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17A-188 (4)
PROPOSAL NO. 1 SHEET NO. \ \C t'��C�`' \�Y��;�. C1 1 �U DATE ('N"y 'A o� ;DPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT ADDRESS Q.r G 1 b \ 1 )DRESS DATE OF PLANS 1©� cam, �1:.k LONE NO. ARCHITECT Ve hereby propose to furnish the materials and perform the labor necessary for the completion of NP <A 1171-on a . v � ear 2 O ` r a ;II material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- ;ations submitted for above work and completed in a substantial workmanlike manner for the sum of l Dollars ($ �FXx1 '�Ilb� ) payments to be made as follows. bc.'A Respectfully submitted - '�ny alteration or deviation from above specifications involving extra costs vill be executed only upon written order, and will become an extra charge Pe �. wer and above the estimate. All agreements contingent upon strikes, ac- Jdents,or delays beyond our control. Note—This p osal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature � J Date S -U b Signature Adams 3818-50 PROPOSAL MADE IN USA A 1 o��lv.>•r�TO Grit-) of ,Toj;#I alll toll _ g 6 ;3i asaxchncctIz DEPARTMENT OF BUILDFNG INSPECTIONS 212 Main Street ' Municipal Building a Northampton, Mass. 01060 WC)JUCE, WS CO)UENSATTON msurtl,�nCF Ar<F- DAVIT Qi ccuscJperrt�i flee) v,rith a pl-ncipal place of business residence at: do hereby certify, under the pains and penalties of pegjury, that / I am an ernpioyer providing the follo%vine \,,,onccr's colnocnsabon coverage for illy employees v,,Oi-mlg on t111's job Niu--air_r) ----- (r pinion Dasc) ( ) I am a sole proprietor, general contractor or homeov=r,Der (circle onel and have hired the contractors listed below vyho have the follo%ving worker's codoensz ion policies: (Nnnlc of Con!: ci0r.1 -- - Onsl]r3nc Cotnnan}'rPGUCf 1�tur1lLYr) (1:x)1f8U0P. Dale) (Name of Covtracior) (Liisu nc Company/Polio,Number) (Bpi- eon Date) (Name of Connector) Qnsura.nc: CompanyfPoLcy Number) (Expiration Date) (Name of Counselor) (Iamrancz Comra"/Policy Number) (Expiration Date) (aaach additional 'rhcct ifnccc Mfwm-6.a pertaining to sll ooa�nc".on) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:ptczsc be awut thu wltilo bomcow wbo employ pcjom w do m-_+.-.,•a0C wus'st:aioo cr rcpau work on a d%w-U g of not moct than tbruo units is Wt ich the bomoaa-ncir r=4cs or oa the gvunds zppurtensii thctto arc opt genertily ooerdatd to be cmploytrn under tba waled%oompcm-eiion Act(GL152,n I(5)�applicrrion by a bomoovima for a liecnx cc permit may evidcOoc the Icg3d rtahu of an*=;p toyer under the Works eg Compoosalion Aa- I undcreAnd tbai i oopy of thu cmr®mi may be focwnrded to the Dcpartmaoa of L>du%nid Anadeor!Offioo of L.-,coo for the oovcrxgc vcrMcaiioo and that f_irtnr to aoalrc covcrasc under soctioa 25A of hIOL 152 can Iced to the imposition of aimind pcna - 000sisting of a fine of up to S 1 300.00 and/or imprisoomcrd of up to ooc year tod civil pco..fua in the form of a Stop Work Order and a fim of 5100.00 a day agaiasl me For&P_-,•,v- I u, oaly Permit Number Lot Signahtrc of Li nittcc UOT CTION 8 - CONSTRUCTION SERVICES d.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone „E. an" SEES red`Home I'm Not Applicable ❑ Company a e RegistrJa o Number <:�4 41 -I � -- Oa- Addr ss 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 affidavit will result in the denial of the issuance of the building permit. igned 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 he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Emplo\ces 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 S ec a li ble New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes_?S,No Adding new bedroom Yes _No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ house and - 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? 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 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 1 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. 'gned under the pains and penalties of perjury. ZrintN eof caner/Agent Date t 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 Parkin Spaces Fill: (volume&Location A. Has ajpecial Permit/Variance/Finding 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 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. Are there any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: r � City of Northampton ilding Department 2,12 Main Street Q 3 ' Room 100 qr mpton, MA 01060 pho 413-587-1240 Fax 413-587.1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This s teyl five 1.1 Property Address: ' 5 ' / Map s Zone tilt Eift1 „, srt�icf SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Olt me(Print) Cu nt Mailing Address: l Telepi^J Signature 2.2 Authorized A ent: a,p N (Pri Current Mailing Address: \b Signature Telephone S GT# N'3 - ESTIMATED CONSTRUCTiojN C05T5 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) 13 PTV Check Number ? This Section For Official Use Only wilding Permit Number:_ Date Issued: Signature_. Building Commissioner/inspector of Buildings Date 21 KIMBALL ST BP-2000-0964 GIS#: COMMONWEALTH OF MASSACHUSETTS ✓Iap:Block: 17A- 188 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofin BUILDING PERMIT Permit# BP-2000-0964 Project# JS-2000-1764 Est.Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin CDT CONSTRUCTION 130152 Lot Size(sq. ft.): 14810.40 Owner: TOBIN GEORGE D&MARGARET W Zoning: URB Applicant. CDT CONSTRUCTION AT. 21 KIMBALL ST Applicant Address: Phone: Insurance: 158 NORTH MAPLE ST (413) 585-8677 Workers Compensation FLORENCEMA01062 ISSUED ON.5/3/00 0:00:00 TO PERFORM THE FOLLOWING WORK:STR I P & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 5/3/00 0:00:00 1897 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo