29-034 (2) dw � r� p� t Page No. Of Pages
NEWMAN'S CONSTRUCTION
697 Bridge Road
NORTHAMPTON, MA 01060
(413) 586-0273
PROPOSAL SUBMJ TO PHONE
DATE
STREET 51rq —
JOB NAME
1r)w
CITY,STATE and ZIP CODE
A JOB LULA I
y tarn
ARCHITECT DATE OF PLANS
JOB PJONE
We hereby submit specifics o' s and stimatestor:
A
flAA12,S �41 t+.-.t`Zt
...............
............... ...................
.......... ........ ...
......... "v*.........
..........
ZJ*1.......40lb 1/�75� 7�7
..................................................... .........--------- .................1.........................
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MtPrOPOSt hereby to furnish mate, i la
d lab-,Z n I complete in accordance with above specifications,for the sum of:
4-k 1
Payment to bpaAe as folknvs: dollars($ IL3 Y-ox C)c
H pine Y\
All material is guaranteed to be as specified. All work to be completed in a
manner according to standard practices.Any alteration or deviation from above,.7.= 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 delays beyond our control.Owner to carry firs,tornado and other necessary insurance. Note:
Our workers are fully covered by Workman's Compensation Insurance, withdrawribyusmistp=1 proposal ay days.)
rndArreptaurr of Proposal —The above Prices,specifications
and conditions are satisfactory and are hereby accepted. You are aLftrized Signature
JtL
JC�
to A��V
to do the work as specified. Payment will be made as outlined above. I —
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DEPARTMENT OF BUILDING INSPEC'T'IONS
212 Maui Street ' Municipal Building
Northampton, Mass. 01060
WORICEWS COMPENSATION INSURANCE AFFIDAVIT
L Mbl1nW An
{tict;aserJpermittec)
with a principal place of business/residence at:
lQ�� tl (phone#) I1A -7,
(,streeticity/stalrJrip)
do hereby certify, Under the pains and penalties of perjury, that:
I am an employer providing the fillowwi g worker's compensation coverage for my
employees working on this job:
� za -1 n�" Cam. tAe.y-)(-y1-4go'
(Insurance Company) (Policy Number) Mxpira on ate)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the fbllowing worker's compensation policies:
(Name of Contractor) (Insurance Compauy/Poiicy Number) (F_xpiradon Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F—\piradon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sbcct ifnoaeasry to include irfwmatiar patauhing W at1 oeedrahton)
( ) I am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awam that whilo hoc=%men wbo employ p==to do maiatcaance,c=vruc6oa or rcyair work on a dwelling of
act MOM than throe units is which the bomeow=midcs or oa the gr«rrds appurtenant tba eW arc ooe gran ally oomidcr d to be
employrt s under the hvorka's comp=s4cm qd(GL152,ss 1(S)),application by a homeowner for a lice=or permit may evidence tho
legal ctatua of an otuployer under the Workees Compacuatioa AoL
I understand that a copy of this rhtemeui aray be fccwerded to tho Do pertnxat of LxkL-%risl A.aidmta'Cdlioo of Its wu for the
COBood=d that failure to aatan coverago under sxtioa 25A of Mf1L I32 rxr lead to the impositioa of criminal
penalties
004sisung of a fine of up to$1,500.00 and/or imptisoamcnt of tip to ore year and civil peaalties in the form of a stop Work order and a
&A of S100.00 a day against me
For dq=ft W W tsao 0013'
} s pe mit Number _
A
SECTION 8?-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicaable ❑
Name of License Holder : �_ ��� f l�ll'11Qt.ti�1 C50LA1AQ
License Number
Address U Y Expiration D to
199 ur Telephone
��teg s ere dome mprgyement� ontr��o �� �� , � �„,
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-:WORKERS' COMPENSATION INSURANCE,AFFI DAVIT(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 1.52(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
M
e '
SECTION 5 DESCR]P ,IdNOF PROPOSED WORK checkall applicable)
s n a,.'1+...:,✓mfi» •6, 33;:3..+M:ice Aa^J.'�,Pa R. .,,�2a.„Y>>..,. i>>w..- ce,y...i., i � ..v. ..„.,..' .
i
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: __*nPA- f to.fA� MM e LW�C�y�E�t=�� -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
Via. If Nevin ho se}and�ot iditlon to eicisting:fi��using.:complete the"f61'1bWihk
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. Mascheck Energy Compliance form attached?
In. 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-OWNERAUTHORIZATION -,TO BE'COMPLETED WHEN
OWNERS:AG`ENT O,R CONTIRAG',dk:APPI IES FOR;BUII DING PERMIT
as Owner of the subject property
hereby authorize _ to act on
my behalf, in all matters reIauvc Lo work auincrlZeO Dy mis building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereb clare that the statements and information on the foregoing application are true and accurate, to the best of my
knowlepte and belief.
Signed under the pai`nss and penalties of perjury.
Print Nam
Signature of Owne Agent Date
' y
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 DON'T KNOW_ _ YES
IF YES, date issued: _
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW _ _ YES
IF YES: enter Book _ Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
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 NO
IF YES, describe size, type and location:_
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YE. , describe size, type and location:_
s
Northampton
.g Department
1 Main Street S
om 100
3 2OSort 'ton, MA 01060 k .
Ophone 413.5 7-1 40 Fax 413.587-1272 '.
�PECi 1044 {�
APPCI il`?E T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION,
z E
mpleed by offiThis section to bco
1.1 Property Address: o
'^ b EYl M tj ce
U f
Zone Overlay District r
t
Elm-St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
yea Y\
Name(Print) Current Mailing Address:
_ Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
com feted by ermit applicant
Building (a) Building Permit Fee
2. Electrical ® � (b) Estimated 1 otal 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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building''Commissioner%Inspector of Buildings Date
BP-2003-1227
GIS#: COMMONWEALTH OF MASSACHUSETTS
F' CITY OF NORTHAMPTON
"Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1227
Project# «. 35-2003-1898
Est.Cost: $3340.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Cyrus Newman_ 064690
Lot Size(sa. ft.): 11979.00 Owner: RYAN GRACE S&JAMES M RYAN
Zoning.URA Applicant: Cyrus Newman
AT. 40 PIONEER KNOLLS
Applicant Address: Phone: Insurance:
697 Bridge Road (413)586-1093 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.6/30/03 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE FRONT OF HOUSE
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 s; nature•
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/30/03 0:00:00 3793 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo