25A-157 / Proposal Page No. of Pages
\
NEWMAN'S CONSTRUCTION
697 Bridge Rd.
- Northampton, MA 01060 1107
413 - 586 -1093
PROPOSAL SUBMITTED TO PHONE DATE
STREET / /l . JOB NAME
r
CITY. STFjTE and ZIP ODE 0E+0 JOB • C ION
.S
ARCHITECT / DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates tor:
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Fi r Prapoir hereb to furnish material and labor — complete in accordance with above specifications, for the sum of:
mix .17t UU i 7 [ i - jrz• C f � -- ' dollars ($ G3 ! C ("C )
Payment to be m..: as foil :
Alr .‘ CO r - - 4 /ti , .C) •6I `Ii "'", • - ! *:, 0 -.! '-' ( -; . )
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All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized 62 "
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This prop al ay be O
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not ac d withi i days.
/.
Cr �Y
/ Accrptancr of Proposal — The above prices, specifications
f
and conditions are satisfactory and are he eby accepted. You are authorized Signature (� -.......11.#
to do the work as specified. Pay ent will e made a outlined above. J
\ Date of Acceptance: J / Signature /
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, act as their own constmthon 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/footines (before backfilfl
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 insvections 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
Date
Address of work
location
.,.
• . ,
. The Commonwealth opyassachusetts
,— Department of Industrictl ACcidetzts
Office of Investig,ation§ , •
"Eianz_.--. n
, 600 Washington Street •
tz.. -4-nlirz.-- .
: TE11:15_, o Boston, .112,4 02111
. '
www.mass.gov/dia , 7.
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _
Applicant Information - Please Print Legiblv
Name pusines.i/orpthiationfindividuao: ,A,/ E€A) n1,4 S
• . ' .:, ,
.•
• - Address: 64 7 ri;....L-: Y) t c U . , • • .
-
City/State/Zip: ) ,1„..,.., e 4 mi.:), OE) 0 Phone.#: 5 Y 6
Are you an employer? Check the appropriatebox: • . .Type of project (required): /
1.0 I am a employer with. 1— 4. 0 I am a general contractor and I
d. 0 New co ' 'on
have liired the sub-contractors
employees (fall and/or part-time).*
listed on the attached sheet. 7- 0 R,emodeing
2_0 I am a Sole proprietor or partner-
These sub-contractors have .8. 0 Demolition -
ship ami have na erployees
working forme in any capacity. ep231oyees_ancilia_ye workers' : - ..... . -. •
9: falruilditikaalidein
[No workers' comp. insurance ' - comp.-intumncei .- _ _ .........._______ : - . .
10.0 Ilectrical repairs or additions
,_..., r .- . 5. 0 We are a corporation and its
3. 11 1 am a homeowner doing all work officers haVe‘ercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. - right Of exemption per MGL
12.0 Roof repair' s
insurance required.] t ' - . c. 152, §1(4), and we have no •
13.0 Other . ,
employees.: [No workers'
, • • . .
comp. insurance mqiiired.l. . . • •
' *Any applicant Mat checks btrx inmost also fill out the section belowshowing **workers compensation policy infonnation. ' . . .,., •
t Homeowneri who submit this affidavit .imting they are doing all work and thi hire outride contraCtori must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the mane of the subcontractom aid rine whether or notMose.entitics have •
einployeer. If the sub-connaCtorahaVe ariployeeg, they must provideileir wcirkeis7 =rap poky number.
• I am an employer that isproviding workers' co mpensation insurance for my einplOyees. Below is the policYand job site
information. . . 6 . •
Insurance Company Narae: a at (...; vt-xilit. '• a %/N. C S . CC) ." s
. ... „....•• ....,..,
Policy # or Self-ins. Lic. #: C y L ( 1 S 1 - „,L '", If Expiration Date: - c'' 7)11: .
. .
Job Site Address: „7 MK 5 k••• , • . ' City/State/Zip:'
,
Attach a copy of the workers': compensation policy declaration page'(showing the policy number and irtation date).
. • . : . • . , .. " .
Failure to secure coverage iS reqiiiiittiiiiitei Seeti 152 lead to the ikisitiEtri Of aiininal. tienaliies of a
fine up to 51,500.00 and/or one-year iminisonmenc as well as civ 11 penalties in the form of a STOP WOR..IC-OBDER and a fine
of up to S250.00 a day against the yiolatOr. Be advised 'that a copy Of this statement may be forwarded to the Office
ifiv . -
_ fa keieby :cern)", under the pains peadrks ofperjuryiltaithe in ' ...
. .
Signature : • - ' . Date: 4 .-i M . Z -
, . _
Phone ii: sy —, 09 1" - - : ' ' -.-. - ' ' ' . . - . •
Official use otzly. Do not write hi this area, to be completed by city Or townaffiC.iaL
I . ' • • , • ' . .
•
City or Town: .- Permit/License # ' __ ....
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalin 5. Plumbin g Inspector
6. Other ,
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ L
Name of License Holder :, ( ►Z 1 �r t/ vv, A / 0 ( $ h `i 6 d
/ License Num er
6 q 7 f�n..• nIL Pc). Ait.i d •79 isc .f/ 4 / V/ S
Address Expiratio Dat
r J ------ ' s - , --. t ---109
Signat Telephone
9 :Reigstti d ttrtri 4iiitwiro emiiif tc iE . w „ 0 . w M , R VE::E Not Applicable ❑
HClL) Al /S 6),, .5 , /y F07
Company Name , l / Registration Number //) 0
X 77 PA—. f Q?nO Ad ress Y Expir Da
Telephone 57 —/O r 7
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.t.. 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 I/ No ❑
nolniviuwneritmon-
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 -vear 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 ❑ Replacement Windows Alteration(s) ❑ Roofing IX
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding [D] Other [0]
Brief Description of Proposed -s ' i [ 1
Work: STS: ( 3 L� 4 a.. _L_ t\1 skAk\ tr' r•c .‘ ✓1-%l1c5
Alteration of existing bedroom Yes / No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa if t e nr t ii se ' r r tc rlT c rr t e is ii q:h iuslnq; cr mptefe.th+ :fol OW i1Q:
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
K.U5 4JE 'J Vl/7 A , as Owner /Authorized
Agent hereb 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.
✓z ./5 AIE"1 At-A/
Print Name
Signature of Owner / gent 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 i L'.1 a
Lot Size 1 I } a
4
Frontage i 1 i i „,d, .. _.... . M..
Setbacks Front 1 i ; 4 1 1
Side L:= , R:1 1 L:` 1 R: ` I I
Rear
Building Height f 3 r i
1 i i
Bldg. Square Footage 1 1 i % 1 I =1 1 --- - 1
Open Space Footage
(Lot area minus bldg & paved ` 1 ; 171
parking) ,
# of Parking Spaces — 1 }'¢T
Fill: i 1
(volume & Location) 1 1I1 . t
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW e YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book I Page
E and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q 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 ® ,Date Issued
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location: 1 I
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: i
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 Q NO Q''
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
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� RECEIVED of Northampton z
► Bt ilding Department e �=� ;, l l `
212 Main Street T
4 b
` ° !
APR 1 6 2012 Room 100
ort MA 01060 • ffi r' �6
� � 3 -c 7 -1240 Fax 413 - 587 -1272 7.
OIsPLOFBUIDING ° 1 _
NORTHAMPTON. MA01060 0 - j s ' 4� , , r x
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
,? 5s-I go,,,-f--1,, 5.- 2oine Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
a e ■ atti\ 5-‘N .---‘1-- (1' ‘\1 Va
J5 1 cf
Name (Print) C urrent Mailing Address:
7y — 5 '7 4 410
Telephone
Signature
2.2 Authorized Agent:
C� vi_3 e:.- .� c7 7 �. � �
Name (rint) Current Mailing Address:
Signature Telephone
SECTION -' STIMATED CONSTRUCTION COSTS Z I/DDi 0 v
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) Check Number y�g`
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
234 NORTH ST BP- 2012 -0914
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 157 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0914
Project # JS- 2012 - 001599
Est. Cost: $6400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 064690
Lot Size(sq. ft.): 55756.80 Owner: DRAGON VERONICA J
Zoning: URB(100)/ Applicant: CYRUS NEWMAN
AT: 234 NORTH ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586 -1093 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:4/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 4/24/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner