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32A-004 (3) Page No. of Pages �V PROPOSAL SUBMITTED TO PHONE DATE `Z rk STREET JOB NAME 4 S tr a CITY,STATE and ZIP CODE JOB LOCATION ARCHITECT No rthnempt- 9, 0 UAAW 16LA N T—JOB PHONE J, �k,apin 0-3100"It We hereby submit specifications and estimates for: wt- *r %4 lu "o 4 Z—4 201L We Propose hereby to furnish material and labor complete in-ac-cordaince,wirth,above I specifications, for the sum of: dollars($ Payment to be made as follows: 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 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 Note:This,proposal may be delays beyond our control. Owner to carry fire, tornado and other necessary Insurance. Our withdrawn by us it not ac6pted within days. workers are fully covered by Workman's Compensation Insurance. Acceptance of Proposal -The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature work as specified.Payment wil be mAde as outlined above. Date of Acceptance: Signature SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.Registered Home Impmement Contractor. Not Applicable ❑ rn AZZ. —5 Company Name I Registration Number 1/4- Awn 61 y d Il J 3 55 Address / / t{l3 Expiration Date (,t A`d w , m 0 l0 b Telephone '� 7� �SOC� U�j SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(67))777] 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...... ❑ 11. - Home Owner Exemption 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 El Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [oj Decks [M Si 1 40] Other[WK Brief De cnpti n of Prop sed r Work: ��s�e 11 a. a UL ��5 �t Sjeurr/ass 5 tc�/ C�ii�n.f,�, �In( Alteration of existing bedroom Yes VNo Adding new bedroom Yes No �+/ Attached Narrative Renovating unfinished basement Yes t/ No Plans Attached Roll -Sheet 8a. If New house and or addition to existing housing, complete the following: 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 1, 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 1, 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. Print Name Signature of Owner/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 L: R: L: R: Rear Building Height Bldg.Square Footage % 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 Q DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DON°f KNOW 40 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES,describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 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 Q NO 40 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ( jY° Department use only �� ity of Northampton Status of Permit: _ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability I Room 100 Water/Well Availability DEPT. O`O'°' U'' SPE— crONS orthampton, MA 01060 Two Sets of Structural Plans ON,M A 0'0 3-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 `[q W h a, `— 5t Map Lot Unit 1Ydl4a 0i1(' kh , / 6Q Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: p/� Sd e-P 5 o �Gt�►d l G�e'Q S un?� 5`� NoiQ�i� n Name(Print) C Mailing Address — ? H/3 Telephone Signatur 2.2 Authorized Anent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building (a)(a)Building Permit Fee 3 2. Electrical L\ (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,75- Check Number d This Section For Official Use Only Building Permit Number: Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2013-0639 APPLICANT/CONTACT PERSON SHOTLAND JEFFREY D&PETER SYLVAN&JAMES P SYLVAN ADDRESS/PHONE 31 TEAWADDLE HILL RD LEVERETT PROPERTY LOCATION 14 WALNUT ST MAP 32A PARCEL 004 001 ZONE URC(106)/ /a D THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST LJ ENCLOSED REQUIRE A E ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL STAINLESS CHIMNEY LINER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 118355 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information.