36-243 LICENSED REGISTERED INSURED
WESTERN MASS
.I. MASONSli
383 COLLEGE HWY, SOUTHAMPTON, MA 01073 • (413) 527-1800
QUOTE
To: KATE WILSON Date: 9-18-2008 --- }
46 SOVERIGN WAY Quote# 674389
NORTHAMPTON MA Project: CHIMNEY
Phone: 586-1803
Description of Work To Be Done:
THE TOP SECTION OF THE CHIMNEY HAS WATER DAMAGE TO THE CAP AND THE TOP TWO
COURSES OF BRICK.
I THE CAP AND TWO COURSES WILL BE REMOVED AND A NEW CONCRETE CAP WILL BE
FORMED AND POURED AT THE TOP.
A CLEAR BRI(;K SEALER WILL BE APPLIED TO THE WHOLE CHIMNEY AS WELL. !
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WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR- 3950.00
IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS,FOR THE SUM OF:
This quote may be withdrawn from us if not accepted within 30 days. 86BQ�tL�Nt
I Q Y
Quote Prepared By: David Osiecki �
TERMS:Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an
j 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.
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PAYMENT TO BE MADE AS FOLLOWS:One half of quoted amount is due when job consbucticn 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.
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ACCEPTANCE OF PROPOSAL:The Above Prices:Specifications And Conditions Are Satisfactory And Hereby Accepted.You Are Authorized To Do i
` The Work As Speoified.P ent Wilf Be Made As Outlined Above.
Signature: Date )f Signature: Date-
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act 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 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
r �r.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office bf Investigations
. _ 600 Washington Street
Boston, MA 02111
_ - www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/PIumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individ dual):
Address: 3e3 Cd`l��
City/State/Zip: 5GaA n Phone#: Tc' �C�'�r�•
Are you�n employer?Check the appropriate box: Type of project(required):
1. am a employer with 4. I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole propri etor or partner- listed on the attached sheet. 7. ❑ Remodeling
These sub-contractors have
ship and have no employees S. ❑Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp.insurance comp. insurance.:
required.] 5. F-� 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. Plumbing repairs or additions
myself. [-No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill 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?�6 y� Expiration Date:
Job Site Address: �6 s��'�6 � 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
Investigations of the DIA for insurance coverage verification.
I do hereby certi nder th ins nd penalties of perjury that the information provided above is true and correct.
Sienature: Date:
yea
Phone#: �
Official use only. Do not write in this area,to be completed by city or town officiaL
Citv 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#:
A
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: J Not Applicable ❑
Name of License Holder QA'',O �'[�'
License Number
,.3
Addres Expiration Date
Si at a Telephone
Not Applicable ❑
9:'Registere "Homeim0r6 meet Contra
/ r /r � /3L4�
� f
Company Name Registration Number
C /U
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.1!52,§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 ermit.
Signed Affidavit Attached Yes....... No...... ❑
Homt , er x emntia 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 buildine 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
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑] Other[o]
Brief Description of Proposed �
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and.or addition,to existing h:ous-ina, complete the:followina:
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 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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE. 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
&C K, 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 enalties of perjury.
Print Name
Signature of w r gent 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
Side L: ..._. R __. _ L
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces --
Fill: s
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
JOIN
NO 0 DONT KNOW YES
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0, YES 0
IF YES: enter Book ;, Page 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 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 Northampton Storm Water Management_Permit from the DPW is required.
��� Depaent use only 3;
qty of Northampton status of rrn+ �h a
Building Department . CurbutfDneway Peranrt '`sue �a
1f�
'112 Main Street Setiarer/Sept
\ a�lablry
RoQom 100 1ar�Well'Avauab�*} r
r'
`r Northampton, MA 01060 Twti Sets,oEStructfjtAF ans
phone 413��87 1-2'40 Fax 413-587-1272 Pl�t� to t�laris
Othe'' pea y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
JQUPr j✓, W14
Map- Lot Unit
/ Zone Overlay District
-Elm St District CB District
SECTION -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �,/ /
Nam (Print) Current Mailing Addres :
Telephone / U/
Signature
2.2 Authorized Agent:
Name(Pr t) 00, Current Mailing Add ss:
SignatuA 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=(1 +2+3+4+5) ��'�G.0 C) Check Number d �s
This Section For Official Use Only`
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
46 SOVEREIGN WAY` BP-2009-0814
GIS#: COMMONWEALTH OF MASSACHUSETTS
&:36--143 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
Pennit# BP-2009-0814
Project# JS-2009-001211
Est.Cost: $3950.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WESTERN MASS MASONS 133234
Lot Size(sq. ft.): 60374.16 Owner: GREEN SCOTT T&NAHO GREEN C/O CATHLEEN O WILSON
Zoning_SR(100)//WSP 11 Applicant: WESTERN MASS MASONS
AT: 46 SOVEREIGN WAY
Applicant Address: Phone: Insurance:
147 MIDDLE RD (413) 540-1959 WC
SOUTHAMPTONMA01073 ISSUED ON.41612009 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY
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 4/6/2009 0:00:00 $25.003503
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo