29-132 (2) r • • e
J)raposal Page No. of Pages
it NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 1013
413-586-1093
PROPOSAL LIBMITT DTO PHONE DATE
7"-a%L6
• STREET JOB NAME
CITY,STATE and, (ZIP CODE yJd JOB LO ATI
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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BlP Propus hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
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r,,. — _ma.. _._ ....__ dollars($ j<Q®. ).
Payment to be m e as follows:
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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
involving extra costs will be executed only upon written orders, and will become an extra Signar
tu e
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:Thi prgposal may be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if n t Cepted within days.
Aarptance of Proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature C
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature
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n DEPARTMENT OF BUILDDNTG INSPECTIONS /=
INSPECTOR 212 Main Street a Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as iris/her construction sup,-.: ,- sor. 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 any 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 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 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
Office of Investigations
° 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: (A-4 B�r i&;e 2
City/State/Zip:mn�-4-- ka MC.41E�X, lc a Phone.#:
F ou an employer?Check the appropriate box: Type of project(required):
I am a employer withL 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no emTloyees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.
$ 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.X Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 131J Other
comp. insurance required.]
*Ay
t pppliacn t Tiat checks ox#1 must also fill out the section below showing their workers'compensation policy information-
Homeowners
who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sh,et 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
information.
Insurance Company Name: G Y? 4 J--n< co
Policy#or Self-ins. Lic. #: _ MjetA Expiration Date: -
Job Site Address: ���(�, . City/State/Zip: F C) 1 069 2—
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 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 penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Sizna afore: X Date:
Phone#:
FBoard only. Do not write in this area,to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
i 4
SECTION-8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: j Not Applicable ❑
Name of License Holder:
Na License lNumber
641 "� ' �� I' )9
Address Expiration Date
Signature Telephone
' Not Applicable ❑
9 'Reaistece"d Elorri`e I"mpcoveiiient~Contractor.�,,,� ,�„ °`.,,,�. :,�.i,, = -k .. w�.w
Company Name Registration Number
0I- - ri 5121 1 -
Address Expira ion Clate
Nor��r� ►►�Zj 1 t
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...... ❑
11 ='.Homy QnerEx �
on
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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0 1 K
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O] Other[O]
Brief Description of Proposed (n�
Work: ZYI (l ill U ) ri ��VVC irCC)F-
Alteration of existing bedroom-Yes No Adding new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a If IVe>nr hotise-an&` addition-to existing housin t-compl"eta the.foitowtng:
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 wit' 100yr. 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
_s
Lie�(l ]7Zf �1 as Owner/Authorized
Agent he by 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 14arne
Signature of ang/Agent Date
3
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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
Buildin.-Department
Lot Size
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved e__I
#of Parking Spaces
(volume&Location)
A Has a Special Perm t/Va o/F i ever issued for/on the site?
— NA... DON'T ...~.. ^�^ .^~ ��_/� ��
IFYES, dateissued-
'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO C ) DON7 KNOW YES
~� '
IF YES: enter Book | Page. and/or Documnnt#
B. Does the site contain u brook, body of water urwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobmobto/oed Obtoined x~� Date
� '
�~� ' '0 '
C. Do any signs exist nn the pruport �� ��y? Y[3 v�� N8 �~/
IF YES, describe size, type and location: |
D. Are there any proposed changes to or additions of signs intended for the property? YES x�� NO 0
|F YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part ofa common plan
that will disturb over 1acre? YESK ) NO ���)
��
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
Deparfnent,use only '
City of Northampton Status ofPermtt
Building Department Curt CtJtlDrNeWpoy ermit8
w �
212 Main Street Sewer/Sepfic....
brtrty: "
Room 100 ili
orthampton, MA 01060 two Sets of StruciurafPlans
r
ph n4 3-587-1240 Fax 413-587-1272 Plot/SEte Plans
Oth ll
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION A='SITE INFORMATION
1.1 Property Address: This'section'to be completed by office
ii Map Lot Unit"
ly l e Zone Overlay. District
Fl . y- ,Inc 1'tiAU 0 IQ(,, •Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record:
Name(Print) Current Mailin Address:
-C�►L c\
Telephone
Signature
2.2 Authorized Agent:
Nam (Print) Current Mailing Address:
e /�'.
(u ) �
Signature Telephone
SECTION 3_E TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building i 00 (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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
w.r
BP-2009-0572
GIs#: COMMONWEALTH OF MASSACHUSETTS
1 . 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-2009-0572
Project# JS-2009-000813
Est.Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 142807
Lot Size(sq. ft.): 11325.60 Owner: KOLODZINSKI EDWIN A
Zoning:URA 100 //WSP Applicant: CYRUS NEWMAN
AT. 26 GOLDEN DR
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.121312008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL RUBBER 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 12/3/2008 0:00:00 $35.006196
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo