36-011 (2) PROPOSAL
Jesse C. Montgomery
JCM Home Improvement PROPOSAL No.
46 Oak Street SHEET NO. -
Florence, MA 01062
DATE
c� ,) q C
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT
NAM ADDRESS
�a r''1 vogrn\O� ryl
ADDRESS
e 4 n
DATEAF PLANS
PHONE NO. ARCHITEPT
W hereby propose to furnish the mated is and perform the labor necessary for the completion of cx
rf ,, fir'€ !Y i
h t*
s .t/r i�-ct. ` l r� 1 ",e r-s t,,.•B 1 0 U-.'n i i X
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All material is guaranteed to be as specified, and the above work to be performed in accordance wi the drawgs and specifi
cat' ns submitted for above work and completed in a substantial workmanlike manner for the sum of !fir" �rTtavrr7 f
� ��' Dollars ($ f 00 )
with payments to be made as follows. L�f' 5L� L N-si t
Respectfully submitted
Any alteration or deviation from above specifications involving extra costs rY•
will be executed only upon written order, and will become an extra charge Per a n r"'
over and above the estimate. All agre ments contingent upon strikes, ac-
cidents,o beyo our ntrol. . Note—This proposal may be withJdays.
by us if not accepted within a
i
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the`work
as specified. Payments will be made as outlined above:
�••. t, r"�..
Signature o .A- 'L t,-
Date :.` �' �.. Signature
G 381850
MADE DE IN IN USA PROPOSAL
U I
0
�[SEACI(RECttE
cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S /COOM.EENSATION INSURANCE + + AVIT
I, �eS ! -Sc q-) c'-»
censec/permlttee)
with a principal place off business/residence at:
9 Qci. K ST• Po(e%c / ( f 1. 0ffq)1(phone#) y I S GP�'C �oz
(st=Ucity/statelriP)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Dale)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Corrrpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Conmpai y(Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Hxpiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E> ration Date)
(atiac�additi r a ifno—y to inchidc rnfocrnatioo ptttni¢ing to all ooatmcfon)
( I am a sole proprietor and have no one worl"ng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aw-A c flue while bocncowoc who employ pcnom to dD maiutcunc4 cons tucf�on or repair work oa a dwelling of
no(meet than theca ttn rt,in which the hcamwucr resides oc eo the g ouryll apptutenacu thado arc wt gcixrany ooandcrcd to be
cmploycrn under the worker's ccrnp'-nsatica Act(GL152,s 1(5)),Application by a homcoana far a Beefs cc permit may evidcacc the
legal ctawg of&n amployor under the Woriccle Componzatioa Acc
I ua&rsund that a copy of thin wtcmcnt may bo forward d to tho Dcpartmmt of IndzL ial Arcidm&Ofrioo of Ia—rwce for tbo
—age va-i£cation and that failure to aca=covcrago under section 25 A of MOL 152 can lead to tho impozif oa of criminal penalties
oomisting of a fmc of up to S1,500.00 attdlot imprisoanx of up W one year and civil pemltia is dic form of it Stop Work Ord`and a
fino of 5100.00 Icily tgainst Me-
1 For dcputttrYdal u�o only
pclinit Nulnbcr
_
map"', _Lot# _
S lITC _ PCCIIllttCC: — Ate—
R7iL.'• n:::..
SECTiOt 8 �Cb'N5,TRUCTIQN SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 0✓n 077 i C7
License Number
q (0 01 0�� / P� `/ /12 3
Addr Expiratio Dat
Sig ur Telephone
e. v men , r r Not Applicable ❑
C'SS� /t•c y»e l 34Y Q 741
Company Name Registration Number
Address % Expirati n Dat
� f f'i/1C (D Telephone J � �
SECTION 10=Wd KERS' 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...... ❑
lid t - n
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 ❑ Replacemen Windows Alteration(s) ❑ Roofing ❑
Or Doors ,0�
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: klep c(! f9ren wg 31w T 4vo, 7 t-*z
ct YtC4 0 a rr\ J i r%
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative❑ Renovating unfinished basement Yeso
Plans Attached Roll 0- Sheet❑
. IflUdMI 6 a and al atlditidi o,.ezis°tang:housing,."complete the.:`fo'1"lowing:
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?
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
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
el as Owner/Authorized Agent
hereby declare that the staterriqritk and in mation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
SigneAunder pains and pe n (ties of perjury.
Print Signat Date
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 Perm it/Variance/Findin ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Rr 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, descri size, type and location:
D. Are ere any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
�J t off, orthampton
Bulldlgp Department
2 20x2 212,iw ain Street
L, M AY `moo m 100
No r mpt n, MA 01060
fr M P Fan er b13-%7 12 0 Fax 413-587-1272
01
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Glen a .
SCE 06r(fS I�[, �Map.;
1 I Ci�°I✓L
istrict
—" Elm'St District
�� B District .
SECTION 2 -PROPERTY OWNERS HIP%AUTHORIZED.AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Lq c, 6i/
J i 3� �fYl C3�'1nC� u 1K
Vame Print) j Current Mailing Address: Dn
es� 00 If 0 ✓�
iign ture Telephone
3E TION 3 -/EST[ TED CONSTRUCTION COSTS
tern Estimated Cost(Dollars) to be Official Us&�Only
completed by ermit applicant
1. Building
j (a) Building Permit Fee'
?. Electrical (�
L..� (b) Estimated Total Cost of
/ ®d Construction from_ 6
3. Plumbing Building Permit Fee
I. Mechanical (HVAC)
i. Fire Protection
i. Total = 0 + 2 + 3 + 4 + 5) 600 Check Number /a
This Section For Official Use Only
3uilding Permit Number: gs GR Dateissued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0952
APPLICANT/CONTACT PERSON Jesse Montgomery
ADDRESS/PHONE 46 Oak Street (413)585-8482()
PROPERTY LOCATION 58 FOREST GLEN DR
MAP 36 PARCEL 011 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid %3 1Z
TyReof Construction: SHEETROCK MUDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 077410
3 sets of Plans/Plot Plan
THE FqCfOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94fMATION 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 Co n
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.
+ r
BP-2002-0952
GIs#: COMMONWEALTH OF MASSACHUSETTS
+ CITY OF NORTHAMPTON
Lot: -001
Permit: B u l i d i nl7
Category: BUILDING PERMIT
Permit# BP-2002-0952
Project# JS-2002.1544
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sg. ft.): 14766.84 Owner: BOMBARD RAYMOND A&JANET R
Zoning.URA Applicant: Jesse Montgomery
An 58 FOREST GLEN DR
Applicant Address: Phone: Insurance:
46 Oak Street (413) 585-8482 ()
FLORENCEMA01062 ISSUED ON:517102 0:00:00
TO PERFORM THE FOLLOWING WORK:S H EETROC K M U D R00 M
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/7/02 0:00:00 1312 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo