17C-124 (5) PROPOSAL
C. °r%+ 4 1'"'r�w'l9 e � f [.e�sr,71�t? T PROPOSAL NO.
/ ` SHEET NO.
9' ✓'' 2- 4 /s.. t! DATE
PROPOSAL SUBMITTED TO: 71 WORK TO BE PERFORMED AT
NA ADDRESS
orNj
' .
ADDRRS '
el L ,
I DATE OF PLANS
PHONE NO. ARCHITECT
We hereby propose t q furni t e materials and perform the labor necessary for the completion of ' ✓ t�Y� i^c
'i E " fr G 7ct 55
L-eadl-01r.
Lie J
A! 1 t C�u All
One ew lo C Q r-q-5 r 4
� � �,�,- •`' / � `� /cam� : F
1 G I/ W Q c��S , rte e J a m c is
'0r/%
All material is guafanteed to be as specified, and the above work to be performed in accordance with the drawings nd specifi
ca ions submitted for abov work A and/completed in a substantial workmanlike manner for the sumo /� -7� k v`
FpvYtc / F Dollars ( c 01Z )
with payments to be made as follows., L? 7"v t oNefy c CSma`� tom► '►'
/ t� 6jQr_ �fly'/O/`" �l.-. 'S. �s •> t'� �I�MF-�l.��t.,, e
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 a reemenvt^s�contingent upon strike , ac-
cidents,or delays beyond o�control. 3QC `co � - � 0.)r`
i' � '➢ Note—This proposal may be withdrawn
� f
by us if not accepted within days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You re authorized to do the work
as specified.Payments will be made as outlined above.
f Signature
Date /3) Signature
c paa�A c sa,f3-s° PROPOSAL '�
! f
•-�ttAMP .
O a
9 , g (rx� lOr� �L7Z#���111�J�III1 -
� e �asaRrhnsrcca'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COWENSATION INSURANCE AVIT
ttec)
with a principal place oof,business/residence at: pv�
`ll( Qa K J'�'� Irtba?rt-C Al-1- 6 W (phone#) 411
(str eet/city/sta1-e/�p)
do hereby certify, under the pains and penalties of penury, that.
( ) I a n an employer providing the following worker's compensation coverage for my
employees wonting on this job:
-- (Insumnoc Company) (Policf NtL,rber) -- - J (Expimrion Date)
( ) I aml a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Narne of Contractor) (Insurance Company[Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compa:rr/Policy Numb-cr) (Expiration Date)
(Name of Contractor) (Insurance Coiir n iPoticy Number) (Expirabon Date)
(Name of Contractor) (Insurance Company/Policy Numb-i) (Expiration Date)
(atiactr addi sheet ifnc« zy to include inform cn pertaining to all o�itacton)
i
( I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whilo homeowA-o=who employ perz.om to do o aisstcainc�oantructioa or repair work ou a dwelling of
not more than than units in which the homoowncr resides or on tho grounds apVutcnnat tharto arc oo(gencraily co¢ridacd to be
eap10yCr3 11 the wort x cazpeasation Act(GL152,ss 1(5)),application by a homcowna for a bccac oe permit may evidence the
legal ctatuc of an omployer under tbo Wore Compomaiiou Act_
I undcntsnd tint a copy of thiv riatcmmA may be forwa d od to the Dcpartzm of In&u.7ial Accidmr>'OfS of Ia;rrrwce for the
coverage vcrificsiion and that failum to seatre coverago under section 25A of MOL 152 can lad to d,imposition of aiminA penalties
oomistiag of a fine of up to S1,500.00 and/or imprisoamctlt of up to one year and civil pcaaltia in the form of a Stop Work Order and a .
firm of 5100.00 a day against mc_
For d:::::L
PerMa
Si o ttcc_ e
c
SECTION 8.-CONS. _UtT NON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : evU 67.7 4-J 1
License Number
• 010 6 �2-
A Expirati Da
Si Telephone
" ,E. A �n � � i- .� V Not Applicable ❑
E n rh fors. � .���.� . ���.� ��,� �......F� PP
SeSSe c e'M C11, / 3'� 7
Company Name Registratio Nu ber
_ Or, K o 63
Address ,(� rr�� n (� Q[� Expirat n Da
CA (`c VtC e M . V .L Telephone ! r(1 lZ
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...... ❑
���>~ �om�e�OYv�ne ;�xempt><on
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 buildinil 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 Chapt,, 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 -
� r
SECTION 5 DESCRIPTION OF PROPOSED WORK,( all aRplicablea
New House ❑ Addition ❑ Replacemen indows [Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: �� �4u II �le� V f /P lu5 3-,,-, c° ^Wc "
Alteration of existing bedroom Yes�No Adding new bedroom Yes No ,/
Attached Narrative❑ Renovating unfinished basement Yes V No
Plans Attached Roll ❑- Sheet❑
s�a'�ifN"e"�ho s .�alitl�cilatltlition to~ezis"tiny:housrng;°:cornplete' the„fal:low�n°g:
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 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=.QWNER 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
as Owner/Authorized Agent
hereby declare that the stateme.Lh and i f rmation 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
Yqrn
e
S az
Sig re o r g ate
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/Findin ver 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 eds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Do ument #
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 Com i sion?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YZdesc e size, type a nd location:D. ny proposed changes to or additions of signs intended for the property ?YES_
No
IF YES, describe size, type and location:
City of Northampton =
Building Department
212 Main Street
Room 100 ;
Northampton, MA 01060 $ .f
phone 413.587-1240 Fax 413-587-1272 Pio / ateP; "
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 - SITE INFORMATION
This section to1be cam f tee by,offtce
1.1 Property Address: 1 1
C� � )�Cr'I Tr"+C'!� L-�V• Map Lot ��� ��. �� �:3�Unit ��
v ,r
Zone
veriay,District
Elm St. District CB Dis3nct
-
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT°
2.1 Owner of Record:
Name(Print) Current Mailing Address:
----- Telephone
; Signature
2.2 Authorized Agent:
J'1 QY1 elwl e�' zl
Oak 5f.
jName rint) Current Mailing Address:
I
Sign ure Telephone
SE -TION:3 - STI ED 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 1311
��yy,, This Section For Official Use Only
Building Permit Number:_ A6tlba- 953 Date Issued:
Signature:
Building Commissiciner/In'tpgcfor of Buildings Date
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