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17A-291 (2)
PROPOSAL P��Q ,.. �. SIiEF�iNCS,�t. L octK kv-C-tYt�e (V-1(� 01 0 G cl, DATE PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT NAM ; ADDRESS © C� ADDRESS 7 DATE OF PLANS PHONE NO. ARCHITECT We h reby propose to furnish the materials and Worm the labor necessa for the completion of !n CL © C.� • w +1 ; nct 4 .a p V r *n t�^ 1'10 0 n 1 ' -- CA f �- (NA o R C J n' " ern o f a 2 ti r" -iC ✓in Cp All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings anf�±speci nations submitted for above rk and completed in a s stanti I workmanlike manner for the sum of � . L12s o0 4-0'- l OJ vo CEO. OO ' 1''O C4� Dollars ($ with payments to be ma as follows. �3 G, .A-rct l /96 a-f- -')*n i"Sh Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per over and above the estimate. All agreements contin pon strikes, ac- cidents,or delays b yond c r control. Note—This proposal may be withdra. by us if not accepted within 0i da ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. are authorized to do the we as specified. Payments will be made as outlined above. Signature —K, Date Signature MADE IN S N C 3818 50 PROPOSAL 04 CtiMlP 0 B 8 GIt� laf wart 4allip toll ae j,3�asaArhttactta• m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE ATITIDAVIT (li censee/permi ttee} with a principal place of businessJresidence at: (phone#) (street/city/staieJzip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Colupany/Poticy Numbcr) (E-,#ra ion Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Numb(u) (Expiration Date) (Name of Contractor) (Insurance Com=, y/Policy Number) (Expiration Date) (attach- Dash s cct ifnc Jude infotinsrion pertaiairg to all c atractora) ( I am a sole proprietor and have no one worl"ng for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that A4,ilc homcowvm who cmplay prom to&m intro.Z cc sn c oa or rc mir work oo a&«cuing of not more than thaw units in which the homeowner re=de3 or oa(he g ounds appurtenant thcrcto L2 no(gcncr-l y coasidatd to be eaTloyrrs under the wark&r C=Pcmatioa Act(GL152Ss 1(5)�application by a homoo",=for a L-54 cc permit may c idenoe the legal axarc of an employor under tho Workcet Compensation Act I undcr:taad that a copy of this ctntcmcm may bo forwarded to tho Dcpartrnco2 of lnd,,trill Aocad-&011loo of Inairanco for thm coverage va ificafioo and that failuro to secure coWnTo tinder scciioa 25A of MGL 152 can]cad to the imposition of criminal pcnakics oon ittiag of a fine of up to S1,500.00 and/or imprisonaseIIt of up to one year and civil peualtia in tic focm of a Stop Work Order and a f=of S 100.00 a day tgaimt me. For dcpartnr� use only Permit Number Mapt Lot4 Signa of rmittce e r SECTION 8CbNSTRUCTIQN,SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License N mber AAA i 0,311 :a00 3 j s Expiration Date re Telephone Bred ' mp'rovement Contractori� ., SEEE .,,..,.. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid� will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili, 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 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 SECTIONS fDE SG IPTION,ir',Q PROP-OSED aIIVORK check'a31 a licable wTa.M. r p rA „. 3 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] I Brief Description of Proposed Work: w �� 'r e e Alteration of existing bedroom__Yes V No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes V No Plans Attached Roll ❑- Sheet❑ 6a Ifi New ho se.. d or adtlit'o ,to ezistin'` Fi: sin cords`l AVt1WXfol1VW1'h 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. 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 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 „©INNER AUTHORIZATION -TO=BE COMPLETED WHEN OWNERSAGENT ORCONTR'gGTOR"APPLIES"FOR".BUILDINC PERMIT as Owner of the subject prope hereby authorize to ac 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 Name Signature'0 w nerLP Date (L 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: R: 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 ver been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Reg' of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # r k body of water or wetlands? NO V DON'T KNOW B. Does the site contain a b oo , b y 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. Ar there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: r r, 2 C Northampton s LS Par g Department Main Street r. OCT — 2 2001 Room 100 a + No pton, MA 01060 Sets f Al 587 1240 Fax 413-587-1272 Plots/5i N e P a s DEPT Of BUIL I NORTHAMPTON,MA 01060 Ot�herSpec .; APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to,be.Complted fftce 1.1 Property Address: �t:ot C? L Zone,, OverlayD�strt C� - �' 1 Q� � Elm St. District CB-Dis#r�ct SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Nam Print) Current Mailing Address: Signa re Telephone SEC ON'3 - E3 (MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building a if,q (a) Building Permit Fee 2. Electrical l.� (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) (�' F � Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 78 HI14REST DR, BP-2002-0368 GIS#: COMMONWEALTH OF MASSACHUSETTS Mpg:BjQck:,17A;7!291 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2002-0368 Project# JS-2002-0557 Est.Cost: $4200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sg.ft.): 21 257.28 Owner: PLATT RUTHERFORD H& Zoning:URA Applicant. Jesse Montgomery AT. 78 HILLCREST DR Applicant Address: Phone: Insurance: 46 Oak Street (413) 585-8482 () FLORENCEMA01062 ISSUED ON:1013101 0:00:00 TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER EXISTING 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/3/010:00:00 1076 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo