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35-207 (5) I , LICENSED REGISTERED INSURED WESTERN MASS , MASONSta 383 COLLEGE HWY, SOUTHAMPTON, MA 01073 • (413) 527-1800,540-1959 WMMESTERNMASSMASONS.COM J- QUOTE r To: JULIE KOSSON Date: 3-28-2008 1238 BURTS PITT RD. Quote# 24387 FLORENCE MA Project: CHIMNEY Phone: 584-6381 Description of Work To Be Done: BECAUSE OF EXTENSIVE WATER DAMAGE, CRACKED CONCRETE CAP, SPAULDING BRICKS, THE TOP 5' OF THE CHIMNEY MUST BE REBUILT, THE TOP 5'WILL BE REBUILT USING NEW FLUE, BRICKS AND LEAD FLASHING. A CONCRETE CAP WILL BE FORMED AND POURED AT THE TOP. ALSO CUTINS WILL ALSO BE REDONE SO WATER SHEDS OFF THE CHIMNEY BETTER. INSTALL TWO PIECES OF STONE TO SHED WATER, WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR- 1 $ 4950.00 IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS,FOR THE SUM OF: This quote may be withdrawn from us if not accepted within 30 days. jel��.tO Quote Prepared By: David Osiecki PROatlAM TERMS:Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.By signing this quote you agree and understand all the above terms and conditions that apply to this job. Any changes that are to be made,must be discussed prior to construction and agreed upon by contractor and may also effect to the final price. A454 PAYMENT TO BE MADE AS FOLLOWS:One half of quoted amount is due when jab construction has begun.Remaining balance of bill will be paid in full when job is complete.A Finance Charge of 1-112(18%annual rate)per month will be added to any unpaid balance over 30 days. ACCEPTANCE OF PROPOSAL:The Above Prices,Specifications And Conditions Are Satisfactory And Hereby AocWted.You Are Authorized To Do The Wok As Specified.Payment Will Be Made As Outlined Above. Signature: Date: Signature: Date: Thank You For Choosing Western Mass Masons! HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the riht under 780CMR 108.3-4 to Iact 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 backfin 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 occupanev 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 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 Coinnionwealth of:Alassachusms Depar.-me;[t afI.= d[[sr.ice!_�cciderzts ©;J-ce of 1'nveslizaria=zs _ 600 T ashing ton S:r eet Briton, N 1A 02111 nw), .rrzass.coz/dia Work- r Compensation insurance Affidavit Buildersi Contractors„EIectricians,'Pirtirabers _A_r;al]Cant Information Please Print Legibly Na:1e (Business�Organi ationTndivicuaI : ��fj/ fti �.i�f1�J /�� �1 %� AuCT�_SS: C/ Citv,'StatziZip: Phone r: Are you an mplover?Check the appropriate boy: Type of project(required): 1. a.=a employer with � 4• ❑ I am a general contractor and I I employees (full and/or part-time). m have hired the sub-contractors 6. ❑New construction 2.❑ I a a sole proprietor or parmer- listed on the attached sheet. 1. ❑ Rernodeli= ship and have no employees These sub-contractors have S. Cj Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance.4 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [-N-o workers' coma. right of exemption per_MGL 12.7 Roof repairs insurance requited.] T c. 152, §1(4),and we have no employees. [No workers' 13.7 Other comp. insurance required_] 'Any applicant that checks box=, must also 5lI out the section below showing their workers'compensation policy infonration. Homeowners who submit this affidavit indicatins they are doina all work and then hire outside contractors must submit a new affidavit indicatins such. �4_-ontractors that check this box must attached an additional sheet showing the narrr of the sub-contractors and state whether or not those entities have emplovees. If the sub-contractors have ertmlovees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job sire Irsuranct C—ornpany wame: c,,/r Policy r or Self-ins.Lic. T: �yl� y Expiration Date: 'C//ry Job Site:address: �U�y v /�rr�� /�✓�l� .((/J ' City/State/Zip: /_,.ef!^r, 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 25 A of_MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the ford of a STOP WORD ORDER and a fine of up to X250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investizanons of the D'—,k for insurance coverage verification. I do hereby terrify[ e the p ins an p nalties ofperjury that the information provided above is true and correct. CiQnatu?re: Date: `�y G Phone J jicial use only. Do Pot write in this area, to be completed by city or town ofj"zciaL Cin-or Town: Permit/`License Issuing Authority(circle one): I.Board of Health 2.Buildina De-oartMent 3. Ciry/Tow-i Clerk 4.Electrical inspector 5. P'umbin?Inspector i 6. Other I� comjct Person: Phone I SECTIOiN E -CONSTRUCTION SEPV10ES E.1 Licer._<ed Construction Suoerviscr. Not Applicable ❑ Name of License Holder eG ��6 License Number �dcress Expiration Date 3iar e Telephone 1 I 1.Reoistered Home Improvement Contractor u,H, Not Applicable ❑ :omoanv Name Registration NNumber ✓G .� `-s f7J d .ddress Expiration Date Telephone ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(&j.) Corkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. aned Affidavit Attached Yes....... r No...... ❑ I 1Iome`'Onergxgu 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 uidv'ad lai lvr I'=w by does not possess a Ec=se Provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 103.3.5.1. 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 Of racial,that heishe 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 Norunampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature T S=C-ION 5- DESCPIPTION OF=ROPOSED WORK fcheck all ar)olicabiet ' l+ New House + Addition Cf Replacement Windows Alteration(s) C I Rooting I Or Doors r i Accessory Bldg. El Demolition u New Signs [Cj Decks [-r Siding[p Other[?:�j I Erief Description cf Proposed Work: a /f (,. ` 'Alteration cr"existing bedroom Yes No Addinc new bedroom Yes No 00 IS Attached Narrative Fenovatinc unfinished basement Yes No Plans At,ached Roil -Sheet 6a If New house arro or addition,to exis fha housinc :cornbfete'-tht 606 n nar a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathroom=_ i 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 c. Energy Conserraticn Compliance. Masscheck Energy Compliance form attached? h. Type of construction L is construction within 1 CC ft. of wetlands? Yes No. Is construction within 100 yr. flocdplain Yes No J. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. Cantig T_nk .r.7.j Ce:... Dn.Ja.e ..ElI �.,1^y'water Supply - i SECTION 7a--OWNER AUTHORIZATION TQ EE COMP€.ETED-WHEN OWNERS AGENT O! CONTRACTOR APPLIES FOR BU.ILDING�.PERM1T I, 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 as Owner/Authcnzed -.gent hereby deciarc that the Siatemert5 and information on the foregoing application are true and accurate, to the best zf my kncWe^gE Iand belief. Sicred under the pains and penalties of penury. I P-int Name Scrai_re 3, �wnerr^ .;t 52C.i0i 4. BONING I At' information Must Be Compteted. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This coiumn to be filled in by Building Department Loi Size Fr ontaee Setbacks Front � Side L:.. _.__.�_ R: _...._ L -. ..., _,: R. Rear Buiiding Height Bldg. Square Footage % _._.. Open Space Footage -- (Lot area minus bldg&paved T mancine) #of Parkine Spaces Fill: (volume&Location) - —- - 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 DONT KNOW n YES...,_ IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 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 0 NO 0 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 0 IF YES,then a Northamoton Storm Water Mdnagemenf Permit from the DPW is required. Department use only City of Northampton t s f erfiit: Building Departmer� �_�._' ay Permit 212 Main Street Sewer/$e cAvailability Room 100terlUU�'vailability Northampton, M,4. 01060 Two Se$s"ofS ctural Plans phone 413-587-1240 BaX,413 X58/-1272 M Plan l- APPLICATION TO CONSTRUCT,ALTER,R A71 T NOVATE OR DEMOLISH A ONE OR iWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit Zone Overlay District Elrn St District C8 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: "1 C.- r`� �c1,5 TO Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: 651'es K, Name(Print) Current Mailing Add s: Signer Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS' Item Estimated Cost(Dollars)to be Ofciaf Use Only - completed by permit apolicant 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 This Section For Official-USe.Onl _ Date.. Building Permit Number Issued: Signature: ------ - Budding.Gemmissione�/lnspectoroi•- ui trigs � Gate BP-2008-1184 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-2008-1184 Project# JS-2008-001746 Est. Cost: $4950.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WESTERN MASS MASONS 133234 Lot Size(sq. ft.): 71002.80 Owner: KOSSON JULIE&MARCIA MERITHEW Zoning: SR Applicant: WESTERN MASS MASONS AT. 1238 BURTS PIT RD Applicant Address: Phone: Insurance: 147 MIDDLE RD (413) 540-1959 WC SOUTHAMPTON MAO 1073 ISSUED ON.6/27/2008 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY TOP 5' 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 6/27/2008 0:00:00 $25.003219 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo