25A-157 (2) / Proposal Page No. of Page \
NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 1080
413 - 586 -1093
PROPO SUBMITTED TO PHONE DATE
STREET /1 JOB NAME 0 .4.-/ 0 51 -- -3
C % L L ,11 ) JOB LOCA (/
E and ZIP
/ 616 C:G '/,'"3(7) ,dch .), 4 s
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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Iii r Prupasr hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
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S 1 X -, ° : 7�rN.2 4am iN�ci' 'c">i -- ......... .- dollars ($ . C,, (.. j_ � )
Payment to be m Ae as follows: `>
/70/ • i 0 f 5 /:J ✓e / G) t b /3 r 2 1,),: :L i! c 7' I G '`` �' i c :'✓ � �YYtp I . G'r'l1
All material is guaranteed to be as specified. All work to be com ed in a workmanlike r
manner according to standard practices. Any alteration or deviation from above specifications Authorized
Signature ,1 .------„,
involving extra costs will be executed only upon written orders, and will become an extra g 6,2
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 proposal ay be � —
\ Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepte hin (., day
� j
// Acceptance of Proposal — The above prices, specifications \
and conditions are satisfactory and are hereby accepted. You are authorized Signature / _1.40
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: O �/ 61 i Signature
r:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1 08.3.4 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 hall 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 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 reauired) 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
iermits 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 tome.
Date
Address of work
location
.,
. .
• ' n
. The Commonwealth of Massachusetts
. =.4.7.....= . Department of Industrial Accidents . ,
Efigr.... e Office of Investigations
600 Washington Street
el 1= 7:177P"'" Z Boston, MA 02111 . .
—. . •
WWW.mass gov/duz
- .
. .. . -b
•
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
' Applicant Information - Please Print Legibly
..4
Name (Businesi/Orgardiation/Indivi6a1): j,l'i.,_44.g..02t/....5
•
• • Address: 6q 7 , / t 7?,-.9. ,
City/State/Zip: ,06.1 / iiii i a orl Phone.#: Sird — /.0 1 _
,
...,.
Are you an employer? Check the appropriatebox: • -Type of project (required): '
ig I am a employer with 2_ - 4• 0 I am a general contractor and I
•
6. 0 New coistruCtion
have hired the sub-contractors
employees (full and/or part-time).*
10 I arn a tole proprietor or partner- listed on the sheet: 7. 0 R,eroOdeling
ship and. have no employees These sub-cOnuactors have. .8. 0 Dentolition -
• working for me in any capacity . emiloyees_and have workers .
9 0 .Thiilditikaldifitin
# -
[No worIcers' comp. Msniance - ccamP- . : .
requir5 ' . 5 . 0 We are a corporation and its 10.0 Electrical repairs or additions
. .
3. 0 I am a homeowner doing all work officers haireGercis ed their 11.0 Plumbing repairs or additions .
myself [No workers' comp. right of exemption per MGL
12.0 Roof repair' s . •
. : c'. 152, §1(4)', and we have no •
insurance required.] t • ,
1ll Other c •
employees. [No workers' 3.
, . .
comp. insurance reqiiired.j. . . • :
*Any applicant That checks box #I must also fill out the section below showing tbeirwockers' compeasation policy information.
t Homeowneri who submit this affidavit infficatiag they are doing all work and then hire outside contractors must submit new affidavit indicating such.
:Contractors that check this box must attached 812 additional sheet showing the name of the subkartiactors and state whether ornottbose =ides have . •
employees. lithe sub-contraitorshaie employees, they must provide their workers ' comp. policy number.
-
lam an employer that is providing workers' compensation insurance for my einplOyees. Below is the policY'andjob:site
information.
. •
Insurance Company Name: 6 c Li 0( jac-;
. .
Policy # or Self-hs. Lic. #: CyluK" / -- 1Z 5 r- Expiration Date:
/
lob Site Address: ,.136 24i $ • - City/State/Z7Kkt c)
• Attach a copy of the workers' compensation policy declaration page (showing the policy number and date).
_ . . _ .. .. ....
Failure to secure coverage as reqUire'd Seetib25A 152 can lead to the iinPOSitib'ti2Oferiiniriil.i:■enaliies of a
fine Up to 51,500.00 and/or one-year impisonme4 as well as civil Penalties in the form of a STOP WOBIC-OBDER. and a fine
of up to 5250.00 a day against tiie yiolatcir. Be advitecl that a copyOf this statement may be forwarded to iiie.OE.celof . . . .
ffive - - : - - 70 . 7° -- --:- . '
_ ifird 11:er'iiiiiih iiii;ti; tie iainTi. qndierge:ioilidiir; thUlthiiifO'rnsaiibnp rOvitteiiiOvalsiruerrmO
Sienatire: 1 1 LI' • • ' - - - : - .: '' -------- 15 - i f/ . 6 /./ — • • • ' '
Phone #: • /5,Fe5 -- ID F.i i - • . . . . •
. - Official use only. Do not write in this area, to be completed by city Or town'official ., ..
City or Town: -
Issuing Authority (circle one): - Permit/License # • , ., '
1 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 : ( V J yV' /4- IL / C (-' ` I b g v
/
License j 3 Number
6 tr'Z Y>._ ` L1 _� \mow d vl 7�)
Address Expirati Datt�e
•
Signs 1 Telephone
Realster r#.Home Im rov meni. rae bra � ...ti «�, ° M . � . r Not Applicable ❑
Company Name Registration Number
A/ A-A1^ 4 6 6v S 7 5 "e�� E
Address A II Expirat o n ate
q.t.; L P c O�k� /ii Telephone ' 76 — ,a 77
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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 ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [O] Other [Cl]
Brief Description of Proposed
Work: 51 (") ? L i• t L 1 rS k s' ��e.\ S
�`z
r
Alteration of existing bedroom Yes No Adding new bedroom Yes - No
Attached Narrative Renovating unfinished basement Yes / No
Plans Attached Roll - Sheet
6 If e'Nl :hd ilii i tififi i f ilt'ii : rg Us'ttIq C ' le the o H4 t1 la:
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 la - 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.
S ignature of Owner Date
1 2,L) 5 i w f} ('v , 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.
cJ 'S /2 i.w tv^ G
Print Name /
J2.—
Signature of Owner"' nt Dat-
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 '
Setbacks Front r
3 I
Side L:1 = R: 1 L: _...... R.
Rear =1 I l ,
Building Height
1 ____ i
Bldg. Square Footage [1 �'- I 1
t i 4
Open Space Footage %
(Lot area minus bldg & paved j I m . ,!
parking)
# of Parking Spaces
Fill: i ia,
(volume & Location) v t
A. Has a Special Permit /Variance /Finding ver been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:o
l
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 52). YES 0
IF YES: enter Book i 1 Page_ l and /or Document it!
B. Does the site contain a brook, body of water or wetlands? NO _a DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 7r
IF YES, describe size, type and location: ; __.........
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 3
IF YES, describe size, type and location: i 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 0 NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
N :. :'a asp !- a 4% ® i �'`" 4. 4
r –_— City of Northampton �. ® 4`.
ild Department . i 1 �� .:-,M'''',11,,44--)-- ,� A
E EIVE ,
212 Main Street = _ g
Room 100
APR J - vEa A
620 2 No rtham p to n, MA 01060 °"' ° '
` phone , 13 -587 -1240 Fax 413 - 587 -1272 ,, .
DEPT. OF BUILDING INsm e ® " , 47 1:1-.'; �^ � Fig
CT 10NS ,, ,
AMI"TON, Mri ui ub0
APPLICATION TO Cc5 griUCT, 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
s Map Lot Unit
c23C NU Zone,. " ' , Overlay District
Elm St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: r(
Cl-,cti2.5. �2q 4 i/J : 3H No ,(54 * I��.y._ kt
Name (Print) / Current Mailing Address:
5 .- -E. y 5" 740
Telephone
Signature
2.2 Authorized Agent: ��)) A � (C--- l
, vs )J Few i ' .457 ' /5"n. r G Jt/ l�`"`^�L Name (Print Current Mailing Address: t
• , SI -to 5'
Signatu e Telephone
SECTI J' 3 ESTIMATED CONSTRUCTION COSTS I
6 C'
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 ' 7 2 / v , 3
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r .
230 NORTH ST BP- 2012 -0925
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 -0925
Project # JS- 2012- 001610
Est. Cost: $6300.00
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: 230 NORTH ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586 -1093 Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:4/25/2012 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 4/25/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner