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CONTRACTORS INVOICE
WORK PERFORMED AT:
TO: T50-my
1 b✓ n �
DATE JYOUR WORK ORDER NO. OUR BID NO.
DESCRIPTION OF WORK PERFORMED
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All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications
provided for the above work, and was completed in a substantial workmanlike manner for the agreed sum of
Dollars($ ).
This is a ❑ Partial ❑ Full invoice due and payable by:
Month Day Year
in accordance with our ❑Agreement ❑ Proposal No. Dated
Month Day Year
d MADE IN CONTRACTORS INVOICE
adams MADE IN USA
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r� DEPARTMENT OF BUILDTNYG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northwnptoii, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as h�is/her construction sups.'%' 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
p�0.
A E �Zcaa,tchnsrlle' _
o DEPARTMENT OP BUILDr)\10 INSPPCTIOI:S —
212 Alain Strcct ' Municipal Building
Northampton, Mass. 010GO
vv O RT2 R'S C O NIEP EN S A TI O N C'i S L.mAN CE A ITZM A VIT
(Ii ccn.sxJpermi lice}
%VILh a prirtcipal place of business/residence at:
(sit/ci t•J/stuc�a p)
do hereby cer fy, under thc.pzinS and penalties of perjury, :hat
( ) I am an employer providing dic following worker's cotnocasadon coverage Ior my
empiovices woriong on tius job:
(Lnsu_ran=Comr.:w) (PQUC-, Numbcr) --- (L:pirador, D2L.) "
O I am a sole propr;eror, genera! contractor or homeow-Der (ccie one) and have hired
the cono-ac-tors listed below wbo hive the foilo%V'Mg worke s ca�oerL��on pe!icies:
(Itlamc Oi Co:=Cio") (In urJncc Corrlpall)-/PoUCi T�tt1II1_G:) Ji.>IiJ ^n DeIC)
(Name of Contractor) (1nslrzn COMoan)vPol.im, (LXDU bon Date)
(Name of Conlzacto;) (Lasurac= Compavy/pOL-q-Number) (Expir600 Daic)
(Name of Contractor) (a7m-any CompaQy/Policy Number) Date).
e>ccl.ir nco�,to inctuc6 iaforta.7 oo pa-taiai.as to a.11 mcr-son) i
C
I am a sole proprietor and bave no one wor�dDg for me.
( } I am.a home ONvoer perforrn.ing all the work myself.
NOTE:plea be cw=re r5.*..Jjja beoxor+ ,,w-bo employ pcaoa,to do o, =-:c.,.o r repair work oa.d%,-1-Z of
ODE Mott th_o ter---1? in win 6 the bomocwnc r=do oc oa the p-ouo,:j,zppL�tba-c o Lz ooc Ccnrtty mcrdaod to be
eitployc unc'_e the kuieh==P
oa Act(GL152.n l(5)�=-pplinljw by a homco0.ocr Iv:bcx.or pazart rty cti;ct—tf:c
Iegs1 n, of ea-=;)Ioyo uodar d,o W.+.-,Coaapomilioa neL
I uaden�d t�:Dopy oC thia mt.®eaa may be foe-+.nrd.-0 to tbo pegartmeat of ln6>sxrie!Aeadu�Y Otr oe of 4�ooe Cor,Le
cova-ase vciGc=ioa--ad ai--L L•iJLM to I=d,=r soe oa 23 A of T.(QL 152 c.a ted to the i=p�oa of riminol penallio
eooai:r g of a GDC of up to 51}00.00 andlor oCup to Doc yc3r e.od coil pmaltia in the fora,of a Slop W-il or'de pad a
rrm of S 100.00 day tvia-A Mc-
For dq�rca+= u,c only
Pcrmit NUML--T --
I.(np —_ Lot
Sip�a of Lict�scclPcratiacc ��
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable]❑
Name of License Holder:
icense Nu ber
Address Expirat n Date
Sionature elephon
9. Registered Home Improvement 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.G=_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_aparcel 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 0
Accessory Bldg. ❑ Demolition ❑ New g j Decks [E:J Siding [ Other[01
) io 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
sa: If New house and 6r addition to existing housing','complete thefollowihg:
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 COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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
I, as Owner/Authorized
Agent h?rahy 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 Name
Signature of Ow ent Date
G-'
~
'
Section 4, ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
'nis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage % 7-7
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varia nce/Fi nd i ng ever been issued for/on the site?
�� ��
NO x^~��� DO07KNOVV «~� YES x_�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � ] DON7KNOVV YES��
IF YES: * enter Book Pagei and/or Document#
�� ��
B. Does the site contain mbrook, body of water orwetlands? NO �~��� DONTKNOVV «_� YES �_�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �-� Obtained �~� Date Issued:
�~� �~� . .
C. Dn 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, on,or filling)over 1 acre or is it part nfo common plan
that will disturb over Iacre? YES ���� NO ����
IF YES,then a Northampton Smnn Water Management Permit from the DPW is required.
Department use only _
City of Northampton Status of Permit:
—�— `(� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
NQV 5 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
C/ /e, Map Lot Unit
Zone Overlay District_
6 01(?6'P Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Maili Addres
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATE&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) Check Number
This Section For Official Use Only
Building Permit Number te
r.
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
11 NORTHERN AVE BP-2007-0561
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-038 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cat—may BUILDING PERMIT
Permit# BP-2007-0561
Project# JS-2007-000808
Est.Cost: $4800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN CONSTRUCTION 141721
Lot Size(sq. ft.): 6011.28 Owner: HALLER LESLI G&MATTHEW G
Zoning: URB Applicant: AMERICAN CONSTRUCTION
AT. 11 NORTHERN AVE
Applicant Address: Phone: Insurance:
24 WEST SCHOOL ST (413) 433-6882 () WC
WEST SPRINGFIELDMA01089 ISSUED ON:1111512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SLATE ROOF
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 11/15/2006 0:00:00 $25.00MO
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo