36-162 LICENSED REGISTERED 410 INSURED
WESTERN MI.-;=i cc
isMASONSIL
147 MIDDLE ROAD, SOUTHAkpr "ON, MA 01073 - (413) 540-1959
WWW.WESTEP MASSMASONS.COM
QUOTE
To: MARK WAMSLEY Date: 6-22-2007
1086 BURTS PIT RD. Quote# 7878489
FLORENCE MA. Project: CHIMNEY
Phone: 427-8228 t
Description of Work To Be Done:
EXISTING CHIMNEY WILL BE TAKEN DOWN TO THE ROOFLINE AND REBUILT WITH NEW
BRICKS, FLUE AND LEAD FLASHING.
A CONCRETE CAP WILL BE FORMED AND POURED.
REINSTALL METAL LINER AND TOP PLATE.
DISPOSE OF ALL OLD MATERIAL.
WE HEREBY- OSEiOFuRNISH MATE=RIALS AND LABOR, $ 2050.00
IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS,FOR THE SUM OF:
This quote may be withdrawn from us if not accepted within 30 days. `rn�BOMtNI(
Quote Prepared By: David Osiecki W19 Mry
TERMS:Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will became 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.
Arty 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. Y/SA
PAYMENT TO BE MADE AS FOLLOWS:One half of quoted amount is due when job construction has begun.Remaining balance of bill will be paid
in full when job is complete.A Firnance Charge of 1-1!1(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 Accepted.You Are Authorized To Do
The Work As Specified.Payment Will Be Made As Outlined Above.
Signature: Date Signature: Oats:
1"1071
Thank You For Choosing Western Mass Masonsl
�Zt1AMP�.
Lzty of Nort allip#nit z s
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5i DEPARTMENT OF BUILDr11,1G INSPECTIONS /=
INSPECTOR
212 Main Street • Municipal Building
°�� 5•°�'
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 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 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
a 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): tlf 1"S j e!, -,
a ti.
Address:
City/State/Zip: Phone.#: r �f y l' �r
F2. you mployer?Check the appropriate box: Type of project(required):
y am a employer with 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. �tieling
ship and have no employees These sub-contractors have g. ❑Demoliiion
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 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.E]Roof repairs insurance required]t c. 152, §1(4), and we have no 13.❑ Other -5
employees. [No workers'
comp. insurance required.]
*Any-appp—lican a c ec boX41 mustalso rill out the section below showing their workers'compensation policy information.
--
t 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 sheet 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:
Policy#or Self-ins. Lic. #: �F-°d?yr`, `(, / Expiration Date:
Job Site Address: lb., G, ,fit, %1
City/State/Zip:
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
Investizations of the DIA for insurance coverage verification.
I do hereby certi n r t pain d penalties of perjury that the information provided above is true and correct.
Si ature:
Date: v _
Phone#: `� ✓ '�f
Official use only. Do not write in this area, to be completed by city or town offcciaL
City or Town: Permit[License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Apppllicabllee 11 Name of License Holder: �/ �:/ C%� Od / �
License Number
Address Expiration Date
YU i
Sign i A700, ` Telephone
3.Re ister'ed Mo_mrripovement Coritracforz h Not Applicable ❑
Company Name Registration Number
S
Address Expiration Date '
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidayJt must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildkfg 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-vear 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[0]
Brief Description of Proposed .
f�, ,
Work: RC �;
Alteration of existing bedroom Yes No Adding new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If New house-anii.or-adclitrorr fo existin4 ousEitECi coriiplete:the:fo[lowl>Zg:
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 stones?
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 will in 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
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/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.
0'A- -i) �-
Print Name
Signat4 of weer/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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. . ,
Has a Special Perm it/Varia nue/F i ndi ng ever been issued for/on the site?
IF YES, date issued::— |
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
' �----------1
IF YES: enter Book ' Page! ( and/or Duoumant#
�� �� ��
B. Does the site contain u brouk, body of water or wetlands? NO �_� DON'T KNOW �_/ YES �~�
IF YES, has u permit been nr need to be obtained from the Conservation Commission?
Needs tobe obtained �-� Obtained �-� Date Issued:
\~�/ «_� ' �
C. Do any signs exist on the pnoperty �� ��� YES v�� NO v��
IF YES, describe size, type and location: � !
D. Are there any proposed changes toor additions of signs intended for the property? YES 0 N0 0
IF YES, describe size, type and location: !
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orioit part ofo common plan
that will disturb over 1 acre? YES ��y ) NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only.
City of Northampton StatusoUPerhit
q
Building Department curb-Cft�tDnvewsyPerrnt n
212 Main StreeteweffSepttcAvatlabtlrty
Room 100 Watertttuetl Availabt[tiy :`
Northampton, MA 01060 FvstaSetsofStrUctufal"Prans
phone 413-587-1240 Fax 413-587 127 . 16i%itel lans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR D LISH A'ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
L- a 1"+ ' section to be completed by office
1.1 Property Address:
Lot Untt
Zone Overlay District.
-EImSt.District 'CB District
SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT -
2.1 Owner of Record:
dL ri( LA'1A' '1sl �
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name Pnnt Current Mailing Address:L
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
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 =0 +2+3+4+5) < )- Check Number 7f w
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-0069
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
dot 001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0069
Project# JS-2008-000098
Est. Cost: $2050.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin WESTERN MASS MASONS 133234
Lot Size(sq. ft.): 11543.40 Owner: WAMSLEY MARK
Zoning: SR Applicant: WESTERN MASS MASONS
AT. 1086 BURTS PIT RD
Applicant Address: Phone: Insurance:
147 MIDDLE RD (413) 540-1959 WC
SOUTHAMPTONMA01073 ISSUED ON.711912007 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY TO ROOFLINE
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 7/19/2007 0:00:00 $25.002942
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo