12C-114 BP- 2010 -1188
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 -1188
Project # JS- 2010- 001723
Est. Cost: $10540.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10105.92 Owner: STAMPA MAURA J
Zoning: URA(100) //RI/WSP Applicant: STAMPA MAURA J
AT. 95 RICK DR
Applicant Address: Phone: Insurance:
95 RICK DR (413) 584 -2876 O
FLORENCEMA01062 ISSUED ON. 612412010 0.00.00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY FROM GROUND
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 6/24/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton ,max
Building Department,,
212 Main Street r
Room 100
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
V e- Map" Lot Unit
Zoe �xerlay Distract
1 a
Elm St. District _ CB District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name nnt) Current ! Mailing Address:
113
Telephone
Signature
2.2 Authorized Acient:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by ermit applicant
1. Building I0 rr'o (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) Chedc Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature: 6 2�( li d
Building Commissioner /Inspectorof Buildings Date
'
Section 4. ZONING All Information Must Be CompLeted. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
11is 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
A. Has a Special Permt/Variamce/ Finding ever been issued for/on the site?
�� ��
NO ��� DON7KNOVV �~� YES �~�
IF YES, dateissue&
IF YES: Was the permit recorded at the Registry ofDeeds?
NO 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO DON7KNOVY 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained �~� �btained y~�` Oate|ssued' ---Y
v�� '[____________|
C. Do any signs exist on the property? YES 0 NO �
_~
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradingexcavation, or filling) over 1 acre orioi| part ofa common plan
that will disturb over 1acre? YES� � NO K �
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aualicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [[- Other [EI
rief 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
s : It 6ig" law d fia f i ifi , u tobsla co i e re,:fot ris :
a. Use of building: One Family X 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? "' -:> Fireplace or Woodstoves Number of each t
g. Energy Conservation Compliance. asscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes A 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.
I. 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'
� ING�_ - C Cx as Owner of the subject
property
hereby authorize p C l "I 'A S e 1.6 � S L E
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Print Name
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder P ext .S
License Number
C5
Address Expiration Date
dq� 1 ( Gi I( mPr
Signature Telephone
r
`fr3 S'G 3-2-17 S
S; Recilsl�Brdo :Irrit�raVeiiiienttiirafor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1Q- 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...... ❑
Mv
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 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(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 La s and State of Massachusetts General Laws Annotated.
Homeowner Signature
T
s ~
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
U 600 Washington Street
Boston, MA 02111
1 www.massgov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Pleas Print Le�
Name ( Business /Organizatiowlndividual):
Address:
City /StatelZip: Phone-#:
Are you an employer?. Check the appropriate box: Type of project (required)•. r
1. ❑ I am a employer with 4., [] I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub- contractors
2. Q I am a sole proprietor or partner- listed on the attached sheet y E] Remodeling
ship and have no: aloyees
These sub - contractors have. .8. [] Demolition
working for me m as �a-�:and have workers'.
king y capacity. - 9 [] $us�dtig addition
[NO workers-' comp. insurance
5 We are a corporation and its 10.[] Electrical repairs or additions
required ] 5. ] officers avet' xercid their see 11. eb' repairs or additions
3. ❑ I am a homeowner doing all work ffi h .; 0 Pl . � � .
myself (No workers' comp. right of exemption per MGL 12.0.Roof repairs
insurance required] t c. 152, § 1(4), and we have no
to ees. o workers' 13.[] Other
.. � y [N
comp. insurance requited.}.
'Any applicant -that checks box #.lest also fill out the section below showing theirworkers' compensation policy information:
t Homeowners who submit this affidavit.indi==g &ey are doing an work and then hire outside contractors roust submit a new affidavit indicating such:
1 Connactors that check this box must.attached an additional sbeet showing the name of the sub contractors and state whether or not thoseentities have
e mployee , . i f the sub- corriractors have employ=, they must.provide their wmi=s' comp. policy number.
f am an employer that is providing workers' compensation insurance for my employees Belpw is the policy god job site
information.
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site A dd r ess: City/StafelZap:
Attach a copy of the workers' - compensation policy declaration page the policy number and expiration date).
Failure. to secure covemge:as required unikr Section 25A ofMGL` c 152 can Tead to the imposition of penalties of a
fine up to $1,500.00 and/or one- year 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. Be advised that a copy of this statement may be forwarded to the Office of
InvestitTations ofthc DIA for'uisurance coveraze verification
rdo hereby certify under thepains ofperjmy that the information p ravidedlrbavE- s�ruP_aa cLcnrred
Signature: / ate
Phone #
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. CityfTown Clerk .4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
STAELENS MASONRY
246 Mountain Road
Gill, MA 01354
Tel. (413)863 -2175
June 17,2010
Maura Stampa
95 Rick Drive
Florence MA
ESTIMATE
This estimate is for tear down and rebuild of existing chimney and
fireplace to ground level. Chimney exterior to be of brick. Interior
fireplace face to be of river rock(cultured stone) facing. Existing
stone hearth to stay as is. New fire box to be built of refractory
brick (not metal heatilator). This estimate also includes
installation of stainless steel liner for furnace.
Estimated cost. $10,540. 00
A 35% material deposit is required at beginning of job.
Balance to be paid upon completion of work.
Mass. Contractors license# 83290
Workers Comp. and Liabilty Insurance # 009 -87 -1689 National
Union Fire Ins. Co.
Please call with any questions.
THANK YOU