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24A-018 . . LICENSED REGISTERED INSURED als WESTERN MASS JMASONS vow 383 COLLEGE HWY, SOUTHAMPTON, MA 01073 • (413) 527-1800 WWWINESTERNMASSMASONS.COM QUOTE To: DAVE HAWTHORNE Date: 10-23-2009 91 PROSPECT AVE. Quote # 84897 NORTHAMPTON MA Project: CHIMNEY Phone: 246-7988 Description of Work To Be Done: FRONT CHIMNEY THAT WAS HIT BY A TREE, MUST BE TAKEN DOWN TO THE ROOFLINE AND REBUILT. THE CHIMNEY WILL BE REBUILT TO THE SAME HEIGHT, USING NEW BRICKS, FLUE AND LEAD FLASHING. A PRECAST CONCRETE CAP INSTALLED AT THE TOP. WE HEREBY PROPOSE TO FURNISH MA i tRIALS AND LABOR - $ 2450.00 IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS. FOR THE SUM OF: This quote may be withdrawn from us if not accepted within 30 days. BBBONLSNE B RELIA Quote Prepared By: David Osiecki 15 -V BILITY PROGRAM 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 appty to this job. , fttltiAM 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. PAYMENT TO BE MADE AS FOLLOWS: One half of quoted amount is due when job construction has begun Remaining balance of bit 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. 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 Date Signature: Date: \\ Thank You For Choosing Western Mass Masons! 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 regnlatinns The inspection process requires that the building partment 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.permitissued, 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. mate _ _ Address of work location y _ The Commonwealth of Massachusetts ,_,, Department of Industrial Accidents ' I _W I� F Office of Investigations t; 600 Washington Street EV i Boston, MA 02111 �� . www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/IndividuaI): L& j i 1 e / ze / v J i f,fecfl C 1_} Address: 3P? ci`4e City /State/Zip: ,_ .�%�/l dld2.) Phone. #: (97 c - Are yo 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. ❑New constriction 2. El I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship and have. no P loyees These sub - contractors have. 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y # - 9. 13.❑ Other ❑ Builrlir� addition . - -.. [No workers' comp. insurance _ comp.lnsurance__. 10.0 Electrical repairs or additions required.] 5. ❑ We are a corporation its ❑ P 3 _ ❑ J affihsmeawaer dei$¢l �,ork office ve exercised the 11- Plumbing- 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' camp insurance requir and ed} *Any applicant that checks box #I 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. $Contactors 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 ormation. X Insurance Company Name: / . Policy # or Self-ins. Lic. #: d 2 Y Xs ?C/ Expiration Date: 1 a Job Site Address: 7( / a - 4/11'r. T 6 /I -- City /State/Zip:7.4 ' Attach a copy of the workers' comp tion 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 pens cries in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. rie 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 ce,*ti nd • . the , . t and penalties of perjury that the information provided above islrue_and_co rrect____ _ _ . A Ale Ski nature: �� t ate: ,- 3.. . Phone #: L 5_ 0 2' ) `-' ,L ' Official use - only_ 7Do not write in his arrea, to. be completed by city or town ofi-ciaL City or Town: Permit/License # Issuing Authority (circle one): 'L-Board of Health 2. Building Department 3. City/Town Clerk 4. EIectricai-_1pector 5. Plumbing Inspector _ ___ 6. Other r y Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : l t _- (21C'f, t • c 3,7K License Number 3PL3 / 5 /7-5 Address Expiration Date t e Telephone 9. Registered: Home lmprouert entfiantr "° ^. ..,..a , .Y,',. No Applicable ❑ i Z� `f` � Agd ' _ H .r . 4W" Company Name Reat ion Number Address Expiration Date Telephone 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 buildin permit. Signed Affidavit Attached Yes No ❑ a Winer. z The_current_exemption for "homeowners "mss 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 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 Ur man3 — ces, Sta e . • • . ° • r .r s-General= Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Windows Alteration(s) t l Roofing n Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other [D] Brief Description of Proposed Re � �C ck� ! r KG Work: ( y Alteration of existing bedroom Yes No ` Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a_If N°ew: house °and or addition to extsti:nq h ©uslml;. come ]et the .f Ltowin 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 n 7 g , 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. ()AI/ (); Print Name , , 7 7 6 , / „ . . 1 „ Signature .J own- /Agent 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 i s % 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 g Page, i 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 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D: --there any d c nges to or a rtions o signs inten d 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. City of Northampton 5s Building Department Cu dte 212 Main Street z S eW2C S °� am : o 'I� s r .. z, ''''._:°.i Room 100 . , ,,, . , Northampton, MA 01060 Tti�Iro Se� f tt t iira l�fans N �" ,r, k phone 413- 587 -1240 Fax 413 - 587 -1272 ' to s° , 46 W ,k d� 2 -_.,. it eE"SpeGtfy,04 - > '4 a4 1z , ,` � . , � v , Via+' , r- , -1_ , , T , ° :,e 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 Map Lot Unit / to /,¢c. Zone Overlay District Elm St District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 10‘..‘f4/4 / _/ Name (Print) Current Mailing Address: e2g6 / ^�f�� Telephone Signature 2.2 Authorized Agent: ;0 - C (i 3J3 c l X7 G . Name (Print) Current Mailing Address. (5-022 —II a Sign e Telephone SECTION 3- 'ESTIMATED CONSTRUCTION iCOSTS ' • Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (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) 62 f�j - ac- Check Number ,3 1 )61 if gl This Section For Official Use 'drily Date Building Permit Number. Issued: Signature: Bulding Commissionedlnspector of Buildings Date 119 PROSPECT AVE BP- 2010 -0120 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 018 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- 2010 -0120 Project # JS- 2009 - 001532 Est. Cost: $199950.00 Fee: $1199.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH CHAPDELAINE & SONS INC Lot Size(sq. ft.): 11238.48 Owner: WOOLF JASON A & KAREN ANNE SULLIVAN Zoning: URB(100)/ Applicant: JOSEPH CHAPDELAINE & SONS_INC AT: 119 PROSPECT AVE Applicant Address: Phone: Insurance: 87 SHAKER RD EAST LONGMEADOWMA01028 ISSUED ON :8/31/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 1 STORY ADDITION & 2ND FLR (MSTR BEDRM)ADDITION OVER EXISTING,RENO FAMILY,BATHROO,KITCH &STUDY 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: f % 1 'e 1 " House # Foundation: let / . , Driveway Final: 1 Final: 3 '1 / iv Final: , ep pc) tf6 Rough Frame: cy Yl q� /0 f3-6? 5-1.119 Gas: Fire Department Fireplace /Chimney: Rui& i' f11: Insulation: 01K /41://./ J/ i� }' Final: J 11 -4 tf Smoke: Final: dK 3 /(410 La THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy +* 1 t ignature: FeeType: Date Paid: Amount: Building 8/31/2009 0:00:00 $1199.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 - 1272 Building Commissioner - Anthony Patillo