38D-066 (3) •*-
Work Statement
11/11/09
Client: Alan Seewald Contractor:Reece Caraker
60 Revelle Ave. Mass CS #85564
Northampton, Mass. Northampton, Mass. 01060
413- 237 -4710 413 -584 -3036
Rebuild existing 2 flue chimney from roof line up to 2 feet above ridge as per code.
• Erect 3 tier light gauge pipe staging upon sun porch roof to allow chimney access.
• Remove stainless steel vent caps from flue pipe.
• Remove all old bricks and lead flashing down to roof line.
• Match existing bricks with closest fire code brick dimensionally.
• Rebuild chimney from roof line up including lead flashing and new flue pipe if needed.
• Replace and secure flue caps.
• Point brickwork approximately 9 -10 courses below roof line as needed.
Labor and materials excluding pipe staging: $2250
Payment schedule: 1/3 @ job start point, 1/3 @ job mid point, 1/3 @ job completion.
i
Client: Contractor:
✓ ri i
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 proc_ess 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
-- - - - - -- - -} mits- in-- conjunction,to the -bu 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.
Date
Address of work
location
1 , i
The Commonwealth of Massachusetts
. ...
Department of Industrial Accidents
E►i� Office of Investigations
k
.
60D Washington Street
Boston, MA 0?111
7.,....._.- a. � ' www.massgov /dia
-Workers' Compensation Insurance davit: Builders/ Contractors (Electricians /PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): /2(5--c. C C47&(
Address: h 'p( /�
City /State/Zip: "1� %L/G4Z( 7 / fiI ! Phone #: z /( 3 _ 9 9 '30 3
Are you an employer? Check the appropriate box:
1. Type of project (required) :
CI am a employer ez with 4. I am a general contractor and I
Y 6. 0 New construction
loyees (full and/or part - time).* have hired the sub -contractors
2. I am a sole proprietor or partner- listed on su the attac ontractors hed sheet have 7. 0 moelin
shin anrt have. P loyeea These b - c. 8. Demolition g
working for me in an capacity. employees and have workers'
wor
g Y P rtY• 9. Q Building addition
[No workers' comp. insurance romp. nisrrranr.P_$.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. C] I ara-alemeowner -d ing -allwork — o c have exercise .their 11.- repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no .
employees. [No workers' 13.0 Other
comp. insurance requited.)
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this afidavitindicating 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. lithe 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: •
Policy # or Self-ins. Lic. #: ' Expiration Date: --
Job Site Address: City /State/Zip:
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. Isle advised that a copy of this statement may be forwarded to the Office of
Investigations of the Dice coverage verification
I do hereby_ certify,,•'''' the - s and penalties of perjury that the information provided abov is true and_correct___ __
M ire: W i ate: (( /2 ,
Phone #:
1 - Official use only. Do not write fr this area, to be completed .y 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 : /G 1 Cfl ""e - 7 4 S > Lv
License Number
i 'c G! 5% ItP - ; crtti s's 3/73/2 c7 ( r
Address ' Expiration Date
( y(3 -- —30 a,
Signatu Telephone
9. Registered Home Improvement Contractor . E ,.w .,.. Not Applicable ❑
c � �� � r /6o
Company Name /Jc Registration Number
1� 1 12 � ,,
T� ��ok+: 4 V
Address Expiration` at
Telephone y 1` - S 3 f 30
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑
I loo n f9wner motion
T_he_current_exemption for "homeowners " was extended to include Owner 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 Ordinan S at an d - •-
s-Generai -Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [p Siding [0] Other [I
Brief Description of Proposed `L ,/I n
Work: L'lr+( 'L�i' ' I 4j /f6'?e/�H/c / f(v /ltl�s ! 4 1 'ii '
l G-
Alteration of existing bedroom Yes '/No / Adding new bedroom Yes '� No
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll - Sheet
sa If�,NeW.4fou�e::`and �r actdi: #�n,:to exis�inc� fioiaslnA ;.comt}I "ete,ffe,fc��foini�c:
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 Ta- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR
, as Owner of the subject
property /
hereby authorize MIL C. C Oree l k
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
AP
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:___ L:`_ R _ .
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(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?
NO 0 DONT KNOW 0 YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page? and /or Document # _.
B. Does the site contain a brook, body of water or wetlands? NO 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 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
` D7 a any proposed c - ang el to or a itions o signs intTri eifor `ie property ? YES 0 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
City of Northampton
Building Department PAcutifoPil
�'
212 Main Street
Room 100 e.s Ian Ac ` 0
Northampton, MA 01060 ' s Iatwxv,
phone 413 -57 -1240 Fax 413- 587 -1272 a � P�a � x �
pe
APPLICATION TO 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
?,e? fa Map Lot Unit
'Zone Overlay District
Elm St.'Distrtct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
/( 3 9 7 - 97/
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /' `r � (a) Building Permit Fee
2. Electrical 'T (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 1 ��/ (/ �� t9 '
This Section For Official se Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings - Date
Vt, LL AVE BP- 2010 -0520
GIS #: COMMONWEALTH OF MASSACHUSETTS
;.8D` - 066 : 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 -0520
Project # JS- 2010 - 000734
Est. Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: REECE CARAKER 85564
Lot Size(sq. ft.): 12022.56 Owner: SEWALD ALAN & HOLLIS M ALTMAN
Zoning: URB(100)/ Applicant: REECE CARAKER
AT: 60 REVELL AVE
Applicant Address: Phone: Insurance:
246 NORTH ST (413) 584 -3036
NORTHAMPTONMA01060 ISSUED ON:11/13/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR CHIMNEY, POINTING & FLASHING
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 11/13/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo