11A-049 1hapasal Page No. of Pages
NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 1064
413-586-1093
PROPOSAL SUBMITTED TO PHONE DATE
STRE JOB NAME
t In fA`L C�'v t
CITY,STATE and ZIP CODE JOB LOCATION
v. Y
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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r_; _ _ _J. Yt - . ,'S.. _ i? , v kj 7aa.°mo d pa, c
or TD DSr hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
O d 1
It Payment to be made a follows: QU —dollars($ ,o�o^ d ).
5 Q A- CU'C
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices.Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tomado and other necessary insurance. Note:This proposal a be
Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepte ithin ✓u days.
rirr of proposal ——The above ricer specifications z�rre�to � � prices, p
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: 6 1 i'11 c� Signature
INLA O'Get)
TV% E M NIT
ECDOYIIE 1-11 ;ER X! iEDTIONA C 'G VLEDC E
Tire&,--.-r� aijows &e honjecw�-er Le rgIL-, =der 780(--2,f 108.3.- to
/11 1 L oils
a-c-L C-E 4--iLdr Con-s--uCtion. cr. The szzazt 6�faes
W-L6 o-I'r-I a oil �e/s-e resides or Lnt--z(L,to be, a one or two fam-Ey
d� . Is t Ch us-=dlcr fa=. , s=ctures. A
a:--acLed or.deached s=c-ai-r= acs 0 Su -., 'd
person 7�c Ccm-,,ZU==ore th= one ho=e iz, a-LXC-Yer-r per-,cd, sLaII not be consi ,ere.d a
home 0--,Ymer."
T-Ihe- fGF LIne Clrf Of
.1per-scra(s) 'Who seek Lo-
exc�=ptzcn, to act as 'UL-e=' 07wz cczSt[-,x—=I aw
tLal.b-,,dog` sc You become re-spo=ible for complian-ce wRh state buildin-z- ccde�
=d reTalations- re-qua-res that t'-,,e buLd.mg department be cz--'7e,--!
to iz,sc ec—,wrr,-zz zc-s, -- ch jrcild- cbe1bre bacIdUA
so-notzlb-e holes (before uour). a rou,gh buRdin-g;hisnect-on(before work-is
irz�;ectian (ifrecuIred)a-ad-, finn? The
these=- ,ecdors before the work is corc'--jed-, failure to
-
secure these 1=1je--n-Gris can result in failure to obtain a ce-t gate of O.Ccuu:anc-v
Umta4h--
E-tLe hc=.eo w�er Eirel.ctLer trade-< to pe:f'orm-wori plaz—nb in g- gas) the
wul, be r--ucz--ible to r.-Lake that tEe L-aZes h.L-ad se---. e their-proper,
In cr,-: b uilding per=!-, their required
on a--d that the-V —t
i=pections.FaElure cic'[Le Ldividuzl =des to sec-,z- e the pe,=:5=d insp"ec-LiGzs as
rem .s are
rade
cz:-- D E TLA Y the p r cji--- u-=,I such dk=ie as t Le proper 1: and t--Ecr
un-de=--,z--md the above-
(Hr-.m owner/resid,en t2 s si azure r e q,L,estin e-zem-p tio n)
C;2:,j-0 SCLed,,Ie a T r_ e-� build --zary f -e buEd'
1. tZ pe=cr--ne-- or the Z pent
D ate --------
.. ........
— j Office of Investigations
Washington Street
Boston, MA 12111
W yv.mass.gov/dirt
Workers' Compensation Insurance Affidavit: Builders/Contractors/E lee triciansIPlumbers
A I✓plicant Information Please Print Leglbly
Name (Business/Or�zanizadon/Individual): 37 MewmaL ,, 1),B Iq N1 e )mo,rt'n C-E�"1C�' - _
A 4,4 S 1 ctrl f 6 —
Zuui
City/State/Zip: �� �Prar_e m:
you an eMployer7 Check the appropriate box: Type of project(required):
!. I an a employer:with 3 4. ❑ I am a-eneral contractor and I
employees (fuH and'orpart-time;. have hired the sub-contractors
6: ❑ New construct'
2.❑ I ana a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. (? Building addition
[No workers' comp. insurance comp. insurance.?
required.] 5- ❑ Wd are a corporation and its 10.7 Electrical repairs or additions
❑ ;am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself: [No workers' camp. right of exemption per MGL 12.C5�Roofrepairs
insurance required.] ' c. 152, §1(4), and we have no e
13.❑ Other
employees. [No workers'
comp. insurance required.]
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicarin, they are doing all work and then hire outsidecontractots must submit a new affidavit indicating such.
=Corr;actors rat chec:<this bo;<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 tliat is providing won'ters'compensation insurance for my employees. Below is the'policy and job site
information.
Insurance Company IN GjU)0�a =ns J
Policy=or Self-ins.Lic. #: C-4W QF-2996 Expiration Date: '
Job Site Au ress: to y i I I PSr' . City/State/Zip: AS. V-iQ
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 S 1,500.00 and/or one-year imprisonment, as w-elI as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 52-50.00 a day--pinst the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DI-k for insurance coverage verification.
l da hereby-cert, rrndc,the-prdrrs7rn�lp�rrries eperjai;nr Fssatne in formation provided above is true and correct:
:iznature: Date:
L4 13 tz-4
'-ci�zL'zse--�z1z1`.r--I?_c��zr�•i�rte.uzshis_arerz�to b�_cnmaleted by cih•or town o cial --
City tar Town: PermitLicense T ��
Issuing uthority_ (dircle one):
,.,.7 > i � t ! t ! 7 t T�? m' i7 T11�pel:tor �I
�. lJ a: f�l r-!t.!.t� -. y17 r,
DL11Q1 1�� 11 tTcril L iI Y, i v vu C1Cr;i E;LL' _ t a. �Il5prL'
i
b. 0th.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑'
Name of License Holder: _l)f. 'S /V 6-4)rYLQ.� 914' `Q
License Number
Address Expira on bate
Signa Telephone
s.Registered Home Improvement Gorrtractor. .. '', _,. ._. . .,., Not Applicable ❑
1��(?ltirlCt;r�1 �_y�S�fiziC- iF7 ti ILA2PCT4-
Company Name Registration Number
VA bt Wc+ k ' 2UiO
Address f Expiation ate
hJCjr J I IL) rrt C{ y l � JQ � (U Telephon4�l?���7.-c i
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...... ❑
Qwii& aemp
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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Ci Siding[pj Other[❑]
Brief Description of Proposed
Work: l'r,Nje r r�Ve ,- ` IeL. L I i-4 Ck
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 andge addition.to ex stinq`'hausinq,.00mplete the foI[oinrinA:
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 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 as Owner of the subject
property
hereby authorize
to act on my behalf, in ail matters relative to work authorized by this building permit application.
Signature of Owner Date
�f✓V ,I ��f'i� ►'ti�Cr y 1 as Owner/Authonzed
Agent h reby 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.
C\i r Uti� l Y1 g_-L
PrintfName� __ .___.....
Signatur ner/Agent Cate
0
IL
f �
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.. .._ _m L: R.,_..._,,...
Rear
Building Height
Bldg.Square Footage _._. % _ ..._... _.....__.
Open Space Footage __ %
(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 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW C) YES
IF YES: enter Book Page µ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW () YES
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 0
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 Watef Management Permit from the DPW is required.
r
r
Department rise only
City of Northampton Status:of Permit'
Building Department Out Cut/Drtveway Perri tt
212 Main StreetSewerSepttcvariabflity
- Room 100 Water/Well AvaiCabd�ty
p� LJ
Northampton, MA 01060 Twa Sets of Structural PFans
phone 413= 87-1 0 Fax 413-587-1272 PlotStte Plans
Other'Slaecrfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,,-St`f'E INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
JVr I�o'ne �Jf.
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) urrent Mailing Addr s:
14 t�1
Telephone
Signature
2.2 Authorized Agentn �� /`t I
Frl'(l r lcd• 1162U.4. Iv�C�
Na (Print) Current Mailing Address:
Signat a Telephone
SECTI N 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building v-0 (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) ca Check Number
This Section For Official Use.Onl
-Date
Building Permit Number. Issued:
Signature:
- -----
Building.Commissioner/lhspector o m mgs - Date
S LONE D BP-2009-1036
GIS#: COMMONWEALTH OF MASSACHUSETTS
k*:Block: I lA 049 ,f 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
Permit# BP-2009-1036
Project# JS-2009-001494
Est. Cost: $5250.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEWMAN 142807
Lot Size(sq. ft.): 11107.80 Owner: ST PETERS ROBERT A&JANE M
Zoning URA(100)/ Applicant: CYRUS NEWMAN
AT. 5 VILLONE DR
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:61912009 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 6/9/2009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo