29-349 (7) for a period of one year following the final acceptance of the work or final payment for work under the
contract.
Massachusetts Contractor Licenses
• Copies must be made available upon request
e icense Information is not reauired for sub-contractors
Home Improvement Contractor's Registration# 151682 Expiration Date 0612112014
Construction Supervisor License # 097254 Expiration Date 0412912016
Elevator Mechanics License # Expiration Date
(Required for projects w/elevator or wheelchair lift installations)
Lead License
A license is required by the Commonwealth unless: (please check which one applies,;
❑ Home Built in 1978 or after
a Less than 6 So. Feet will be disturbed
Name of License holder Jailyn Gonzalez
• Deleading Contractor License# Expiration Date
• Lead-Safe Renovation Contractor License # LR001639 Expiration Date09/18/2018
• Lead-Safe Renovator Supervisor License # Expiration Date
Certificate of insurance
Insurance Carrier State Auto Name of Insured Jailyn Gonzalez DBA JR Construction Com
Policy # C800572582
I, the undersigned, hereby certify the above license and insurance information is valid under the
penalties of perjury this 23rd day of June, 2014.
Signature of Contractor
Jailyn Gonzalez/JR construction Company
Name of Contractor/Company
Accepted 1- .� z
Signature of Homeowner
Signature of Homeowner
Date
ti/)2 P)0IA.
TOTAL PROJECT COSTS (Subcontractor, Materials, Labor)
Work Item Total Cost
Egress $o.UU
Exterior Modifications $6,000.
Bathroom Modifications $3,786.uu
Carpentry $0.
Kitchen/Laundry $0.
Permanent Adaptive Design $825.
Permit(s) $175.
Disposal/Dumpster $300.
Total Project Cost $11,086.
TOTAL COST COVERED BY HMLP: $11,086.00
ADDITIONAL ITEMS
Please provide the hourly labor rate for any additional work that may be requi red]reauestec..
General Contractor General Laborer Rate $25.00
Other Plumber Rate $65.00
Other Electrician Rate $60.00
Timeline
Estimated Start Date: August 26, 2014 Estimated Completion Date: September 13, 2014
Payment Schedule Milestones should reflect identifiable measures of progress, for example:
completion of rough plumbing and framing:
(Borrower Contribution, if over$30,000) $ $0.00
Up front material Costs: $2.975.00 Description: Permit & Exterior Modification Materials
Milestone 1: $2,399.06 Description: Bathroom Materials & Subcontractors
Back deck and stairs done; old shower removed and new one in-place
Milestone 2: $1.125 Description:Permanent Adaptive & Disposal of trash
Kitchen floor installed and site job cleaned up, labor for kitchen floor
Milestone 3 $3,478.00 Description:Part of labor
=inai Payment (10%): $1,109."" Description: After final inspection: Rest of labor
Certification Statement
The quality of workmanship and finish shall be, consistent with a high quality of workmanship and
finish in accordance with industry standards for like projects. The Contractor warrants a) that
;natenals furnished pursuant to the proposal and will be of first class quality and new unless
otherwise stipulated, b) that the work will conform to the requirements of all authorities having
jurisdiction and, c) that the work will be free from defects and encumbrances. All work performed
under the contract shall be warranted by the contractor to be free from defects in labor and materials
Quantity: Cost:
❑ Windows:
Quantity: Cost-
0 Doors:
Quantity: Cost:
❑ Framing:
Quantity: Cost:
❑ Foundation/footings/slab-
Quantity: Cost:
❑ Electrical:
Quantity: Cost:
❑ Plumbing:
Quantity: Cost:
❑ Gas:
Quantity: Cost:
❑ Ductwork:
Quantity: Cost:
❑ Mechanicals:
Quantity: Cost:
0 Finish Carpentry:
Quantity: Cost:
❑ Flooring:
Quantity: Cost:
❑ Other (describe):
Quantity: Cost:
❑ Other (describe):
Quantity: Cost:
❑ Other (describe):
Quantity: Cost:
Material Cost (total) Is this an allowance? 0 Yes ❑ No
SUBTOTAL PERMANENT ADAPTIVE DESIGN COST
Subtotal Material Cost: $400.00
Subtotal Labor Cost: $425.00
Subtotal Plumbing Cost: $0.00 Plumbing work performed by subcontractor? ❑ Yes ❑ No
Subtotal Electrical Cost: $0.00 Electrical work performed by subcontractor? ❑ Yes ❑ No
ti/72/?01 A.
Central Air Conditioning
Please describe the full extent of work being performed (i.e. new ductwork, electrical upgrade, etc.): _
N/A
Location (s): Materials:
Manufacturer: Model No.: Cost:
Subtotal Electrical Cost: Performed by subcontractor? ❑ Yes ❑ No
Other Adaptive or Safety Design Modifications to Interior Living Space
Please describe the full extent of work being performed: To level kitchen floor, we propose to install
new VCT
❑ Window locks
Quantity: Cost:
❑ Specialized door locks
Quantity: Cost:
❑ Alarm system
Quantity: Cost:
❑ Security Lighting
Quantity: Cost:
4 Other (describe):Kitchen subfloor and finish vinyl floor: Manufacturer: ArmstrongModel No. 51830031
Square Footage: 170sg Cost: $400.00
❑ Other (describe):
Cost:
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Addition to Dwelling (new bathroom, laundry & kitchen please use those dedicated sections.)
Please describe the full extent of work being performed: N/A
❑ Masonry work
Quantity: Cost:
❑ Carrying beamllally column
Quantity: Cost:
❑ Insulation
Quantity: Cost:
❑ Roofing:
Quantity: Cost:
❑ Siding:
ti/72 /701 A
Ak
Other Kitchen Safety Features
❑ Cabinet locks: N/A Cost:
❑ Other (describe): Cost:
❑ Other (describe): Cost:
❑ Other (describe): — Cost-
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Accessible Appliances
Appliance Type: N/A
Manufacturer: Model No.
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Appliance Type:
Manufacturer: Model No.
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Laundry Modification or New Construction
Location: N/A
If reconfiguring space, please describe:
Plumbing Hook-upNenting: ❑ Yes ❑ No
Material Cost (total)
SUBTOTAL KITCHEN/LAUNDRY COST
Subtotal Material Cost: $0.00
Subtotal Labor Cost: $0.00
Subtotal Carpentry Cost: $0.00
Subtotal Plumbing Cost: $0.00 Plumbing work performed by subcontractor? ❑ Yes ❑ No
Subtotal Electrical Cost: $0.00 Electrical work performed by subcontractor? ❑ Yes ❑ No
PERMANENT ADAPTIVE DESIGN
Interior Door Modification
Location(s): N/A
Quantity:
Please describe, include dimensions:
Door Material: Width:
Hardware Type
Material Cost (total): Is this an allowance? ❑ Yes ❑ No
bA-
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Floor Joists, please describe:
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Sub-flooring, please describe:
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Insulation Quantity:
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Sheetrock or Plaster Quantity:
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Prep & Paint, please describe:
Material Cost: Is this an allowance: ❑ Yes ❑ No
❑ Other (describe):
Quantity: Cost:
❑ Other (describe):
Quantity: Cost-
SUBTOTAL CARPENTRY COST
Subtotal Material Cost: $0.00
Subtotal Labor Cost: $0.00 performed by subcontractor? ❑ Yes ❑ No
KITCHEN/LAUNDRY
Cabinets N/A
Number of wall cabinets: Height of wall cabinets: Cost:
Number of base cabinets: Cost:
Manufacturer: Model #:
Hardware:
Counter Top material: Cost:
Counter top height above finish floor:
Total Material Cost: Is this an allowance: ❑Yes ❑ No
Kitchen Sink
Manufacturer: Model #:
Sink Height: Sink Depth:
Material Type: Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Kitchen Faucet Type: ❑ Lever-operated ❑ Push-type ❑ Touch-type ❑ Other:
Anti-scalding device ❑ Yes ❑ No
Manufacturer: Model No.
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
ti/72 /')01 A
Grab Bars (Please indicate where and how many grab bars will be installed)
Shower
Quantity: 2 Horizontal 1 Vertical 1 Height 26in Height 24in Diameter or width
Material Type: Smooth Stainless Steel
Material Cost: $86.00 Is this an allowance. ❑Yes � No
Toilet
Quantity.- _ Horizontal Vertical Height Length Diameter or width
Material Type:
Material Cost: Is this an allowance: 0 Yes ❑ No
Other: Location
Quantity: _ Horizontal Vertical Height Length Diameter or width
Material Type:
Material Cost: Is this an allowance: ❑ Yes ❑ No
Flooring
Material Type: Vinyl
Manufacturer: Armstrong Model No. 51830031
Square Footage: 48sg
Material Cost (total) $41.00 Is this an allowance? ❑ Yes q No
Other Bathroom Modifications
Please describe: N/A
Materials:
Material cost: Is this an allowance? ❑ Yes ❑ No
SUBTOTAL BATHROOM(S)
Subtotal Material Cost $1.199.00
Subtotal Labor Cost: $1 387.00
Subtotal Carpentry Cost: $0.00
Subtotal Plumbing Cost: $650.00 performed by subcontractor? q Yes ❑ No
Subtotal Electrical Cost $550.00 performed by subcontractor? Yes 0 No
Any Carpentry Work Required
Location: N/A
❑ Demolition, please describe:
❑Framing/Blocking, please describe:
Is Electrical/Lighting required? 4 Yes ❑ No Please describe Install new GFCI
Subtotal Electrical Cost: $550.00 Is this an allowance: ❑ Yes J No
Sink
Manufacturer: N/A Model No.
Dimensions (height, depth, knee clearance, clear floor space):
Faucet Type: ❑ Lever-operated ❑ Push-type ❑ Touch-type ❑ Other (describe):
Anti-scalding device ❑ Yes ❑ No Other Materials:
Material Cost (total) Is this an allowance? ❑ Yes ❑ No
Bathroom Door Modification
Description of work, include dimensions: N/A
Materials:
Material Cost: Is this an allowance? ❑ Yes ❑ No
Hardware Type:
Tub/Shower Surround Material(s)
Manufacturer: Sterling Plumbing Model No. 62040100
Material Type: solid vickrel material
Dimensions: 35"x 60"x 76"
Material Cost (total) $720.00 Is this an allowance? ❑ Yes � No
Shower Drain
Manufacturer: ECONOSINKS Model No. G15-BRN
Drain Type: Without overflow in brush stainless steel
Material Cost (total) $110.00 Is this an allowance? ❑ Yes No
Tub/Shower Fixture
Handheld Shower
Manufacturer: MOEN Model No. 2550015KN
Material Cost (total) $70.00 Is this an allowance? ❑ Yes No
Shower Head
Manufacturer: MOEN Model No. 3868BN
Material Cost (total) $172.00 Is this an allowance? ❑ Yes No
Toilet
Manufacturer: NIA Model No.
Dimensions (height, clear floor space):
Material Cost: Is this an allowance? ❑ Yes ❑ No
ti/72 /7n1iA
Location: Materials:
Material Cost: Is this an allowance? ❑ Yes ❑ No
Hardware Type:
Fence
Please describe & include location, approximate linear footage and height: NIA
Materials:
Material Cost: Is this an allowance? ❑ Yes ❑ No
Driveway Modifications
Please describe and include depth of gravel sub-base, depth of asphalt base, depth of asphalt finish
coat and approximate area to be modified. NIA
Location: Materials:
Material Cost: Is this an allowance? ❑ Yes ❑ No
i Other Exterior Modifications
' Please describe: Demolish the stairs in one door and build a deck 3'x 8'to connect both doors and
build new stairs with railings.
Location: Rear Materials: 2"x8 2'xT', 2"x4"KDS Lumber.- 1"x6"deck flooring
assorted screws/nails/hangers; concrete cement for base; etc.
Material cost(s): $2,800.00 Is this an allowance? ❑ Yes � No
SUBTOTAL EXTERIOR MODIFICATIONS
Subtotal Electrical Cost: $0.00 performed by subcontractor? ❑Yes ❑ No
Subtotal Material Cost: $2,800.00
Subtotal Labor Cost: $3,200.00
Bathroom Modifications
Please describe full extent of modification(s) : Remove existing bath tub and install new walk-in tub
with surround walls. To level the floor we propose to install new VCT tiles. Bathroom floor dimensions
6'x 8'.
Location: First floor
Is Plumbing work Required? �Yes ❑ No Please describe Install new shower head and drain
Subtotal Plumbing Cost: $650.00 Is this an allowance: ❑ Yes J No
ti/72/7(11 A.
F)
Detailed Scope of Work and Cost
(Note: All costs should include work performed by subcontractors.)
Please complete all sections that are applicable.
Egress
Ram
Location: NIA
Description:
Rise per 1 Foot, Length and Width
Material type:
Material Cost: Is this an allowance: ❑ Yes ❑ No
Ramp Hand Rail
Height: Diameter or width: Material type:
Material Cost: Is this an allowance: ❑ Yes ❑ No
All ramps require building department inspection.
Wheelchair Lift (interior or exterior)
Location: NIA
Manufacturer: Model No.
Is electrical work required? ❑ Yes ❑ No Please describe
Material Cost: Electrical cost:
Stairlift (interior or exterior)
Location: N/A
Manufacturer: Model No.
Is electrical work required? ❑ Yes ❑ No Please describe
Material Cost: Electrical cost:
Elevator
Location: N/A
Manufacturer: Model No.
Is electrical work required? ❑ Yes ❑ No Please describe
Material Cost: Electrical cost:
SUBTOTAL EGRESS
Subtotal Electrical Cost: $0.00 Electrical work performed by subcontractor? ❑ Yes ❑ No
Subtotal Material Cost: $0.00
Subtotal Labor Cost: $0.00
Exterior Modifications
Exterior Doorway
Description of work, include dimensions: NIA
ti/72/7n1 A.
Home Modification Loan Program
Bid Form and Scope of Work
Date: June 23, 2014
Property Owner Name: Dianne Lake
Property Location (street address, municipality, zip code): 56 Austin Cir Florence, MA
Home Phone: 413-584-2475 Cell Phone:
Email Address:
Name of General Contractor: Jailyn Gonzalez
Business Location (street address, municipality, zip code): 44 Beebe Rd Monson, MA 01057
Business Phone: 413-455-9944 Cell Phone: 413-896=6627
Fax#: Email Address: iailynrosario1982 ccDyahoo.com
Narrative description of work scope (attach additional sheet, if necessary):
Outside: To facilitate the entrance in and out the house through the back, we propose to remove the
existing stairs in one of the doors and connect both doors with a deck 3'x 8' and build new stairs with
railings. Inside: KITCHEN: In order to level the floor in the kitchen we propose to install new VCT
tiles. BATHROOM: We propose to remove the bath tub and install a new walk-in tub with surround
walls.
If the project includes any electrical work, list the home's current electrical circuit load capacity (ie 200
AMPS) 110 AMPS
Please describe how the electrical will be effected by the work scope: Install a GFCI in the bathroom
Required Permits (please check all that apply)
Electrical ❑ Plumbing ❑ Gas � Building (if the town/city requires plans, please include)
ti/72 /?(11 A
ALI
TA'r'E A�TO�
mic Insurance Companies INSURED COPY BOP 2696908 01
BUSINESSOWNERS POLICY COMMON DECLARATIONS
f NAMED INSURED AND MMHBV6 AODRESS AGENT NAW Ate ADDS
ii First Named horned is Sim To Be_ R G NEYLON INS AGENCY MC
JAlLYN GO[iRAt_E2 PO BOX 1220
DBA JR RUCTION CO GRANBY,MA 01022
44 BEEBE STREET
MONSOK MA 01067
POLICY PERIOD_ AGENT TELEPHONE NlJW3Ei: AGT.NO.
From: 10103)013 To: 10103M4 (413)467-4"33 0077040
COQ PAONIVEU BY A STATE AUTO INSURED SINCE-
Putnxi s Nkdud kunualnoe Company of Coen.c. 2006
ALUTABLE POLICY_ POLICY STATUS AFTER-HOUM CLAMAS SERVICE
Yes Renewal-SMIrdard 80x766-1�3 or cwn
The coverage and these declarations are effective 12:01 AM Standard Time on 10/03/2013 at the above mailing
address.
BUSMESSENTITYTYPE. BILLM ACCOUNT NIA BRJJNG QUESTIONS?
Iri rividud C13 006721;--1 can a0D-4A49y5D X5118
Dbect Bi111 Insured 44*ay
8{15alESS OEvCJ�T1oN: Carpwft-Resikdeaftl
Upon valid payment of premium when due,these renewal declarations continue you policy for the period indicalfed.
in return for the payment of the premium and subject to all the terms of this policy,we agree with you to provide the
insuranceas stated in this policy.
PREMIUM SUMMARY BY COVERAGE PARTS AND POLICIES
This policy consists of the following coverage parts or policies for which a premium is indicated.This premium may be
subject to adjustment.
COVERAGE PARTS" PREMIUMS
Businessowners Special Property Coverages $27.00
Commercial General Liability Coverage Part $722.00
Businessowners Ewa Coverage $24.00
Commercial Inland Marine-See IM Declaraticros SM 50 00 $78.00
Terrorism(included in total below) $8.00
POLICY TOTAL AT INCEPTION $851.00
If terminated at your request,this policy is subject to a minimum retained premium of $350.00
These declarations together with the Common Policy Conditions and coverage form(s)and any
endorsement(s)identified on these declarations and attached to your policy complete the above
numbered Dolicv.
Countersigned By
(Date) (AWxnr Representative)
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS *t J
\!mils 212 Main Street • Municipal Building
Northampton, MA 01060 sst nly�ti.
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 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 rouqh 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
1, 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
600 Washington Street
r Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual): ocn\
Address: Y4 &J 0-h(' C�
City/State/Zip: 5i!, `)'I A UlyQ Phone #: Lei S`-iSte- 4 y"
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I 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`proprietor or partner- listed on the attached sheet. 7. [,5� Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 F-1 Building addition
[No workers' comp. insurance comp. msurance.T
required.]
5. ❑ We area corporation and its 10.❑ 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.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13. Other ���i �1e r
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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:�n�ry a R�.VA(d `t1.VYc)1Y<, C�Imoci r i �
Policy#or Self-ins. Lic. #: S)2�-8 Z Expiration Date: 1 L 1Q S J 1`1
Job Site Address: Vv ��-,�i, C� r ('��' nt t City/State/Zip: �:�rk
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 hereb7tify under the pains and penalties ofperjury that the information provided above is trite and correct.
Si ature: �j C.�G1 ICS 1 (4 rZ� Date:
Phone#: w
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/Liceuse#
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: !! �j Not Applicable £
(' /12 1 ✓ ` �
Name of License Holder: Win \i� ci C 3 ��
License Number
Address Expiration Date
a G) Q4�-1
Signat a Telephone
- ,
9 Registered Home Imbrovement Contractor Not Applicable E.�_. _ - -
�/� Ccn �-ru } I^�%�l C� r,c:,n L� i�tc 1 S t ti v2
Company Name Registration Number
Address Expiration Date
Telephone.Lot-�) �i s J'"4gD1i'l
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.x... £ No...... £
1L '=.Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F7 Addition Replacement Windows Alteration(s) Roofing
Or Doors (-
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ] Siding [O] Other[O]
Brief Desr� gy�,of P os /
Work: f d r-e-nJ oce br— 11k(b
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a..lf<New house'and•.:or"additi"on tomexisting.houslnq, cornp`(ete the:�followinet:
a. Use of building : Ohe 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.
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, )t cnn�Q- Le du as Owner of the subject
property �{
hereby authorize
to act on my behalf, in all matters relative to work auth rized 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 Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This cohmm to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front -
1 I�l rM._-,..- y....._..,.- t
Side L:` ! R:l_ ! L:{�-_— j R:'
Rear __—_� l -
Building Height
Bldg.Square Footage
Open Space Footage 3 %
(Lot area minus bldg&paved �!
parking)
#of Parking Spaces —
Fill:
(volume&Location) --------�--------.,.---.-------,`
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW Q YES Q
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book It Page i� and/or Document#±� i u
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW C) YES 0
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 Q NO Q
IF YES, describe size, type and location: $ Y
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO O
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 Q NO Q
[F YES,then a Northampton Storm Water Management Permit from the DPW is required.
Deparfm us o X , '
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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 gffice
l v } �a, CI ✓ Map Lot Un
,
1 o f eY c(f ] M Zone Overlay District
_Elm St iDistnct CB::Dlstnct
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT: .
2.1 Owner of Record: C4h rN e L c;
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print)' Current Mailing Address:
Signat Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building -9 11i0 -Ili a Building Permit Fee
�(L% O 9
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) (,D (�+. ' Check Number
This Section For Officiaf Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings; Date
File#BP-2015-0101
APPLICANT/CONTACT PERSON JAILYN GONZALEZ
ADDRESS/PHONE 44 BEEBE RD MONSON (413)522-9944
PROPERTY LOCATION 56 AUSTIN CIR
MAP 29 PARCEL 349 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out V:A L44 it 144r,
Fee Paid
Typeof Construction: REPLACE TUB
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 97254
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN,F99MATION 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 Commission Permit DPW Storm Water Management
on Delay
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.
56 AUSTIN CIR BP-2015-0101
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-349 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2015-0101
Project# JS-2015-000030
Est.Cost:
Fee: $45.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAILYN GONZALEZ 97254
Lot Size(sq. ft.): 14157.00 Owner: LAKE DIANNE S&DENNIS C
Zoning: Applicant. JAILYN GONZALEZ
AT. 56 AUSTIN CIR
Applicant Address: Phone: Insurance:
44 BEEBE RD (413) 455-9944 () WC
MONSONMA01057 ISSUED ON.712412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE TUB
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 Sianature:
FeeType: Date Paid: Amount:
Building 7/24/2014 0:00:00 $45.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner