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17A-221 (4) JCM HOME IMPROVEMENT Estimate P.O. Box 329 Leeds, MA 01053 Date Estimate# 7/8/2008 61 Name/Address Bob&June CAS /{4+—S 182 N.Maple St. Florence,Ma.01062 Project Description Qty Rate Total Roof repair's.Detail's below. LReplace 2nd story roof 3 sides measuring 600 sq.8. 2:Replace lower 1 story roof measuring 200 sq.8. 3:Replace facia at rear of building along uper eve's edge as needed and reinstall gutter. NOTE:Roof area's have only one layer and the new roof will be installed over the existing roofing. All labor, erial,cleanup d permit fee's included in price. 2,000.00 2,000.00 SIGNED: �gfCQ-� O O DATE Total $2,000.00 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNIR 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 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 rough 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 I, 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 lozssacituserts Depar tment oflndustr iaT Accikenrs D,J--ce ofL:vesri anions _ - 600 J"ashin�ton Street Boston, MA 02111 xWw.nlass.CIO iIdia Workers' Compensation Insurance Aff�dayit: Builders,/ContractorsiEiectricians, iurr.bers ADDIJCant information Please Print Legibly Na.i-ne (Busn essl,Organizarion'Tndividual): _ Address: City/State/Zip: Phone_: 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 construe ion .❑ �,f employees (fu 11 and/or part-time).* have hired the sub-contractors 2.lo/� I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. Cj Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. F7 We are a corporation and its 10. Electrical repairs or additions 3.❑ I am a homeowner doing all wont ofEcers have exercised their I LE]Plumbing repairs or additions myself. [-No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] ' c. 1f2, §1(=1),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box T1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors trust submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities rave employees. If the sub-contractors have ermlovees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. 1r.�_r2rre('nmr.any dame- Policy r or Seif-ins. Lic. m: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration p age(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 1-52 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o:`up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLL for insurance coverage verification. I do hereby certify un Wpenalzies ofperjury that the information provided above its trz e and correct Siona±t re: Date: 0 ©� Phone G// 7— Official use only. Do not ivrire in this area, to be completed by city or town ojffciaL Citv or Town: Permit/License r Issuing Authority(circle one): 1.Beard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.P`u:ibing Inspector 6. Other � j i Contact, Person: Phone SECTION 8 -CONSTRUCTION SERVICES E.1 Licensed Construction Supervisor � Not Applicable ❑ Name of License Holder: -le,,-;, w 0 m e; 0-r7 / Q license Number Lie-its . 114, otoS3 roll �ol� �aaress - �^p D(� ,p Expiratidn :i at Telephone I �.Registered Home Irtmravemert contractor - Not Applicable ❑ :omoanv Name Registration Number ddress Expira ion Date Telephone ECTION 1A-WORKERS'COMPENSA71ON INSURANCE AFFIDAVIT(M G L.c. 1152,§25C(6}) 'crkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. oned 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.CI'IR 730. Kith Edition Section 1033.5.1. Definition of Homeowner:Peron(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 actin.-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 b-DESCRIPTION OF PROPOSED WORK(check all aoolicable� New House r7 Addition ❑ Replacement Windows Alteration(s) C Roofing Or Doors 0 Accessory Bldg. t_1 Demolition ❑ New Signs [D] Decks [F] Siding[p] Other[G] I Brief Description pf P oposed Wcrk: p Vs a �t\ new ro es �c.��eP b�,rtr' St r.,q( �yF 80 Alteration of existing bedroom Yes V No Addinc new bedroom Yes �o 7 Attached Narrative Renovating unfinished basement Yes ✓ Ne Plans Attached Roll -Sheet 6a. If Newhouse'and'oraci&tlon fo QXISiI7lgti0U5i�1CT.`coinr7fete th+r-fa[iavYing: 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 Woedstoves Number of each g. Energy Conservation Compliance. Masschecic Energy Compliance form attached? h. Type of construction i. Is construction within 1C0 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 IOW 4EOS AGENT 0 R,CONTRAC OR APPUES-FOR BE)IE.D.1-U Er'ZMIT i as Owner of the subject property hereby authorize to act on 1 behalf, in all me -rs relative to work uthorized by this building permit application. 77-7 t x Signatur Owner Date :]PSSC /ern fr)e"M `1 as Owner/Authcn�ed Agent"womw„ereoy declare that the statements a information on the fcrecci g application are true and accurate, to the best cf my knowledge and belief- , icred urder the pairs and penalties of perju Print N- .e . . Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Exist'n- Proposed Required by Zoning This column to be filled in by Building Department Lot Size Setbacks Front Rear Building Heig Bldg Square Footage % Open Space Footage % #of Parking Sp A. Has a Special been issued for/onthe site? � NO v_�-\ DON7 KNO0/ YES �~»—� / IF YES, date ta ' IF YES: Was the permit recorded at the Registry of Deeds? NO �~��� uvn ' ^mu,, 0 /ES IF YES: enter Book Page Document#/ � NTKNOY 0 YES 0 B. Does the site contain a brook, body of water or wetlands? NO IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained �-\ Obtained �~\ Date Issued: �-� ' \~� ' ' L_____-__-__J C. Do any signs exist on the property? YES 0 NO 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 N��~ IF YES, describe size' type and location: E. Will the construction activity disturb(clearing,grading n. or filling)over 1 acre orisU part ofa co,nnonplan that wi|/disturb over 1acre? YES �v�) NO IF YES, then'a'Northampton SFoFF,�-0V��-M�-nag—ernd,-,-ifPE�hnit from the DPW isrequired. ( Department use only City of Northampton Status of Permit: Building Department Curb CutfDriveway"Permit, 212 Main Street Sewer/Sep6cAvailabilit. Room 100 WatedWVellAvalability' " -- Northampton, Mr. 01060 Two Sets bf Structural'Plans ;ane 41`3=587-1240 Fax 413-587-1272 Plot/SitePlans Offier Specify APPLICATION TOIdC'I STRU4T,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING µ $ECTIQN 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 10 AT Jet S7. Map Lot Unit �C�0f—C,-7e(f t4JA Q �C?�' Zone Overlay District Elrn St:District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailin Address: Telephone Signature 2.2 Authoriz d Agent: Name(Print) Current Mailing Address: fe Telephone SEC Ti MATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ©e; (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) O[ ME% j Check Number This Section For Official Use Only -- Date:- Building Permit Number Issued: Signature: ��Building,,Commissioner/Inspeefo�oT- ui amgs Date 182 NORTH MAPLE ST BP-2009-0032 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-221 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-2009-0032 Project# JS-2009-000043 Est.Cost: $2000.00 Fee: $25.00 - PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 134274 Lot Size(sq. ft.): 18730.80 Owner: KLAES ROBERT&JUNE zoning.URB Applicant: Jesse Montgomery AT. 132 Nr)RTH ;:nARl,E ST Applicant Address: Phone: Insurance: P O BOX 329 (413) 585-8482 Q LEEDSMA01053 ISSUED ON.71912008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 800 SQ FT 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: 14- Final: Smoke: Final: D R THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAT S. l Certificate of Occupancy Si nature: --- FeeType: Date Paid: Amount: Building 7/9/2008 0:00:00 $25.001748 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo