17A-272 (5) . PROPOSAL
NEWMAN'S CONSTRUCTION
697 Bridge Road
NORTHAMPTON, MA 01060
(413) 586 -1093
PHONE DATE - k1D To: 0 c�tr ' flY / al �� K. eh 6 / a �i
.mss I-�-/ "", JOB NAME / LOCAT N
f /d,-z AI - Se#''
JOB NUMBER JOB PHONE
We hereby submit specifications and estimates for:
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WE PROPOSE hereby to furnish material and labor — complete in accordance I the above specifications, for the sum of:
210 ftt.t.) 1 JAd✓Lt cX 5 el ,v1 \J•5_ — . d dollars ($ ig-75: C2O ).
Payment to be a as follows: /
d .---/ • ‘°', ri // eli..)01 4.4-or, k /c)fr()
All material is guaranteed to be as specified. All work to be completed in a profes oni al ,
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our Note: This propos. ay be
workers are fully covered by worker's Compensation insurance. withdrawn by us if not acce• -. within e6 LJ days.
ACCEPTANCE OF PROPOSAL — The above prices,
specifications and conditions are satisfactory and are hereby accepted. You are fie„
authorized to do the work as specifi d. Payment will be made as outlined above. Signature "�
Date of Acceptance: & f 7 "/ 1 Signat
PRODUCT 13128T FOLD AT 1<) TO FIT COMPANION 771 DU -O -VUE ENVELOPE. PRINTED IN U.5 A. B •
.
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
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
• „
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office Of Investigations
7 tF �M. 600 Washin Street
Boston, MA 02111
.,v www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly.
Name ( Business /Organization/Individual): Yh Cs-) t,
Address: , G '? Qc
t ,n
City /State /Zip: o Phone #: /' 1 A
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub contractors 6. Li New construction
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
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
q ] oficers have exercised their 11. Plumbing repairs El I am a homeowner doing all work f h id hi
❑ g airs or additions P
myself [No workers' comp. right of exemption per MGL 12.18 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ 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.
1 -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: Gl t1 4.0 D NS . O _
Policy # or Self -ins. Lic. #: (,1 C [ ?j V2-CV Expiration Date: / 1
Job Site Address: 13 (3 M_ 'S± City /State /Zip: 1 f n-t, it MA' G
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 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 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 7/
Phone #: I ` _ - w
Official use only. 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Y
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: A / Not Applicable El
Name of License Holder : /� ��1�N1 AA! I Ip 16 W
Y License Number
Address Expirati D e
S3 -10 c l Th
Sig Telephone
9. Registered Home.Improvepient Contractor: ° ` , r Not Applicable Cl r. (-ai Yh ` ` ` ` 1 es)vx � J i-7 O^7
Company Name Registratio umber
Address ` \ Ex tion D to
Telephone S"Efz ' (0" ('S
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 ❑
11. - H ome. O`vrier E -Kemp ion
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 1083.5.1.
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [J Addition ❑ Replacement Windows Alteration(s) n Roofing XI
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [E] Decks [0 Sidin they
Brief Description of Proposed
Work: 11 -r_ __ L- a ro ', t4 Li- v4.Moc rt 1200 (G
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to e xisting housing, complete the following:
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? 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 .
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
1, , 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, C t� 1�Q(t,) , as Owner /Authorized
Agent hereby de fare 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. \An cLi Ai„)
Print Name /
, _,...,
Signature of Owner /Lent Dat,
Section 4. ZONING `---
Existing Proposed Required by Z mg; 1 ,
This column to filled,in by ',es I
Building Depa ent
Lot Size
I Frontage � --� —~
Setbacks Front r --- � �--� �---
Side L: �___�D��--�
Rear
Building Height r ---- [----] �---�
Bldg. Square Footage �--- F % �---� F �--�
Open Space Foo-� � '
(Lot area minus bldg & paved
parking)
# of Parking Spaces �--� ----^ ^----
Fill: --—-----
(volume & Location) �------- -----�
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
0 �� ��
NO \~� DONTKNOVY «�� YES �_�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO �� DONTKMOYY YES ��
IF YES: enter Book Page , and/or Document #
�� ��
B. Does the site contain a brook, body of water or wetlands? NO v�� DONTKNDVV v�� YES �_ ��
/
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ^�� Obtained x-� Date
�-� �_� ' � i__-__-___'_-�
C. Do any signs exist on the propert �� y� YES «�� NO v_~ ��
�
F ----------- --- ------'
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 /—\
IF YES, describe size, type and location: "
„ . _
E. Will the construction activity disturb (dealing, grading vmbu�nr filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES K ] NO K )
��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use onty
e e City of Northampton Stag
Building Department . CurbCu/Diluewa etm
O1S 212 Main Street Sevrerlse ttcA piIab C y
Room 100 Waterlititeil Av*btfity
' . hampton, MA 01060 Two Set ,ofStructuralFian
• 1°4 one 413 - 587 -1240 Fax 413 - 587 -1272 Pi S Fan
Other'Speafy' .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
, '3 Q 41;,1-- Map Lot Unit
fd Y2- etC� 11� Zone Overlay District
I ` Elm - St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
.__I 6 i ` ( 137
Q t‘c S #1�0 12,E 1A E_
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent: .
Name (Prin) Current Mailing Address:
<1 6 C1
Signature ( Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS t 6 / s 0 c
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building r (a) Building Permit Fee
2. Electrical 7 (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) Check Number i;g0 #t36"-
This Section For Official Use Only
•
Building Permit Number: Isste
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
4 F
138 OAK ST BP- 2012 -0164
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 272 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP-2012-0164
Project # JS- 2012 - 000248
Est. Cost: $1875.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 064690
Lot Size(sq. ft.): 18730.80 Owner: FIELD JON
Zoning: URB(100)/ Applicant: CYRUS NEWMAN
AT: 138 OAK ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586 -1093 Workers Compensation
N O RT HAM PTO N MAO 1060 ISSUED ON: 8/10/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: NEW FLAT PORCH 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 REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/10/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
138 OAK ST BP- 2011 -0557
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 272 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP-2011-0557
Project # JS- 2011- 000809
Est. Cost: $92000.00
Fee: $552.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN ZIEMINSKI 017889
Lot Size(sq. ft.): 18730.80 Owner: ZUKOWSKI PAUL A & MARYELLEN SALA
Zoning: URB(100)/ Applicant: JOHN ZIEMINSKI
AT: 138 OAK ST
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:12/21/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 16 X 32 ADDITION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
/ Footings: _ � �
Rough: 3 3 �/ 4? Rough: 3 0 House # Foundation: ®V r ��'
r \>-) -„ Driveway Final:
.�, Final: s 6! j 1��
vv
�1yL� Rough Frame: OK g -1-i C'
31u
Gas: Fire Department Fireplace /Chimney:
Rough: (-FAO A`tairil l( Insulation: r) s'- l - ft Cwit-'
Final: ,.5 _/ j 11 , Smoke: Final: 0k5- i t (( CM$&
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE • IONS ei Ade tx.t.t..
Certificate of Occupanc Signature:
FeeType: Date Pa d: Amount:
Building 12/21/2010 0:00:00 $552.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck – Building Commissioner