12-017 Stephen Camp Construction
46 East St.
Easthampton, Ma 01027
(41 3)527 -7124
Submitted To : Frank Heston Phone- 584 -6895
Address : 19 Country Way Date - 8/28/11
Florence, MA 01062
We hereby submit this estimate for - Roof Job
To start the house roof I will strip all old roofing materials.
I will install all new drip edge and ice and water shield.
The shingles will be 30 year architectural style.
I will install continuous ridge vent.
Price = $ 5950.00
The back porch roof will be stripped and I will install a rubber roof.
There will be new drip edge and new flashing for the skylight.
Price = $ 1250.00
The garage roof will be stripped and I will install 15 Ib. felt paper with new drip edge.
The shingles will be 30 year architectural style_
Price = $ 1800.00 Trash Removal = $ 6
Contractor Supervisors License number 082531
Home Improvement contractor Registration number 135204
I propose to supply materials and labor -in accordance with above specific. tions.
This proposal may be withdrawn
By us if not accepted within 30 days Authorized Signature t
Acceptance of proposal Signature �V1 1 i
p p P �
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 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 hone owner exemption, -to act as their own: construction super visor, 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 fonndation/footines (before backfill)
sonotube holes (before your), a rough buildine 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 occunancv
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
ermits 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 tome:
Date
Address of work
location
}
•
The Commonwealth of Massachusetts
_ •Department of Industrial Accidents .
it
iii Office of Investigations
:: f '
_ 600 Washington Street
' f v �` 5 Boston, MA 02111
�t www.massgov %dr'a
-Workers'. Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Orgaaization/Individual):. Vhc. ( 4
• Address: �‘ Z t'" S`71/4c-•e 7' ;
• Z)/p 7
City /State/Zip: fli i4-Y Phone. #: 2 --- Z /zy
Are you an employer? Check the appropriate box:. , T project /��
. . 1 am a general contractor and I � e of t r P ] (required):
1.,� I am a employer with 4
•
Z-- . 0 g 6_
— - - -- �. _ — * have- hired- thesub-contractors -- New construction_ -
employees (full and%r parftiue� - --
2. .0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
• sfiip' and have no en loyees
These subcontractors- have — S. 0 Demolition
working for me in an capacity. employees and have workers'
> Y P rt3' 9: 0 Building addition
[No rkers' cornp. insurance comp. menrante,$
re ] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have their . 11.0 Plumbing repairs or additions
' myself [No workers' comp. right of exemption per MGL 1 Roof repairs
insurance r t • • c. 152, §1(4), and we have no • f"'
required.] employees. [No workers'. 13.[1 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 indirAting 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 - contractors have employees, they must provide their workers' comp. policy number. .
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. / .
Insurance Company Name: (: / / Q•'P .L • I ' 4 .
Policy # or Self -ins. Lic. #: S' - J(" 211 / Expiration Date:
Job Site Address: / Y (..4"344 ty /�,ii f . City /star le ✓.6.1 e- -e- / / /C, t Z
Attach a copy of the workers'• compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of aiming penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties is the form of g STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the p - ' and penalties of perjury that the information provided above is true and correct
'v ° '1
-- iJ.: ture: Date:
p 2 -- ? 2‘` / r 0
Official use onl Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical ,Inspector 5. Plumbing Inspector
6.Other •
Contact Person: Phone #: I
'
ON 8' - CONSTRUCTION SERVICES
s � 4.
,; L icensed Construction Supervis Not Applicant ❑0 '
,
Name of License Holder : S 0 225
License Number
GjG = -5>t– 5 -71-v . e. - r... 77 _< 54 // - l/
Address Expiration Date
Sig ature ✓ Telephone
�I: i k 'find"; "f T z 8 I E e i:'4 ' . , tzx Y: X 55 { ' 3 p
`� s l ,, �� �,,� � ���� �. Not Ap plicable ❑ /
Company Name Registration Number
V( ►)— S', -1- -1 - -/ 2—
Address Expiration Date
1 --5 f i c y - ' }i ? / , , 0 / 0 Z ) Telephone 122-2/27
—
SECTION 10- WORKERS' COMPENSATION INSURANCE A,FPIDAVIT (M G L . c. 152, § 25C(0)) .... .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes I No ❑
Y
,.�.=;, , ia,� "fit ��¢�.'_ ai$�xt t.
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
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