36-042 „ c ugust 23, , t t
2010 / a
g II � !1
,4 k” . An ; ,l ,
P.O. Box 892 t , • u ,
Thorndike, MA 01079 E f
TOTAL CONTRACT ' ' «' n "" A t � 1
The contractor agrees to perform t o * w tir l�p " d R = .�" -
SUM of: $5,525.00 (Five Thousand Five Hundred Twenty -F •, a , arse *
- $2,000.00 is due on or before the start date of the job -'
- $3,525.00 is due upon completion of the work above
*If you agree to the work and pricing listed above, please initial here 1 ( and sign at the designated spots below*
If NO plywood is needed, homeowner is to initial here I ( I to accept the total cost of $5,525.00.
*Contractor is to write VOID above if plywood is needed*
If plywood is needed, homeowner is to initial here I I to accept the new total cost of $8,725.00.
*Contractor is to write VOID above if NO plywood is needed.*
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If plywood only needs to be replaced at $2.00 /sq.ft, the total cost will increase by $ 1.
*Contractor is to write increase m total cost per sq.ft. above if this opti en*
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Customers' Signature 1 11 I I�
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! r I G I • i! .11111::, F' ./' c ° ;w,. 3 Date:
�,` , �' 4 � , 4 � , ' ` v t ' d am” ,, F
'-4:,;--p, ,f p r P, 7R r,I :rdf /S fat ; / P - 7 �+IIJ ., , ces -beyond the contractors control arise Including
x
. , r . '''''Y 'fed Date of Completion:
Required Permits
The following building permits are required. It is the obligation of the contractor to secure such permits as the
homeowners' agent: Building Permit
p Lc 6e,r ', We Mark I - & Christine mil- authorize Local Building and Remodeling to act as secure all necessary
permits to c out all work stated in this contract.
11 / le /1()
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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
jermits 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
—W 5t Office of Investigations
9 = u�p� 600 Washington Stree
Boston, MA 02111
r www. mass gov /dia
-Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print LegibIv_
Name ( Business /Organization/Individu 1 C c�,`it / t) ('. ' R 1 ° /I/ i 1- L1( L"
• Address: re% X �S ( 7 / /G'r?/t- l)..J1' ( 1 C 1'(7 ( 7 .
City /State/Zip: - Phone. #: `/l 3 ( 5)- ' 6
Are you an employer? Check the appropriate•box: Type of project (required): /
1. co I am a employer with L1 - 4. 0 I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub- contractors
2_ Q I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
• ship and have. no a loyees These sub - contractors have 8. 0 Denolidon
working for me in any act employees and have workers' �,,,
addition
[
T� comp. insurance y caP ty. 9 13ut1 N workers'' CQII]p. mctmanee # Q . _. ""'6
5. We are a corporation and its 10 0 Electrical repairs or additions
r
equir i officers have Zxi hi
ercsed their • 11. 0 Plumbing r
3. 0 I am a homeowner doing all work h , ❑ mg epairs 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' 13.0 Other •
comp. insurance required. ] . •
*Any applicant that checks box Al test also fill out the section beloWshowing their workers' compensation policy information. .
t Homeowners who submit this affidavit: indicating they are doing all work and thin hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box mustattached 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 mustprovide 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. •
Insurance Company Name: f it' 7 7 /Il 1 4 G -
Policy # or Self-ins. Lic. #: t f1 C. 2-- 2 / S 3 7 l L G 7 6 E - Ut q Expiration Date: I 0 Z : /. t
Job Site Address: 3 5 u 4 ' 'L /11)71- I ? 1 P l> • F t Kit ,v 1 ; ' Li if City/State/Zip : • -
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 ofMGL c 152 can lead to the imposition' of criminal penalties of a
fne up to $1,500.00 and/or one -year imprisonment; as well as civil penalties in, the form ofa STOP WORK -ORDER and a fie
of up to $250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Offi'ce:
Invesheations of the 'IA for insurance coverage verifica c n: _
er
doh
- I --- __._ -_ eby. certrfy minder the pains and penalties of perjury that the infornrattvnprovidertabave _ittruE_agdcnrrrri
Si nat ire: L.: A, , K = d, L ,, gate . .. 1_— �. � c' ,
Phone 4:
Official use only. Do not write in this area, to be completed by city or town offcirg
City or Town: .. - Permit/License # __:. _ ..
Issuing Authority (circle one):
. 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
6.Other , I
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder : / I / t , '/ l I i� r .i / 1(((' 1 C,' Z- (-153
License Number
/ ;() f Z T 1 k '(" 11. 0(7 9 i( 20 3
Address Expiration Date
,
f q/3 5 6/
Signature Telephone
t ReCtistered.Harris:tmprciuetnent arttraefdii. N. ,. c laPE. ry „: „ : gym _ ..... Not Applicable ❑
LOc, 4G 50.l ii j () r Pi- iti l"L. /G Gi 13 F/ Ll `{
Company Name Registration Number
P 5Y , r.10 2 '� ('-i�'C i 4 Ot� 2 S 207
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 C7 No ❑
1 om Owner xem o
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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[ Siding [0] Other [0]
Brief Description of Proposes' , rc 1 �; R %
(;,4 ( (? jS
Work: 7 7iIj tit 15[171 0 Ruvi �� S J�r;v�lG t4i; ?� rip
is
of existing bedroom Yes ' No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes v No
Plans Attached Roll - Sheet
s frw;oari r alcl�iiilc�rxr�tgs nab °c�"nlfe�h �a #tiir:
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
S r L L L' 1. T,;11 , 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
l p
I, (;,)//,/,; !fit , 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.
rit, � ,� � / RI/3174i ( E
Print Name
i?' �U ,/,// � l L — "
Signature of Owner /Agent Date
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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 _ P 1 •
Frontage ----
Setbacks Front ? i
1 ,
Side L i i R :! ` L: r- . R: =_._... J
Rear —111 i 1
Building Height { j
Bldg. Square Footage
Open Space Footage % l
(Lot area minus bldg & paved I 1 _i .. t •. -m
parking)
# of Parking Spaces
Fill: ¢ M ..m
(volume & Location) I , ., A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES Q
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 Pagel and /or Document # -
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q 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 0
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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.
Rc s '* t
City of Northampton „ 4
Building Department
212 Main Street
Room 100
4 44,
�• ';� Northampton, MA 01060 • P _ �� -
- "i phone413 -587 -1240 Fax 413 - 587 -1272
0 ,1*-i i 4SItk,D5 l e ae :ae 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
zo ° `" Overlay District
< ; �, , �. /� � �
i '`° Elm St Dist CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
it/1,4 K (4(1 (' H� S �iG�L 3 �-
t" r1f57/' , C Err,Fic Rn,ter !L4,• v 2
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
, "�,;c� R '( ui" pc (}0 )(: qq 1tr 01079
Name (Print) Current Mailing Address:
J ,P (/
1 � t/C
win �' /� �v� L(( _ I<4 6 " S
Signature fi Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building S Z 5 (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) S , 2- Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
s , BP- 2011 -0526
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0526
Project # JS- 2011- 000864
Est. Cost: $5525.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ANTHONY ROBITAILLE 102453
Lot Size(sq. ft.): 13590.72 Owner: PAGE MARK 0 & CHRISTINE LEBEL
Zoning: URA(100) //WSP II Applicant: ANTHONY ROBITAILLE
AT: 35 WINCHESTER TER
Applicant Address: Phone: Insurance:
P 0 BOX 892 (413) 626 - 5296 WC
ThorndikeMA01079 ISSUED ON:12/8/2010 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 12/8/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner