17A-157 (2) 1haposai Page No. Of Pages
NEWMAN'S CONSTRUCTION
697 Bridge Road
NORTHAMPTON, MA 01060
(413) 586-0273
PROPOSAL SUBMITTED TO PHONE DATE
�s y al.70
STREET I J!9§; ME
4
CITY.STATE and ZIP CODE JOB LOCATION
oLiDC.
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ARCHITECT DATE OF PLANS JOB PHONE
We he
reby submit specifications and estimates for.
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VP Fropm hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
St dollars($Payment be m follows 1r__S
All material is guaranteed to be as specified.AD 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. Ali agreements contingent upon strikes, accidents
&=:yond our control.Owner to carry fire,tomado and other necessary insurance. Note:This p s Ly be
are fully covered by Workman's Compensation Insurance. withdrawn by us it riot a=ccep within
Arreptance of Froposal —The above prices,specifications
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.
A�q,�, 31
04.E O
14
$ � �assac�ttsetts'
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DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
Nce�iermitt=)
with a principal place of business/residence at:
tr►. (phone#)._ij - loci,S
(strceycity/stairlap)
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following wor'ker's compensation coverage for my
employees working on this job:
(Insurance Cody) (Policy Number) CLTiration ate)
( ) 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 Con pany/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(attach additional iboct if noccasary to ine}uda infamahon partaiaing to all oodr=fon)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pl= be aware that veWo bomcoxvcra who cmploy p rl=to do maintc=.cr,o=stn otion'or repair wont on a dwelling of
not morn than throo amts is which the bomoa%v mid=or ou the gnwads apputieaaat ihercto arc not gtnerally ooasidard to be
employers under the worker's compa=iion A t(GL1 appiicition by a homoowncr for a Ganse or permit may evidenoe the
1eg21 nitro of an employer under the Workees Compamatiou AcL
I uadastand t).at a copy of this rutemmt may be forwarded to the Deport,,,, 2 of Industrial Ao idw&Oboe of Imunaoa for tba
oovetxgo verificaiioa and that failtmm to sot m coverago uudcr saxroa 25A of MOL 152 can lad to tbo"imposition of ai=ul penaldcl
oomts[ing of a fitx lof up to$1,500.00 a0Nor of tip to one ytar and eivt7 pena tics in the form of a Stop Work Order and a
film ofstoo.o0&day against tt3e
For&pntmed,I use Only
+ permit Number
�06
r'
SECTiDI4,B-,CONSTii;UCTION SERVICES
81 Licensed Construction Supervisor: y,, Not Applicable ❑
mme of License Holder:L a�1 eo-) 1 V Q t ma•(] C"s OLOq uq
License Number
Address ExpiratiAn Date
C VL
WIN
nature Telephone
r. :. 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 affidavi,
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)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 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
r
S iON D C � PR S D RK kcal > Iicabl`
New House ❑ Addition ❑ Replacement Windows Alterations)❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding( Other[ ]
Brief Description of Proposed Work: 44 - 0 r? U`-i h"\Q �h t cin\-S. r�z i`a Cie r t? `� i co to
— I )
Alteration of existing bedroom Yes__�C No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑•Sheet❑
"�ifNe�' "�o°'�'� �and��c���#"o'�i�"to` existing offing comp`le � h�-fo'tt ' nib.
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 Ni
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 AUTtIORIZATION-TO BE'COMPLETED WHEN
OWNERS=AGENT 4R CO I'I2AGTQWAPPLIES FOR'BUILbINGPERMIT
as Owner of the subject property
hereby authorize to act o
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declafethat the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Si ned un er the ins and penalti of perjury.
Print Name
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&LAcation
A. Has a Special Permit/Variance/Firiding ever 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 Deeds?
NO DON'T KNOW _ YES
IF YES: enter Book Page and/or Document #
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 Irom 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. Are there any proposed changes to or additions of signs intended for the property?YES—
No
IF YES, describe size, type and location:
thampton
h � t u i bpartment
'
�) 21 i� Street
l
.1.00
a or , MA 01050
phone 413-58240k Fax 413.587-1272
1 r ollu["r.,F;art(7"'11S p
url n , cn
ARPtICATroiT 'O CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
Th�sysecti fii�be comp iArd by office
1.1 Property Address: ti r „
t--
�n COX ylx f r y1 ' � . e' 1-MI
h,J'�) y�^ J f� i
,1 ) C 1-y n c)i o
Elm St. District
SECTION'2-PROPERTY OWNERSHIP/AUTHORIZED.-AGENT
2.1 Owner of Record:
L+ F i -Me r 1 FLx ra r cr-vs Qj. V-tgyr or_
Name(Print) Current Mailing Address:
21 Q®
Telephone
Signature
2.2 Authorized Agent:
ao fwL.'r7 l t r,(Jr6/ 0-t-L1 f
Name(Pint) Current Mailing Ad ss:
ignatur Telephone
SE ES TI TED CONSTRUCTIO O T
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ��, (a) Building Permit Fee
2. Electrical (b)Estimated 7i otal Cost of
Construction from S
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) -
5. Fire Protection
6. Total =(1 +2+ 3+4+ 5) Check;Number
Phis Section For.Official UswOnl
Building<Permttlurnber' Date Issued-.'
Signature:
Building Commissioner/inspector of Buildings Date,
F. BP-2004-0021
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0021
Project# JS-2004-0036
Est. Cost: $8360.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Cyrus Newman_ 064690
Lot Size(sc. ft.): 28793.16 Owner: OLANDER FLORA R&EDWIN L
Zoning:URA ADDllcant: Cyrus Newman
AT. 61 FOX FARMS RD
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093
NORTHAMPTON MAO 1060 ISSUED ON.717103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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• Receipt No: Date Paid: Check No: Amount:
Building 7/7/03 0:00:00 3809 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo