24A-003 PRO.ROSAL
- PROPOSAL NO.
SHEET NO.
DATE
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT:
NAME ADDRESS
ADDRESS
C 17 rrA� l ane.
I Yo a ti, l 01000 DATE OF PLANS
PHONE NO. / ARCHITECT
((Sg — V
We hereby propose to furnish the materials and perform the labor necessary for the completion of
— VJNy/- slt C -
- ,SEE Arm 7 C HjO S/j ---
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi-
cations submitted for above work and completed in a substantial workmanlike manner for the sum of pp
Dollars ($ A gco - )
/,, / _ i
..� 000- Gtl�i'a t 71- ,f519 dam. utoil C00,'7 e ,_r
with payments to be made as follows. diJ
0 r
Respectfully submitted ( (1' pia f i thy
Any alteration or deviation from above specifications involving extra costs J
will be executed only upon written order, and will become an extra charge Per 1 `'� 89 0 t/6 ,
over and above the estimate. All agreements contingent upon strikes, ac-
cidents, or delays beyond our control.
Note —This proposal may be withdrawn
by us if not accepted within days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work
as specified. Payments will be made as outlined above.
Signature /
9 13` 1 / S ignature
Date : / `
a NC 3818 -50 PROPOSAL
r
City of Northampton
SH T s1 w
Massachusetts 4 0.
ws
DEPARTMENT OF BUILDING INSPECTIONS
`MC .YS j Th
212 Main Street • Municipal Building � _ 4e
Northampton, MA 01060 s'
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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
ibefore 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
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
=7 Office of Investigations 4 .
i 600 Washington Street .
:� Boston, MA 02111
15, asoorr 4,50'
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): 6(atio 6r-by
Address: t(0 I(c1 WI'.
City/State/Zip: 1/t g
ty p: , f JU S �l7 U(� 30 Phone #: 7 �� y
Are ou an employer? Check the appropriate box: Type of project (required):
1. LJ I am a employer with + 4. [111 I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2. [1] I am a sole proprietor or partner -
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
q ] employees. [No workers' 134 Other Sl (✓r}
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 - 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. I � I
Insurance Company Name: CA] A ._1- nSu fall C1L. ___-
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 2I Tirr ce 61, City /State /Zip: r d ' -4 P/4 0060
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 ' • , ' 'es of perjury that the information provided above is true and correct.
...NNW ,00 0111111111W
Signature: Date: /
Phone #: 3 7t1-1Qq?
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 #:
SECTION 8 - CONSTRUCTION-SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 662,4/1 Cr rt7 /9� I0
Iry 164-111 ..� r ,--,, ^ _/ / ` License Number
t � /, /b IV 0,030 7 -13
Address Expiration Date
37 L IZ
Signature Telephone
9.o.Registeied. Home. Improvement= Contractor ,.fi�,��E ATI4 Not Applicable ❑
r► I (may 1ZUPS'te Sufi D1 4f 1518
Com an Name Registration Number
M lb to 01030 Z- 7-1z
Address Expiration Date
Telephone 37'9 (Z
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c 152, §
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 N/ No ❑
Ii _vf �onne«Owner Exemption
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 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
•
4
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition El Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [O] Decks [G7 Siding [ ] Other [DI
Wor Description of Proposed � 'n/ , S 1 49 "411 / � V ` �/ J
Work: - o i t { I W► J S((/► i/I
Alteration of existing bedroom Yes x No Adding new bedroom Yes X No
Attached Narrative / Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
6a� ff ew ht use:'an or, addition ta , ii1r q , complete t he follo
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 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: WHEN
OWNERS AGENT_ OR CONTRACTORAPPLIE FOR BUILDING PERMIT
I, , as Owner of the subject
property / ('
hereby authorize ! ! Crt
to act on my behalf, in al afters relative to work a thorized by this building permit application.
/ - 9 1z
Signature of Owner Date
I, 46/ 6r4 , as Owner /Authorized
Agent hereby declare that the statements information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains andd ies of perjury.
C (toff Cr I
Print Name
.
Signature of 0 , ent Date i
J
6
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information_ �,,.�, .r ..""'
d
Existing Proposed Require,b3:Zoninng .,. ."411,
This co to be filled in by
Building Depai1 rent +
Lot Size
a i W' ' Q
Frontage •
Setbacks Front j
Side L: R: —___ L:' ' R:'
Rear
Building Height 1 3 i I
Bldg. Square Footage , % L I
( I. I
Open Space Footage , , %
(Lot area minus bldg & paved 1 i j
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
f f I I f
IF YES: enter Book Page; l and /or Document # i
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW 0 YES I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO e
IF YES, describe size, type and location: ! i
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
' r De} rtmea�t use _hi i ,43; o,
t `r .' a i '�`..i " a,, r t s 1?a ?:.a�. p San :z.
City of Northampton Sta of Permit x �7
�G►C Building Department b Cut/Drtyew y Periru d„
C� x'12 Main Street S a / S : ti Avariab ii eg .' fk ,_ -ram*
'
AN i Room 100 Se.W r' P4∎)=43K4 6 . ,, � � ` ;-;
v � No hampton, MA 01060 Two e s o S %rJ t ,ftw— Plans .
phon 41 587 -1240 Fax 413 - 587 -1272 Piw l eIansv
tic nusa� . Other SpeClfy . x
APPLICATI • • N . TRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,1 SITE INFORMATION "
f This secfion to be completed byoffice
1.1 Property Address: �
i s s '� J f. " .; co zg 0th �" f s- ' aa. v d =
v r„ r
2`1 I f✓rr ' n t Ma , a , Lot, F; � brut '� 6 ,,„ w
w s: l�� y d S as 'N.. rt e. 's"Y '! kk' k
"e:}u ,, t, i. i N Y .Y.' : - � Sp 4.U Y4
Zone Overlay D ►str�ct
a
P i n , CIA o �ro�o - ''' -
lrn St.<District " `. D i s trict = �
SECTION 2 - PROP OW NERSHIP /AU TH OR IZED A G ..1,'1•E!:"
ENT
2.1 Owner of Record:
TI 5r b zY 7� rac f �,�
Name (Print) Mailing Afl�� $�: ��� /
Signature j/144 a ID / _ G
Telephone Current ( p 5 8 _'(I Z Z l f0
o
2.2 Authorized Agent: '/0 Ke �!-
G (0►1✓1 6 l t �� y ess:
-f �'l �s, ii i4 7 /03o
Name (Print) Current Mailing Ad r
_/0
371(- 71 �l2
Signature Telephone
SECTION 3 = 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Oniy
completed by permit applicant
1. Building ( a ) Bui Permit Fee
2. Electrical ( E st i m a ted Total Cost of ` _-
•Construc fro (6)
3. Plumbing B P ermit.Fe e '
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Tlig� ( s; th ) Check Number
This Sectionfor Official Use Only .,. \ . - ' .' '''
Building Peim itNumbe r �9
- Date
r `w` Issu
�,
Signature
Building Commis /Inspector of Bui ldings ! bate
•
24 TERRACE LN BP- 2012 -0640
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0640
Project # JS- 2012 - 001105
Est. Cost: $9850.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GLENN GRILLEY 79910
Lot Size(sq. ft.): 12501.72 Owner: GRAB AGNES & THADDEUS J GRAB
Zoning: URB(100)/ Applicant: GLENN GRILLEY
AT: 24 TERRACE LN
Applicant Address: Phone: Insurance:
40 KATHY TERR (413) 789 -0464
FEEDING HILLSMA01030 ISSUED ON:1/11/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE VINYL SIDING
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 1/11/2012 0:00:00 $120.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner