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
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City of Northampton
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Building Department fb��Dew�er€
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212 Main Street S.erlSe
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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!