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NO'POSAL
PROPOSAL'NO.
SHEET NO.,,
DATE
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT.
NAM ADDRESS
e r. wi _ . - r m +
ADDRESS
DATE OF PLANS � 6P"/
P ARCHITECT
HONE NO.
We p4eby propose to furnish the materials and perform the labor ecessary for the completion of dh
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All material is guaranteed to be as specified, and the above work to be performed in accordance w the drawtn s and specif
,Ah cat ns submitted for above wok and completed in a substantial workmanlike manner for the sum of a//— �'�� �`�
�"C_C o I Dollars ($ 7 L OQ
with payments to be made as follows.�.�l��rQ� ZIP)5;
1
t�°7" nc
{� Respectfully submitted
Any alteration or deviation from above specifications involving a ra costs
will be executed only upon written order, and will become an extra charge Per
over and above the estimate. All a ements contingent upon strikes, ac-
cidents,or delays beyond our control, ?, L,� t,t�:- {•�L;,,,� Note—This proposal may be withdrav,
l �
f_ Y by us if not accepted within dad
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the we
as specified. Payments will be made as outlined above. '
Signature
i
g
Date
Signature
GAdanns NC 3818-50 PROPOSAL
MADE IN USA
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DEPARTMENT OF BUILDING INSPECTIONS
212 Maui Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMTENSATION INSURANCE AFFIDAVIT
(li�userJpermittee)
with a principal place of businessJresidence at-.
(Stye:Uc:ty/state/2�p)
do hereby certify, under the pains and penalties of per' y, that
O I am an employer providing the following worker's compensation coverage for my
emplovees working on tliis job-
(Instuan� Company) (Poucy Number) (Fxxpirtion Date)
I :a sole proprietor, general contractor or homeowner (cireie one) and have hired
the contractors listed below who have the following worker`s compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance, Comoa:ry/Polic/Number) (Expiration Date)
(Name of Contractor) (Insuran� Company/Poticy Numb(-,r) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiation Date)
(attach addltiocul vh Lf n<ccz y to n }u e infermstion pzta a rsy o all ox&actora)
i
M/1 am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be avwc that wbilc hoascoµi)C z,Afro cm-play pczo n to cSo ma rrttrn snrc=r:ruc ioa or rrpau woik on a dwcl g of
not M01-C than[hrro units is which the hoaaotivncr rrsidcs a«i tl� outr43 aPWrtcnani tJxreto arc oo(gcrxnily 0owi6crrd to be
cmployrra under the%vorktex cc�rt�iion Act(GL152 n 1(5)},application by a hotncowncr for a licaisc oc periuit m^y cvidcace the
legal stab"of an employe<under thn Woriror'e Cotmpamaiion Act_
I undcx z d thzt a copy of this ctatcu may bo focwor W to rho Dtpwimcai of Industrial Ar6dca&Oflioo of Imivano for tfn
coverage vcrificatioo aad that failure to sa.=coverMgo un&r scctioa 25A of MGL 152 can lead to tb,imposition of criminal pcuakies
oonsistiIIg of a f nc of up to S 1,500.00 imd/or impriaoffi Crd of up to one yrar a yi civil penaYtia in the form of a Step Work Ocdc and a
fins of S 100.00 a day tgaiwa mc.
For dcgat�—only
permit Numbes
gyp;{_ Lot tt
:� Signer of U 'ttee —I��e
.e
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑l
Name of License Holder : `-�C :��. `G�1C1(11'�f" —C 5— 0771
tJ License Number
Li G Q00-5
Add, s QQ Expiratio Date
Sig t re Telephone
1
9` Registeretl Home Iriiprovement Contractor ,_,,,, Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' 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...... ❑
11. Home Owner Exemption
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^indows Alterations) ❑ Roofing ❑
Or Doors N1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: e k '�C" ' �M 5 a'g 7 5�!✓r7 `✓� � -
Alteration of existing bedroom Yes No Adding new bedroom Yes �/ No
Attached Narrative D Renovating unfinished basement Yes " No
Plans Attached Roll ❑ - Sheet U
sa. If New house�andor.additio to'exi'stin housin complete the following:
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? /0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? .2
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
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.
Print carne
k�Signa f 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:-60 R: L: R:
Rear
Building Height I
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin )
# 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 V 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 ere any proposed changes to or additions of signs intended for the property ?YES _
No �1((
IF YES, describe size, type and location:
ty�f t ampton Stat so Pei " . �
artment Cur r ff7 e.
V
212 Street Sewer/,Septic A rl�
OCT — 1 2 01 R 00 wader uVe(i v, Iity
Northam ton, A 01060 Tv�S�ets ofSt�r c ra ans � �F
p 40 ax,413-587-1272 PiotlSlte flans :.
v- OF a IlD
NORTMtigpjoN,MA 01060 Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
. This section to£be completed by office
1.1 Property Address:
,n Map Lot Unit
e
p 4-„1 J Zone 'Over ay, istr'ict
Elm St. District CB District
SECTION 2 P ON F ERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
— _ Telephone
Signature — -----
2.2 Authorized Agent:
Name Print) __ Current Mailing Address:
S gna ure Telephone
SEC ION s3 - ES (MATED CONSTRUCTION COSTS
i Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant_
_
1. Building 11 f)flo (a) Building Permit Fee
1 "7
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 Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
° AVE ` BP-2002-0367
GIS#: COMMONWEALTH OF MASSACHUSETTS
%. ,k :25k.002 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2002-0367
Project# JS-2002-0556
Est.Cost: $4400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sg.ft.): 6621 .12 Owner: SAMOLEWICZ EDWARD&HELEN A&
Zoning:URB Applicant: Jesse Montgomery
AT. 28 COOLIDGE AVE
Applicant Address: Phone: Insurance:
46 Oak Street (413) 585-8482 (�
FLORENCEMA01062 ISSUED ON:10131010:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE STORM DOORS & WINDOWS
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 10/3/010:00:00 1074 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo