C-014 (2) BP- 2010 -0247 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2010 -0247 Project # JS- 2010 - 000311 Est. Cost: $2650.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WESTERN MASS MASONS 089376 Lot Size(sq. ft.): 8015.04 Owner: NOBREGA ROBERT C & ROBERT J Zoning: URA(100) / Applicant: WESTERN MASS MASONS AT. 3 BERNACHE ST Applicant Address: Phone: Insurance: 383 COLLEGE HIGHWAY (413) 540 -1959 SOUTHAMPTON MAO 1073 ISSUED ON. 91212009 0:00:00 TO PERFORM THE FOLLOWING WORK.- REBUILD CHIMNEY 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 9/2/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo �_ s �3tt W ps�i' � City of Northampton m Building Department fb��Dew�er€ YL 212 Main Street S.erlSe �Aatiabl Room 100f� Northampton, MA 01060 phone 413 -587 -1240 Fax 413-587-1272 •: ���, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address f Map Lot Unit 3 Zone Overlay District ElmSt'District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Re ord: Name (Print) Current Mailing Address: .�-�- y Telephone Signature 2.2 Au_ the Agent: w -�, Name (Pri t) Current Mailing Address: Signatur Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit 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) a 6 G Ch�ck:Number This Section Fnrnffirial Use Onl Date Building Permit Number: Issued: Signatures Building Commissioner /Inspector of Buildings - - 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 Side L : � .. R :"—,-- Rear Building Height .. .... Bldg. Square Footage r ? % 7 Open Space Footage _ % (Lot area minus bldg & paved p arking) # of Parking Spaces - - - - -• Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT K NOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES _�_ IF YES: enter Book ` _ Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained r , Date Issued C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: '? D Q�e e e any proposed changes fo or ad�ifions of signs intended foFthe property . YES 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [0] Other [O] 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 sa. If New horse and or acdttioi °to exsfiirrg tousing,:conlilete the folEo�ivarig: 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 sto ries? 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. 1. 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 I' lCc% f as Owner /Authorized Agent he eby 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. Print N e Signat e o wner /A nt Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable 0 Name of License Holder r /LL ? 6/ License Number l- s A Addres Expiration Date g a re Telephone 3.. Registered; kiume .lproveriionfi0aitrac #or: <,,. ..,. M _..,. ., r.,, _,. Not Applicable ❑ Company Name - Registration Number C 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...... ❑ r -The-current-exemption for "homeowners" was e xtended 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 faun 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 sfieneral Laws Annotated. nrt ainp an r Cos. h - Homeowner Signature z The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washin -ton Street Boston, MA 02111 "�� s•• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print LeaibIv Name (Business/organization/Individual): Address: City /State /Zip: Phone. #: C ;;> /0 �- Van employer?. Check a appropriate box: Type of project (required). i 1m a employer with 4. I am a general contractor and I 6. Ej New construction employees (full and/or part- time).* have hired the sub- contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub - contractors have .8. Demolition worm for me in an capacity employees and have workers' g Y P tY # 9. ❑ Building addition [No workers' comp. insurance COQ' - insurance... 10. Electrical required.] 5. F1 We are a corporation and its repairs or additions 3. Q I am- a- homeowner -deurg work - - -- _ .__ offlic_ers a xerc iss-e-d their -�1: � Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12. Q Roof repairs insuran required.] t c. 152, §1(4), and we have no employees. [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 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-convactors have employees, they nwst.provide their workers' camp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site in . . Insurance Company Name: A- c�✓ �t ��G Policy # or Self-ins. Lic. #: 4 2 Expiration Date: ��d J ob Site Address: rti� t�c�l • City/state/ efT - Attach a copy of the workers' - compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage. as required under Secti6n`25A of MGL C. 152 can lead to the imposition of 'criminal penalties of a fine tip to $1,500.00 and/or one. -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification. _ I Rio hereby certi nder e p and penalties ofperjury that the information provided -abovz attrueandcorrect___ _.._ Signature- Date . _ Phone #: �� e Official use only. Do not wine in tau area, — to_be comp ted by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1: Board of Realth 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Ins 6. Other ' Contact Person: Phone #: 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 regul The in peecti on_p�ce _s require that the building department be call 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 onjunct oh,to thebuilding�ermitissued, _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. Address of work location 4 LICENSED REGISTERED INSURED AN TERN MASSWES 1 1. `? .A.M 383 COLLEGE HWY, SOUTHAMPTON, MA 01073 - (413) 527 -1800 WWW.WESTERNMASSMASONS.COM _ QUOTE _ ( To: BOB NOBREGA — Date: 6 -25 -2009 – 3 B ERNA CH E S T. Quote # 67478 LEEDS MA Project: CHIMNEY [Phone. 584 - Description of Work To Be Done: REBUILD CHIMNEY FROM THE ROOFLINE UP WITH NEW BRICKS, FLUE AND LEAD FLASHING. PRECAST CONCRETE CAP, REBUILD TO SAME HEIGHT. 1 WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR - IN ACCORDANCE WITH THE ABOVE SPECIFICATIO FOR THE SUM OF: 2650'00 This quote may be withdrawn from us if not accepted within 30 days. BBBOa4�a Quote Prepared By: David Osiecki FROG 1" TERMS: Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an 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. 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. VISA ! 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 in 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. i ACCEPTANCE OF PROPOSAL: The Above Prices, Specifications And Conditions Are Satisfactory And Hereby Accepted. You Are Authorized To Do F F The Work As S lied. Payment Will �a Made As Outlined Above. Signature t �hat Signature: Date. Thank You For Choosing Western Mass Masons!