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23B-066 (2) , . . , ______ ,,, Ji__ l 1 2-1111E of Consumer Affairs and • usiness Regulation (114---71 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 133234 Type: DBA Expiration: 5/25/2013 Tr# 211555 WESTERN MASS. MASON DAVID OSIECKI 383 COLLEGE HWY SOUTHAMPTON, MA 01073 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal El Employment [] Lost Card DPS -CAI Ca 50M- 04/04- G101216 Office �>lo>finer al si ess egu at,o License or registration valid for individul use only S\.,..., before the expiration date. If found return to: = � � � � �'�'__ i Registration: - HOME IMPROVEMENT CONTRACTOR 133234 Type: Office of Consumer Affairs and Business Regulation z ! •� 10 Park Plaza - Suite 5170 `� � Expiration: 5/25/2013 DBA Boston, MA 02116 ` ERN MASS. MASON DAVID OSIECKI " —'— 383 COLLEGE HWY 4e,,. -__- • SOUTHAMPTON, MA 01073 L Undersecretary N ot vali ' w signature Massachusetts - Department of Public S,tfet■ 1 Board of Buitdimt Rc�2ulations and Standards _ ils€ License: CS 89376 Restricted to: 00 DAVID OSIECKI 383 COLLEGE HWY SOUTHAMPTON, MA 01073 Expiration: 1/5/2012 e7-_-4- Tr#t: 12808 ( "anmi.o.ioncr LARISSALICENSED REGISTERED INSURED RECEI'7 ` _ WESTERN MASS .ENV u r DEPT OF BUILDING INSPECTI � � "'A0 O f LEGE HWY, SOUTHAMPTON, MA 01073 • (413) 527 - 1800 WWWWESTERNMASSMASONS.COM cL61 QUO TE To: tFA BACHINSKY Date: 5 -10 -2011 7 BERKSHIRE TERR. Quote # 7634 FLORENCE MA Project: CHIMNEY Phone: 584 -3834 Description of Work To Be Done: 1. THE CHIMNEY AT 9 BERKSHIRE TERR. WILL BE TAKEN DOWN TO THE ROOFLINE AND REBUILT WITH NEW BRICKS, FLUE AND LEAD FLASHING, A PRECAST CAP WILL BE INSTALLED AT THE TOP. WESTERN MASS MASONS WILL PULL THE BUILDING PERMIT WE RECYCLE ALL OUR OLD MATERIAL WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR - $ 2650.00 IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS, FOR THE SUM OF: This quote may be withdrawn from us if not accepted within 30 days. 10111111S0Atim Quote Prepared By: David Osiecki p� TERMS: Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. By signing this quote you agree and understand all the above terms and conditions that apply to the job. INITIMMIN Any changes that are to be made, must be discussed prior to construction and agreed upon by contractor and may also effect to the final price. 1V1Sr4 PAYMENT TO BE MADE AS FOLLOWS: One half of quoted amount is due when job construction has begun. Remaining balance of bill will be paid in full when job is complete. A Finance Charge of 1-1/2 (18% annual rate) per month will be added to any unpaid balance over 30 days. mast ACCEPTANCE OF PROPOSAL: The Above Prices, Specifications And Conditions Are Satisfactory And Hereby Accepted. You Are Authorized To Do The Work As Specified. Payment Will Be Made As Outlined Above. Signature:, ^ ate: Signature: Date: 1 / " m 8 $ten ` ^' r h t". r a , Masons! �1 "'�l, m� Px�z A '��i { 3H'c '�� :f c�'�m. ._�u�.� 5. a+a.''.'en',# 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 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 to me. Date Address of work location 7 • ' s - , . , • The Commonwealth ofMassachusetts =4. , Department of Industricd ACcidents P k =....--.-=`-= si Office of InVestig,ation.§ „-... ...- ,...,_, "maw, • t, =...6...... gi 600 Washington Street " Boston, MA 02111 . . www.mass aov/dia ..,.- - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers ..- Applicant Information • Please Print Legibly • :: i , -, Name (Businesi/Orginization/Individnal): vUe..S / crA.... A4i5 A/PlIch-t .) . . - - Address: e 3 64-16e_ / , . City/State/Zip: 5- '<A/2- . c)(0 Phone.#: ,roi 2 P - . . . . Are you an employer? Check the appropriate box: . -Type of pi-oject (required): / 1. employer with. 0.1-- 4.. 0 I am a general contractor and I , .. . . 6. u New construction, have hired the sub-contractors employees (full and/or part-time).* listed on the:at sheet: R • . 2_0 I ain a Sole proprietor or partner- 7. 0 emodeling ship •iodhave no cmp.loyees These sub-Contractors have. .8. Q Dein Olition - . . . wor kin g f me i any eapa cini3 ve 7Otkets' ... 9 ..;. 4mg, _ 1 ._,._., - ..„ ,.. o _ ii • • [No workers' comp. insurance ' - comP--n?tunance - - . __—___,............. . . . .. _ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers baire4xeroisecl their . 11.CI Plinitbing repairs or additions 1- . myself [No workers' crimp. • right Of exemption per MGL I-, .•... .. 12..0 ic.00r insurance required.] t - • : ,c. 152, §1(4), and we have no . .. . ex9ployee... [No wor 13.0 Other r • : , . . • comp. insinance rr-quir -ed.]. : ' , • - . . . - . *Any applicant-that checks box a must also fill out the section below.showthg their-Wm-loam compamation policy infonnotbar. 1. Homeowncri who subniit this affida a they are doingall work and thin hire outside contraMora must submit a new affidavit indicatMg such :Contactors that check this box mustattachod an adianal sheet shcrvag the name of the subcontractors and state wirether-crr notthose•entides have .. • employees lithe sitb-contractorshaie cznployees, they must provide their wOrkeis' corop- poficy number. I tun an employer that isproviding workers' compensation insurance for my employees.. Below is the policyand job site -bzformation. /7 •. . 4 . •--- : - . " 6'r ;7C Insurance Company Name: 6 " ''' - . . ' ., / A 1 Policy # or Self-ins. Lic. #: V ' 727 - . Expirition Date: - s t . "7- 0 .` ..--' T • • . o 4' Job Site Address: - C r./CJ , t /C r . - . . CitylStatel'4;:' Attach a copy of the workers': compensation policy declaration page the policy innber andeapiration date). Failure to secure coverage: as 1 SoCtiiii'25K'kif 'MG-I; re: 152 can lead to the iiiiPOS'intii Ofiiiinin4iienalities of a fine tip to S1,500.00 and/or one-year . imprisonment; as well as civil 'penalties in the form of a STOP WOB1C-OBDER and a &.e of up to S250.00 a day against the Be advi that a copythi.s statement may be forwarded to the Ciira,ceof ECeillia I - - - - .- . 7-7-7-7774- 7: 7. • - - I dii : hereby_cerah an ,,, e p , ' , - - 7" dp: , , .* • of , erjury thaithe in:forMatiOnprovided:abciveeiind,earri.rt ' / . _ . . Si u. tare 4 At . --:--- ------ : te --- ( --- 1 ,--- 77 . - . - !fa- . e . - Phone ii: ,r • ....-... .-. ' '. . . . •• 0 - Official use only. Do not write in this area, to be completed by city Or townO:171ciaL . i City or Town: Permit/IAcense # Issuing Authority (circle one): .• ' .. . .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalinspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • - • _ , , SECTION 8 -- CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 0,t, t (/5 /�(� i u `7 // ' 0P-7 ix License Number 30P3 C (( //i S.� / ,. , -z-,04 Address Expiration Date Signat Telephone 9 Rpaistereil,. anie ntii iiitati ; ., ilt to x ., �' Not Appl 0 V k/L/ c S %c r„_, �/ .J �.io /3 Name Number ` L 3S lJ Address Expiration Date Telephone 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 ❑ 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks [EJ Siding [0] Other [0] Brief Description of Proposed 2 - Work: G� �1(A... 7 �6 is el L 4 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet tr g �y K # O kf G �s ti Q Wridkti e it tR � .iii -T % e k*fa of #Qua: 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. Wi l 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 I, , 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 tc 0 G C (r , 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 p� /C pa's and penaltie of perjury. Q Print Name , / K ir Signature of fir : Age 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 i I 1 ' 1 ._ . ______ Setbacks Front I I Side L:i i R: i L:! J R:! _ s 1 1 I Rear ` ' Building Height t 1 F I — 1 Bldg. Square Footage t 1 F--1 % l ; s 1 • Open Space Footage % _, L (Lot area minus bldg & paved parking) # of Parking Spaces Fill: T .,.�� __.- x..._____H (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:' I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book / Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q 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 Q IF YES, describe size, type and location: s D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ■ • FCEt'� •f Northampton - f uil ; ing Department i,,,,1,74-",.':',',. 44,14-...,, � 4 2 2 Main Street - _ 44- - °` ,- Room 100 . ;:: „ :, orthampton MA 01060 o "N ► o 3 7 -1240 Fax 413- 587 -1272 "' , s APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION This section to be compteted by office 1.1 Property Address: 7 ge_res // -� Map L ot Unit Zone Overlay Drstr ct Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record:: 66,c,11 ,,��// .1 / � // // Name (Print) Current Mailing Address �/ 30E-'3`i Telephone Signature 2.2 Authorized Agent: Name (Prin Current Mailing Address Signatur Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applica 1. Building (a) Build Pe rmit Fee 2. Electrical (b) E Tt Constru ction o from (6) of 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ 6. Total = (1 + 2 + 3 + 4 + 5) �(, O , UU Check Number far/ T Section For Official Use OnIy Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 7 BERKSHIRE TER BP- 2011 -1055 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 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: chimney rebuild BUILDING PERMIT Permit # BP- 2011 -1055 Project # JS- 2011- 001699 Est. Cost: $2630.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WESTERN MASS MASONS 089376 Lot Size(sq. ft.): 19906.92 Owner: BACHINSKY LARYSA C Zoning: URB(100)/ Applicant: WESTERN MASS MASONS AT: 7 BERKSHIRE TER Applicant Address: Phone: Insurance: 383 COLLEGE HIGHWAY (413) 540 -1959 WC SOUTHAMPTONMA01073 ISSUED ON:6/15/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD CHIMNEY ROOFLINE UP 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 6/15/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner