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18D-053 (6) Stephen Camp Construction 46 East St. Easthampton, Ma 01027 (413)527 -7124 Submitted To: Glen Curtis Phone- 584 -8402 Address : 80 Damon Rd. Date 7 -16 -2009 Northampton, Ma 01060 We hereby submit this estimate for - I will install 2 vinyl windows supplied by customer. I will install new metal work on the exterior as needed. The interior I will install new wood trim as needed. The customer will do all painting. Price = $ 400.00 The new counter top will be supplied by the customer. I will remove the old and install the new. I will reinstall the sink to finish the job. Price = 350.00 I will supply the building permit. Contractor Supervisors License number 082531 Home Improvement contractor Registration number 135204 I propose to supply materials and labor -in accordance with above specifications. This proposal may be withdrawn By us if not accepted within 30 Authorized Signature .1 Acceptance of proposal Signature 60 lierakzcieemea _ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR A cafj_ff 8 Registration: 135204 \. Expiration: 3/13/2010 Tr# 263477 Type: DBA CAMPS CONSTRUCTION STEPHEN CAMP 46 EAST ST. EASTHAMPTON, MA 01027 Administrator :••••• tt , • e c Board of Building Regulations and Standards Construction Supervisor License License: CS 82531 Birthdate: 11/23/1966 Expiration: 11/23/2009 Tr# 6688 Restriction: 00 STEPHEN P CAMP 46 EAST ST EASTHAMPTON, MA 01027 Commissioner ": i l c� i ! F'vVU�4 -rG vv 8t. UV] - .IL -VV.3 13102 a ..._ - - -- - _-- _---- _--- --- - -- -- -- $1 013 -66- 0409 -00 INCORPORATED UNDER THE LAWS OF 'Th 1, t : ' APR �3 ? ITEM 1. NAMED INSURED: MAILING ADDRESS IDENTIFICATION NO. iI ;TEPHEN CAMP Member Companies of 16 EAST STREET M P EASTHAMPTON, MA 01027 - 0000 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 tEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 D# PRODUCERS NAME AND ADDRESS FINCK & PERRAS INSURANCE AGENCY INC. WORKERS COMPENSATION AND EMPLOYERS 6 CAMPUS LANE LIABILITY POLICY INFORMATION PAGE EASTHAMPTON, MA 01027 -1430 NSURED IS PREVIOUS POLICY NUMBER NDIVIDUAL RENEWAL 008271078 3THER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 ITEM 2 POLICY PERIOD 1•01 A.M. standard time at the insureds mailing address PROM 04/04/09 W 04/04/10 ITEM 3 A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC200306A D. This policy includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Pians. All information required below is subject to verification and change by audit Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re. Premium © Annual ❑ 3 Year muneration 13 Annual ❑ 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754 TAXES /ASSESSMENTS /SURCHARGES $142 XPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $338 MA IINIMUM PREMIUM $ 500 MA TOTAL ESTIMATED PREMIUM $ 2 , 597 indicated below. interim adjustments of premium shall be made: Ej Semi - Annually Quarterly 0 Monthly DEPOSIT PREMIUM • • • HOME OWNER EXEMPTION ACKNOWLEDOEMEN'T 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 y Office of Investigations 600 Washin Street a, Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly • Name ( Business /Organization/Individual): Address: ; 7 City /State /Zip: ,,, , /1 A , d/ 027 Phone #: G� ` (9 -- Are you an employer? Chehe appropriate box: Type of project (required): 4. I am a general contractor and I YP re : p ( q ) 1. I am a employer with 7i ❑ g * have hired the sub - contractors 6. ❑New construction employees (full and/or part- time). 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. a 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 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. m ' . right of exemption per MGL y p 152, §1(4), and we have no 12.0 Roof repairs c. insurance required.] t 13.0 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. � (.‘e). Insurance Company Name: �---e.v✓° � �' /G $ 4r4,74 4 . . ` ! Policy # or Self -ins. Lic. #: 2g 2 �3` Expiration Date: `7 iU Job Site Address: � D , Jl w.) City /State /Zip: /1 nil 0 / ' 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 pe alties of perjury that the information provided above is true and correct. Signature: Date: a — 7-0 7 Phone #: 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 #: H � SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: -- Not Applicable ❑ Name of License Holder : k� "Z C " 0g License Number 16 c . 4 . J / L p _2 3 _ d Address tion Date Si nature Telephone 9. Registered Hot ie `Imiirortemerit i fractoi ;" ';V .. , w,4 . _sy. sr Not Applicable ❑ Company Nanfe Registration Number Address Expiration Date Telephone �1L 7 7/2y 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 ❑ 11. - Hdme 0*i er;Egenr>Ctrttari 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 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacement Windows Alteration(s) El Roofing n Or Doors WI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [0] Brief Description of Proposed � / C Work: /» } Il�% 2 ep/ f.eiviie44 fir hki tkf Alteration of existing bedroom Yes X No Adding new bedroom Yes X. No Attached Narrative Renovating unfinished basement Yes /' No Plans Attached Roll - Sheet 6a. If New house and or addition to existing' housing, cartpletethe foltowlnq: 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 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 54 -efsh-rm t��,1-___ , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best o mf yTR f ro edge an belief. Signed under the pains and penalties of perjury. Print Name die Signature of Owner/Ag-' t Date 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 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 0 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 0 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 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 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. £Department , C it ' city of No rth a mpton .S �Qf tt � l ��� Bu Department • Curt G C744 ie fit P i Y �, 2 Main Street cer� , e•A a �s� � :� g� 3 ll 4 ' M A oom 100 � rnz Air a� �� �.\ \'‘,7',..-- V ^°}� ' ` A l I'm % k °i . 1� ,+ •3� j J .r. ' Ntham Fax ton, MA 01060 Tv c,et o €Structural 'an Al t � p iton X87 4 0 413 -587 -1272 ,P .lotlSte Pr y O t h er ap es fy x . * A $ ARPL,1 *RAN TQ ONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTItkN 1 E INFORMATION in 1.1 Property Addres / This section. to be co, d,by office gel �f/,)+ti��r✓ Map XV Lot Unit 1? LI Zone [y ��Ce hi i2t Elm St District C District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: c-/�P C v, s Yo DABed # — �/ ` ' Name (Print) Ad Current Teleph Mailing ne drs: ,�` ^� 4' — .�7U o Signature 2.2 Authorized Agent: 7 – 7 Name (Print) Curre Mailing Address: f2 2y Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COST Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) B Permit Fee yid - 2. Electrical (b Estimated Total Cost of Constructionr,from (6) 3. Plumbing Building 'Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) / en Check Number ��� 3C This Section Fo r Official Use Oni Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date � S BP- 2010 -0133 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -174 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0133 Project # JS- 2010- 000157 Est. Cost: $400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN CAMP 135204 Lot Size(sq. ft.): Owner: CURTIS GLEN Zoning: GB /GI /SC/WP Applicant: STEPHEN CAMP AT: 80 DAMON RD #7201 Applicant Address: Phone: Insurance: 46 EAST ST (413) 527 -7124 () WC EASTHAMPTONMA01027 ISSUED ON:8/3/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 8/3/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo